Death of a 13-week-old boy in February 2021. Ollie's death was the result of a co-sleeping incident with his father which resulted in brain injury. Prior to his death, toxicological analysis of Ollie's urine revealed the presence of cocaine, which resulted in an interim care order for Ollie and his siblings. Learning themes include: identification of and response to neglect; the importance of home visits to identify poor living conditions; the effectiveness of safer sleep messages; the impact of parental mental health and substance misuse concerns as additional stressors in the family; the role of disguised compliance; and the impact of Covid-19 on supporting families and the capacity of services to respond to their needs. Recommendations for the local safeguarding children partnership include: publish a multi-agency neglect strategy with actions to improve the awareness, understanding, assessment, and response to neglect, and how neglect interacts with parental mental health and substance misuse; review and update the approach to safer sleep messaging as part of a new prevent and protect model for preventing sudden unexpected deaths of infants (SUDI); develop a campaign targeting casual substance misuse amongst parents and carers and warning of the dangers to their children; undertake a review of the local impact on families of Covid-19, lockdowns and the absence of face-to-face visits; and deliver a series of locality based information events for parents and carers with access to advice and guidance.
      
 Title:  Child safeguarding practice review: Ollie. LSCB: Wirral Safeguarding Children Partnership Author: Wirral Safeguarding Children Partnership Date of publication: 2023  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.                           Child Safeguarding Practice Review  Ollie  April 2023  Wirral     Safeguarding    Children  Partnership Table of Contents   Executive Summary          2  Introduction and Methodology       4  Terms of Reference          4  What was known about the Family ?      6  The Incident           8  Key Practice Episodes         9 • The identification of and response to neglect   9 • The effectiveness of safer sleep messages    11 • Additional stresses of parental mental health and               11                  substance misuse • Disguised compliance        13   Out of routine:  A review of sudden unexpected death in   14             infancy (SUDI) in families where the children are considered                               at risk of significant harm   Strengthening Safeguarding Arrangements     16  Summary of Recommendations       19  Appendices           20 • Agencies involved in the review      20 • References          20  Wirral Safeguarding Children Partnership                Page 1 Executive Summary 1.1 Ollie was 9 weeks old when he was seriously injured in a co-sleeping incident with his father on the 6th January 2021. Ollie’s had been unsettled during the night and his father had wrapped him in a blanket and fallen asleep with him on the sofa. Ollie was unresponsive and paramedics were called who managed to resuscitate him, and take him to hospital. Doctors informed his parents there was a significant chance he would not survive.  1.3 Both the attending ambulance crew and police officers who arrived shortly thereafter described the house as being cluttered and dirty. The electricity was off and the parents appeared to be sleeping downstairs. There was a Moses Basket in the front room but it appeared to be unused. 1.4 Later toxicological analysis of Ollie’s urine revealed the presence of cocaine. As a result of this the Local Authority were granted an interim care order for Ollie and his siblings and his parents were only permitted supervised contact. Ollie tragically passed away a few weeks later as a result of a significant hypoxic injury to his brain. A police investigation begun and the case was later     referred to the Wirral Safeguarding Children Partnership who agreed to undertake a Child       Safeguarding Practice Review. 1.5Four key practice episodes were identified and formed the basis of the review: identification and response to neglect; the effectiveness of safer sleep messages; the impact of parental mental health and substance misuse concerns as additional stressors in the family; whether disguised compliance was a feature of the case and the impact of Covid-19 on the family and the capacity of  services to respond to their needs 1.6 Identification of and response to neglect – the poor condition of the home was raised by     services attending the property on the 6th January. The house was dirty and unkempt with parts of it in disrepair and visibly dangerous. Prior to this there had only been one previous concern      recorded about the house being untidy – this was recorded by a health visitor following a visit in 2015, but there is no further detail or record of any follow up, or wider exploration of neglect. 1.7 Ollie’s parents did later admit that the condition of the house was ‘not acceptable’ but said this was a recent issue mainly causes by significant work which was being undertaken on the house. There are no reports from any agencies about neglect being a concern, but it is nevertheless the case that services only became away of the families poor living conditions because an ambulance had been called on the 6th January. 1.8 Effectiveness of  safer sleep messages – Safer sleep campaigns had been running in Wirral for a number of years and practical messaging and advice for parents was a core, and expected, part of practice, particularly for health visitors and midwives. In this case health services confirmed that safer sleep messages were shared with the family. However, the family did not practice safer sleep with Ollie, as evidenced by the incident which led to his death and the downstairs Moses   Basket appearing to be unused. This raises questions for the WSCP about the effectiveness of the messaging and whether a different approach is warranted.  1.9 Did professionals understand the additional stresses of parental mental health and substance abuse? – Both of Ollie’s parents had received treatment for depression and anxiety Wirral Safeguarding Children Partnership                Page 2 issues, and in 2019 Ollie’s father was diagnosed with a panic disorder and referred for counselling. His mother had reported feeling low to her GP but had not returned for follow up appointments. Ollie’s father also admitted to recreationally using cocaine, although he stated this was never when the children were around.. However, there is no record of his drug use in any agencies reports, and therefore no concerns expressed. Similarly, wider agencies were also unaware of the mental health concerns, and therefore there was no triangulation of the issues being faced by the family.  All the children in the family had traces of cocaine in their systems and it seems this was   absorbed by them environmentally, rather than deliberately. Both parents were surprised by this but main-tained that the cocaine use by Ollie’s father didn’t have any impact on his care or safety. 1.10 Was disguised compliance a feature of this case and did the Covid-19 crisis impact on the circumstances of the family or on the capacity of services to respond to their needs? – It is not known whether Ollie’s parents deliberately tried to mislead services, but their behaviour did suggest elements of disguised compliance, such as not taking their children to some appointments, not attending some themselves, and listening to safer sleep messages but not acting on them. The impact of the Covid-19 pandemic and the subsequent lockdowns did remove families from the protective gaze of services, and unfortunately it did give families who wanted to be ‘missed’ the opportunity to avoid services. 1.11 Key findings: • Whilst Ollie’s death could not have been predicted, it is clear that unsafe sleeping was the primary cause of his death and therefore work to raised the awareness of safer sleep       messages must be a priority action for the WSCP • Neglect doesn’t appear to be a significant factor in this case—it wasn’t explored in any detail, however, services were not sighted on the issues facing the family which resulted in a poor living environment which suggests the need for a more robust strategy and an offer of early help for families • Casual parental substance misuse was a feature of this case, and it is concerning that parents maintained that their drug taking did not affect their children. The WSCP should ensure a clear messaging campaign for parents and carers highlights the dangers for children • Covid-19 and its associated lockdowns removed a lot of families from being routinely seen by services. The WSCP needs to understand the scale of this in Wirral and whether there needs to be a wider offer of help to families who might still be struggling but are ‘under the radar’ of statutory services 1.12 Recommendations – Five recommendations are made: • To develop and publish a multi-agency neglect strategy • To review and update the approach to safer sleep messaging as part of a new prevent and protect model for preventing sudden unexpected deaths of infants • To develop a campaign targeting casual substance misuse amongst parents and carers • To undertake a review of the local impact on families of Covid-19 and  lockdowns • To deliver a series of locality based information events for parents and carers Wirral Safeguarding Children Partnership                Page 3 Introduction and Methodology 2.1 On the 6th January 2021 an ambulance attended the home where 9 week old Ollie lived; the ambulance had been called because he was not breathing. The attending paramedics found Ollie to be unresponsive, and he was taken by ambulance to Arrowe Park Hospital where attempts to     revive him continued, and later to Alder Hey Children’s Hospital in Liverpool for specialist care. 2.2 The paramedics, and police officers who attended the scene shortly afterwards both described the home as being  messy and in poor condition. Ollie and his parents appeared to be sleeping downstairs and co-sleeping. 2.3 At hospital Ollie remained in a critical condition. His parent’s were informed that there was a significant chance that he would not survive.  2.4 Following a strategy discussion the Acute Life Threatening Event (ALTE) process was begun. Toxicological analysis indicated the presence of cocaine in Ollie’s system. It was agreed that the threshold for a Section 47 (child protection) investigation had been reached and the Local          Authority applied for an Interim Care Order. 2.5 It was determined at hospital that Ollie had suffered a significant brain injury and his condition deteriorated. Ollie sadly passed away on the 4th February 2021.    2.6 The police opened an initial investigation based on a finding of cocaine in Ollie’s urine. 2.7 The case was referred to the Wirral Safeguarding Children Partnership Case Review         Committee who undertook a rapid review to determine if a statutory Child Safeguarding Practice Review1 (CSPR) should be undertaken. The committee unanimously agreed that CSPR should be undertaken given that Ollie had died and the serious concerns about neglect, the condition of the house and co-sleeping that had been raised.  The Child Safeguarding Rapid Review panel agreed with the decision to proceed with a CSPR. The CSPR was completed in September 2022. CSPR Terms of Reference 2.8 The Wirral Safeguarding Children Partnership agreed that the CSPR should consider: • the family’s circumstances—including the sleeping arrangements with Ollie, stressors and  vulnerabilities • the potential impact of Covid-19 lockdowns and the family’s visibility • the delivery of safer sleep messages • the effectiveness of information sharing __________________________________ 1Child Safeguarding Practice Review (CSPR). A CSPR should be undertaken in circumstances where a local authority knows or suspects that a child has been abused or neglected and the child dies or is seriously harmed. The purpose of a CSPR is to establish what lessons can be learned in a case to strengthen safeguarding arrangements to reduce the risk of similar incidents occuring.  Wirral Safeguarding Children Partnership                Page 4 • learning from the National Panel’s report: Out of routine: A review of sudden unexpected death in infancy (SUDI) in families where the children are considered at risk of significant harm, relevant to this case • learning for the multi-agency partnership and individual agencies  2.9 CSPR activity in Wirral is coordinated by the multi-agency Case Review committee on behalf of the safeguarding partnership. The committee provides oversight to each review and ensures that the review has access to the relevant multi-agency expertise. Membership of the committee       includes the Designated Doctor and Designated Nurse for Safeguarding Children, the Head of   Safeguarding Children for the Local Authority, a Police Detective Chief Inspector, a consultant Head Teacher, and Early Childhood Services Service Manager, and a Practice Improvement       manager.  CSPR Methodology 2.10 The approach for completing CSPR’s is based on the Social Care Institute for Excellence Learning Together methodology2 which involves the gathering of information from agencies        involved in the case and consideration on decision making—why certain decisions were made at the time and consideration of the family’s daily lived experience and whether there were any     additional stressors on the family. The methodology also includes the identification of key practice episodes, which had a significant influence on the way the case was managed.   2.11 The views of the family were also gathered as part of the review process.  Key Practice Episodes 2.12 Four key practice episodes (KPE’s) were identified and considered as part of this review are: • The identification of, and response to neglect • The effectiveness of safe sleep messages • Did professionals understand the additional stressors of parental mental health and       substance misuse, and did these negatively impact the safety of the children? • Whether disguised compliance was a feature of this case • The visibility of the family and the extent the Covid-19 crisis impacted either on the       circumstances of the family or on the capacity of services to respond to their needs   __________________________________ 2Learning Together Methodology Developed by the Social Care Institute for Excellence (SCIE), the Learning Together Methodology provides a        framework for undertaking Child Safeguarding Practice Reviews where the identification of learning to strengthen    safeguarding arrangements is key: https://www.scie.org.uk/publications/reports/report19.asp  Wirral Safeguarding Children Partnership                Page 5 Context What was known about the Family? 3.1 Ollie lived at home with his parents and three siblings in a semi-detached house in Birkenhead, Wirral. The family all identify as white British. The children, for their whole lives, have lived at home with their parents. The family genogram is shown below:          3.2 Prior to the incident which led to Ollie’s death, the family accessed universal services, including health care and schooling, but they hadn’t had any prior involvement with children’s social care. Analysis of the multi-agency chronologies of involvement evidence that the family were well known to community health—a consequence of having four young children, and the older children were well known by their school. There was evidence of some poor school attendance, and a number of missed health appointments, but generally the family weren’t considered in need or at risk.   3.3 Ollie’s father was  known to Merseyside Police having been previously arrested for being drunken and disorderly some years before, and he was one of a number of people arrested at a private house disturbance for affray, and possession of cocaine for which he was given a Caution, and a Fixed Penalty Notice.  3.4 The three older siblings attended the same local Primary School. Between 2018 and 2020 there had been a number of conversations between the children’s parents and the school about         challenging behaviour at home, reluctance of one child to attend, and late attendances by all the children.  The parent’s had also raised some behavioural concerns about two of the children with the school and with health professionals—one of the children had been diagnosed with Sensory Processing Disorder which affected their behaviour. However, no safeguarding concerns had been raised in respect of any of the children, nor had any concerns been deemed serious enough to  trigger a referral into Early Help or Children’s Social Care services. 3.5 Ollie’s father had been prescribed diazepam since 2018 for depression and a panic disorder. In 2020 Ollie’s mother was also treated by her GP for depression and anxiety and prescribed         anti-depressant medication She complained of stress at home and challenges getting the children to school. Wirral Safeguarding Children Partnership                Page 6 28  Ollie’s mother Ollie’s father  38  7  0 5 3 Ollie Born Nov 2020 Died Feb 2021         Sister 2            Sister 1            Brother 1 3.6  Recently there had been a number of non attendances by the children’s mother at telephone appointments and failure to keep GP and hospital appointments for the children. A number of ‘did not attend’ instances were recorded by the midwifery service in respect of the children’s mother. The hospital followed up the non attendances but no safeguarding or wellbeing concerns were   noted. Ollie had three failed appointments in the 6 weeks before the incident which led to his death.  3.7 Following Ollie’s birth, a number of postnatal home visits were arranged. The first visit took place as planned at the home but no assessment of home conditions or Ollie’s sleeping arrange-ments were reported.  Shortly afterwards the family reported that they were self-isolating due to Covid-19 therefore the following ‘visits’ were conducted by telephone and no assessment could be made of the living conditions. The final home visit from the midwifery service on the 24th         November 2020 did not record any concerns.  3.8 The Health Visiting service similarly reported that home visits could not be undertaken due to the family self isolating or the children’s mother reporting to be sick. However, during a telephone virtual ‘visit’ on the 13th November 2020 the Health Visitor provided the children’s mother with safe sleep guidelines and signposted her to further information provided by the Lullaby Trust. This was in keeping with local guidance where, on a pan-Mersey basis, safe sleep messages were         delivered as part of an ongoing campaign by health professionals. The messages included  highlight-ing the dangers of co-sleeping. The local Safeguarding Partnership included the same messages on its website and signposted parents and carers to detailed guidance and advice from the Lullaby Trust. 3.9 It is notable, however, that the safe sleep messages are usually delivered in a home visit at the same time that baby’s sleeping area is viewed and assessed. There is no evidence in the records—including from the face to face visits, that Ollie’s sleeping arrangements were viewed, or that wider home conditions were assessed. And, even though it is recorded that safe sleep messages were shared, there is no record of what precisely was discussed or given to the family.  3.10 As this is not the first review undertaken locally where a child has died or been injured as a result of co-sleeping it suggests that an early recommendation for the Wirral Safeguarding Children Partnership will be to review the multi-agency processes for sharing safe sleep messages with     families, and determine whether other, more effective means for communicating the messages need to be designed or adopted. 3.11 It is clear, however, that the family were known to services for a number of years by virtue of having four young children prior to Ollie’s tragic death. And, in that time the family were not known to children’s social care, or identified as being in need of additional services.  3.12 Home conditions at the time of Ollie’s death were described as being poor which strongly suggests that there was a deterioration in the living arrangements of the family in the months     before his death. Prior to this, and prior to Covid-19 related lockdowns the family were much more visible to services and a number of ante and post-natal visits to the home had taken place, none of which had raised significant concerns.  Wirral Safeguarding Children Partnership                Page 7 The Incident 4.1 At approximately 11.15am on the 6th January 2021 a 999 call for an ambulance was received in respect of 9 week old Ollie who was reported as not breathing. An ambulance arrived a few minutes later at the home address and Ollie was found to be unresponsive and in asystolic cardiac arrest. His father was carrying out CPR when the ambulance arrived. Ollie was dressed in a nappy and had some bleeding from his nose. A Guedel airway was inserted and Ollie was given two doses of adrenalin. Spontaneous circulation resumed after a gap of approximately 23 minutes.  4.2 The ambulance staff reported the house to be cluttered and dirty. Police arrived on the scene and Ollie was taken to Arrowe Park Hospital accompanied by his parents. 4.3 Attempts to resuscitate Ollie continued in the ambulance and at hospital. Ollie’s parents were spoken to by the Paediatric Registrar at the hospital and his mother advised that Ollie had had a cough since Christmas, although his condition had been improving over the past few days. This had been reported to the health visitor during a visit about a week before. 4.4 Ollie’s parent’s reported that during the night of the 5th January he had been unsettled and wouldn’t sleep, but had taken good feed at 3am. At 6am his father wrapped Ollie in a blanket and lay on the sofa with him where he fell asleep. Ollie’s father was awoken at about 11.00am by his daughters and reported that Ollie was face down in his arm crease with his whole face covered and had blood around his nose. Ollie’s father shouted for his wife (Ollie’s mother) to call an ambulance, but she could not find a phone so ran to a neighbours house and an ambulance was called and    arrived within a few minutes. 4.5 The police arrived at the property shortly after the ambulance staff  and described presentation of the property as messy, in poor condition with no lighting and dog food all over the floor. Ollie and his parents appeared to be sleeping downstairs where there was a large sofa and Moses basket which appeared to be unused. The master bedroom contained a mattress which was stood up against the wall. There was also a small open swimming pool in the garden which was dirty and covered in algae.   4.6 The police reported that there was no immediate evidence of drug paraphernalia at the     property and were told that the family were self-isolating due to a family member testing positive for Covid-19. 4.7 At hospital Ollie was described as being critically unwell and exhibiting symptoms consistent with accidental suffocation. He had no movement and was floppy, and his pupils were unresponsive and fixed. The Paediatric Consultant informed parents that there was a significant chance that Ollie      wouldn’t survive and if he did he would certainly suffer from significant neurological problems. 4.8 A strategy discussion was held between health staff, children’s social care and Merseyside Police later on the 6th January and it was agreed that the Acute Life Threatening Event (ALTE)3 process would begin and an ALTE meeting would be held the following day.  4.9 The Paediatric Consultant shared that toxicological analysis of Ollie’s urine had revealed the presence of cocaine. In response to this it was agreed that parents could only have supervised   Wirral Safeguarding Children Partnership                Page 8 access to Ollie and their other children, who were to be temporarily looked after my their        maternal uncle through an Interim Care Order. When informed of the presence of cocaine it was reported that Ollie’s father admitted to rubbing it into his gums to sooth toothache,                 but he couldn’t explain how it had got into Ollie’s system.  4.10 Agencies at the strategy discussion agreed that the threshold for a Section 47 assessment had been reached. 4.11 In the early evening of the 6th January Ollie was transferred to Alder Hey Children’s Hospital in Liverpool. Unfortunately, following a number of scans and interventions over the following few weeks it was determined that as Ollie had sustained such a significant hypoxic injury to his brain and brainstem any meaningful recovery was now not possible. Life support was withdrawn with the agreement of Ollie’s family, and he passed away on the 4th February 2021.  A police investigation and children’s services involvement with Ollie’s parents and siblings are both ongoing.  Key Practice Episodes 5.1 Four key practice episodes (KPE’s) were identified and considered as part of this review are: • The identification of, and response to neglect • The effectiveness of safer sleep messages • Did professionals understand the additional stresses of parental mental health and        substance misuse, and did this compromise the safety of the children? • Was disguised compliance was a feature of this case and did the Covid-19 crisis impact on the circumstances of the family or on the capacity of services to respond to their needs?  1. The identification of, and response to neglect 5.2 Ollie’s parents had lived in the same home for almost 8 years, having moved in just before their   eldest child was born. All their children have been raised there.  5.3 Neglect is defined as the persistent failure to meet a child’s basic and/or psychological needs4, and this includes the requirement to provide a safe and secure environment. Persistent poor home conditions are a common indicator of neglect.  _________________________________ 3Acute Life Threatening Event (ALTE) Published as part of the Merseyside Sudden Unexpected Death of a child/infant (SUDiC) protocol, the ALTE procedure is initiated when there has been any sudden/unexpected collapse of an infant or child requiring some form of active intervention/resuscitation and subsequent intensive care / high dependency unit admission. A multi-agency meeting is held for the purposed of sharing information and determining whether further investigation or review is required.   4Working Together to Safeguard Children (2018) statutory guidance, page 108 Wirral Safeguarding Children Partnership                Page 9 5.4 Poor home conditions were raised as a concern by agencies attending the property in response to the incident on the 6th January. The concerns included the house being dirty and unkempt, with parts of it in disrepair and visibly dangerous. It was also noted that there was no electricity in the house and light bulbs appeared to be missing. 5.5 Prior to this there was a record from 2015, made by a Health Visitor following a home visit who recorded that the house was ‘untidy with dirty bottles and dishes on the floor’. It is unknown what happened as a result of this, but it did not lead to a contact with children’s services or a    referral to early help services. The next reference to home conditions in the multi-agency        chronology was made five years later in 2020 where a visiting midwife reported home conditions to be ‘satisfactory’. Unfortunately, the use of terms such as ‘satisfactory’ is highly subjective but does indicate that there were no causes for concern.  5.6 Prior to January 2021 there is no record of any contacts or referrals being made to children’s services in relation to home conditions or any other indicators of neglect. However, here is no doubt that the condition of the home as witnessed by services attending on the 6th January was in a poor and unsanitary state, and it was an unsafe environment with sharp tools left within the     children’s reach, and unsuitable for children to be living in.  5.7 In later conversations with children’s social care Ollie’s parents stated that they accepted that the home conditions on the 6th January were not acceptable, but maintained that this was an      unusual situation and the state of the home environment had only recently declined from its usual high standard. The parents provided photographs to the children’s social worker which did        evidence the home as being tidy and well decorated months before the incident in January 2021. In Court statements provided in early 2022 the parents stated that home conditions had started to decline as a result of rewiring work undertaken by their housing association. The work caused   considerable damage to the interior walls of the house and created a lot of rubbish which the    contractors failed to repair or remove. 5.8 The parent’s further explained that they were sleeping downstairs on the couch because of the work being done and this was planned to be a temporary measure whilst Ollie’s father redecorated the house room by room. He added that this was taking longer than he had anticipated due to the pressures of having a new born baby, and because lockdown had caused the house to be crowded. 5.9 The police  recorded that when they attended the family home on the 6th January there was no electricity or lighting. The parent’s explanation for this was that their pre-pay meter had just run out of money—which was an unusual situation. The parent’s denied that they might be struggling with bills or debt and said that it was just unfortunate that the electricity had run out when it did. Unfortunately, there is no record of them being asked about the absence of lightbulbs, or any     issues around possible debt being explored further. 5.10 It is clear that on the 6th January the home environment was unsuitable for the family to live in, and was a potentially dangerous place for the children to be. This is agreed both by the          professionals who visited the property that day, and by the parents themselves. There is no       evidence of neglect in any form having been reported previously which suggests that either the home conditions had not been witnessed by professionals, and other indicators of neglect had been Wirral Safeguarding Children Partnership                Page 10 missed, or the situation in the house on the 6th January was out of the ordinary. The latter       conclusion is the most supported, and reasons for the deterioration in the home conditions are explored in more detail below. 5.11 Apart from a previous recorded concern in 2015 there were no other recorded concerns by professionals and the family was not on any organisations safeguarding ‘radar’.  2. The effectiveness of safer sleep messages 5.12 Giving parents safer sleep messages has been an embedded part of practice in Wirral for a number of years. It is recorded in the Community Trusts chronology that safe sleep messages were shared with the family, including advice from the Lullaby Trust. However, it is clear that as the sleeping arrangements in the house were unsatisfactory, evidenced by the unused Moses basket downstairs and the mattress leaning against the bedroom wall upstairs, as well as the parents     decision to sleep with Ollie on the sofa, that the importance of safe sleep was either ignored or not understood by the family. 5.13 The dangers of parents co-sleeping with their infant children, and the tragic deaths of children as a result has been a consistent feature of Child Death Overview Panel activity for the last several years, and is often cited as the most common avoidable reason for infant death in Merseyside.  Consequently, local messaging and campaigns reinforcing safe sleep messages have a been a feature in Wirral and across Merseyside, including the Six Steps to Safer Sleep campaign. Safe sleep messag-es are typically given by health professionals such as midwives and health visitors and include a mix-ture of verbal messages and literature including leaflets, and branded resources such as forehead thermometers. 5.14  It isn’t known whether the safe sleep messages were followed up or reinforced,  or what   Ollie’s parent’s reasons were for not abiding by them. It is speculative to say that the parent’s    decision making was blurred by substance misuse, but given the evidence of cocaine in Ollie’s     system, it  cannot be ignored that this was possibly a contributory factor, in the same way that    using alcohol can result in poor decision making. 5.15 It is appropriate for the Wirral Safeguarding Children Partnership to review the effectiveness of local safe sleep messages and consider ways to consolidate the advice with families, perhaps through an update and publishing of a new Safe Sleep strategy. Any strategy must be informed by local parents about what type of messaging id the most effective for them.  3. Did professionals understand the additional stresses of parental mental health      and substance misuse, and did this compromise the safety of the children? 5.16  Both of Ollie’s parents had recently received treatment for depression and anxiety issues. Ollie’s father had been treated for anxiety and depression on and off since 2009. In 2019 he was diagnosed with panic disorder and referred for counselling. He also later reported to children’s   social care that his mental health declined following the loss of a close friend and concerns about his father’s health—who had recently suffered a stroke, and that this led to him using drugs as a coping strategy, although there is no reference to drug use or suspected drug use in any of the Wirral Safeguarding Children Partnership                Page 11 health chronologies, and Ollie’s father was not known to the local substance misuse service.  5.17 The logical conclusion to draw therefore is that Ollie’s father had not discussed his drug use with any professionals, and that there was no suspicion of his drug use amongst any professionals. It is not known whether discussion of the link between his mental health issues and drug use formed part of his counselling sessions, but no referral to other services followed.  5.18 In conversations with children’s social care several months after the incident with Ollie, his father said that he felt that his mental health had not affected his parenting and would not affect it in the future, even though parental mental health concerns are a known feature of compromised parenting, and this would undoubtedly be exacerbated by drug use. 5.19 In early 2020, a year after Ollie’s father was diagnosed with panic disorder, his mother       attended her GP and was diagnosed with anxiety and depression. In the GP chronology it is        recorded that Ollie’s mother complained about stress at home and poor school attendance by her eldest child. This tally’s with what the school were reporting about school attendance, but it doesn’t appear that the disclosure to the GP led to a referral to early help services, as might be expected. It also appears that there was no ’join-up’ between Ollie’s mother’s mental health     concerns and those of his father. It was advised, however, that Ollie’s mother should self-refer for counselling. 5.20 The following month Ollie’s mother attended a GP review, but did not attend any further    reviews. She later reported to children’s social care that she has never suffered significantly from mental health issues, and went to the GP about her mood, feeling low and having panic attacks. She added that she was given medication but reported that she did not take it due to finding out that she was pregnant.  5.21 Unfortunately, this information was not seen in the context of any other concerns, such as those expressed by the school, and missed appointments, which taken individually may not raise safeguarding concerns, but when seen together may trigger assessments or at least conversations between services and families. The downplaying by the parents of the potential impact on children’s welfare of substance misuse is very concerning, but perhaps driven by thinking it isn’t a risk if it  isn’t done in front of or near to the children. Unfortunately, as this case shows, parental drug     misuse presents drugs into the environment where they can be absorbed by children, as well as the impact they can have on poor decision making by parents. 5.22 Ollie’s father in his statement to the court, commented that he used cocaine on the 5th      January and considered whether he perhaps put Ollie’s dummy in his mouth or his bottle at any stage after administering cocaine onto his own tooth because of toothache but he added that he does not recall doing this.  5.23 After Ollie was born the parents had a new baby, a four year old, a five year old and a seven year old to look after which is a challenge for any parent for more so for those who already feel under pressure. This would have been exacerbated by the Covid-19 lockdown, particularly when the schools were closed, and the family were together for a prolonged period. However, during this time the family were not particularly on any agencies radar. Wirral Safeguarding Children Partnership                Page 12 4. Was disguised compliance was a feature of this case and did the Covid-19 crisis  impact on the circumstances of the family or on the capacity of services to         respond to their needs?  5.24 Ollie’s parents did exhibit some of the features of disguised compliance, for example they    listened to the safe sleep messages provided by the Community Trust but did not act on them, they cancelled appointments, but did attend some, and they claimed to be self-isolating—which may have been true, but if not was a plausible reason for not engaging with services.  5.25 It is an unfortunate side-effect of the Covid-19 pandemic that families became less visible to services—the majority of home visits ceased, and were cancelled or replaced with telephone or video calls. Services were subject to their own modifications, many of which in the health economy happened as part of wider efforts to support the Covid-19 response, particularly the vaccination programme. This inevitably led to some staff being redeployed and the knock on effect on frontline services.  5.26 All services also had to adapt to a general reduction in staff numbers, through infection with Covid-19 or isolation as part of strategies to prevent the spread of the virus. All of these    factors would give a greater opportunity for families who wished to avoid services to become less visible. 5.27 Most services, including the Local Authority and health services used risk assessments during the pandemic to identify the most vulnerable families who required the most attention, for example families with children on a child protection plan were prioritised for home face-to-face visits.   However, Ollie’s family didn’t fall into that category, and didn’t therefore receive the scrutiny that they otherwise might have.  5.28 In regard to the concerns about home conditions which declined around the time of the    pandemic, it is likely that the additional scrutiny brought by home visits would have raised concerns about the home conditions and may have triggered interventions and raised questions about what other issues might be facing the family, and  what other support might they might need.  5.29 The emergency services reported that Covid did not impact on their services. 5.30 It cannot be stated that the loss of visibility of the family due to the Covid-19 lockdowns    directly or indirectly contributed to the death of Ollie5.28 As described above there was at least one occasion when the family claimed to be self-isolating due to another family member having tested positive for Covid-19. However, prior to this they had cancelled or not attended meetings. These had been followed up by individual agencies but there weren’t enough concerns for any one agency to initiate a multi-agency process to share information.  5.31 Health  agencies have reported that due to the Covid-19 pandemic they are not delivering as many face-to-face services as before, but rather are holding meetings virtually and over the         telephone instead. Wirral Safeguarding Children Partnership                Page 13  Out of routine:  A review of sudden unexpected death in infancy ( SUDI ) in families where the children are        considered at risk of significant harm  6.1 The Child Safeguarding Practice Review Panel published a national review of SUDI5 in families where the children are considered at risk of significant harm in July 2020. Even though none of the children in this family were considered at risk of significant harm, or known to services, the findings of the national review are still relevant to this case because SUDI events represent one of the most common reasons why cases are referred to the Panel, and almost all of those incidents is caused by parents co-sleeping with infants in unsafe sleep environments, including those where parent’s had consumed drugs—as happened in this case.  6.2 A key question of the review was how professionals could best engage with and support      parents to ensure that safer sleep advice is heard, understood and acted upon. As stated            previously, Ollie’s case is not the first local incident where co-sleeping has had a tragic               consequence, and it does suggest that the way in which services engage with families, especially those who may be vulnerable, needs to be reviewed to ensure the safe sleep messages are as      effective as possible. 6.3 The review identified a number of risk factors which would make a SUDI more likely. These factors include: unsafe sleeping position; unsafe sleep environment—including co-sleeping; smoking during or after pregnancy; using alcohol or drugs; poor ante-natal attendance; poor post-natal care; low birth weight. Of the known risk factors, co-sleeping and drug or alcohol use are the most com-mon, and both were concerns in this case. Other factors such as poor ante-natal attendance, as part of wider non-attendance at health appointments were also features for this family. 6.4 The review added that social and environmental factors such as deprivation and overcrowding were known to increase the risk of SUDI, and that risk factors can be singular or add in combina-tion.  Since the publication of the review an additional pressure caused by lockdowns in response to Covid-19 has had a negative impact on families, both through the removal of families from the protective gaze of services, and the additional home life stress caused by families being forced to live in close proximity with each other for extended periods of time.  6.5 Both parents in this case had stated that home life was causing them stress and Ollie’s father said that this was exacerbated by the lockdown. 6.6 The review explored the effectiveness of local arrangements for promoting safer sleep, and therefore reducing the risk of SUDI, through feedback from a number of safeguarding partnerships across the country. The review found that local safer  sleep plans  were fairly  generic and  included  ___________________________________________ 5Out of routine:  A review of sudden unexpected death in infancy ( SUDI ) in families where the children are        considered at risk of significant harm. National Child Safeguarding Practice Review Panel July 2022: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/901091/DfE_Death_in_infancy_review.pdf Wirral Safeguarding Children Partnership                Page 14 promotion of breastfeeding, support for smoking cessation, key messages about the risks of         co-sleeping, briefing materials for professionals and promotional activities.  6.7 The review explored the effectiveness of local arrangements for promoting safer sleep, and therefore reducing the risk of SUDI, through feedback from a number of safeguarding partnerships across the country. The review found that local safer sleep plans were fairly generic and included promotion of breastfeeding, support for smoking cessation, key messages about the risks of         co-sleeping, briefing materials for professionals and promotional activities. All of these activities had been part of the Wirral strategy since the birth of the family’s first child, and continued to be the bedrock of ongoing local safer sleep work. 6.8 The national review concluded that such strategies can have mixed results, and parents often reported that messages were inconsistent and that materials were ‘too wordy’. Parents also said that utilising tools such as social media would help make the messages more manageable and would reinforce the key messages. 6.9 The national review did highlight good practice, including the use of high quality materials from the Lullaby Trust—although it did caution that the impact on families was reduced if resources were poorly printed, poorly presented or photocopied. Best practice was often achieved when safe sleep messages were part of a holistic public health strategy which included elements of supporting pregnancy and parenthood, alongside action to reduce health inequalities or poverty, whilst also identifying and simplifying access to early help and prevention services. 6.10 Since the incident which led to Ollie’s death, work in Wirral has continued to develop an easy to understand and easy to access early help and prevention system. This has included the develop-ment of the Family Toolbox, an online early help and prevention website for Wirral families, which allows them to directly access tools which can support parents and carers, details of people who can help, or places that parents can go for help, all without the requirement to be assessed or to reach a particular threshold, or to complete an application form. 6.11 The national review includes a proposed ‘prevent and protect’ practice model as a vehicle for developing and including local initiatives for preventing and reducing the risk of SUDI.                 Development of a local model in Wirral forms part of this review’s recommendations and will be informed by the key learning and recommendations from the Out of Routine report.       Wirral Safeguarding Children Partnership                Page 15 Strengthening Safeguarding Arrangements 7.1 It is the main aim of this review to help ensure that it is as difficult as possible for tragedies such as this to occur. This includes responding to the learning directly identified in this case, but also in considering whether the case ’shines a light’ on the strength of the wider safeguarding system.  7.2 This review has identified a number of concerns and stressors within the family, including poor home conditions, unsafe sleeping arrangements, parental mental health and parental substance abuse, as well as the impact of the Covid-19 pandemic and resultant lockdowns which removed the    family from the gaze of services.  7.3 The review advises the WSCP that the immediate and wider safeguarding system can be strengthened in the following ways. Response to neglect 7.4 Neglect of children is the main reason for another reason CSPR commissioned by the WSCP, and it is a major or contributory reason in a number of learning reviews undertaken over the past few years. A common finding in all the cases is the absence of, or the limited use of evidence based assessment tools such as the Graded Care Profile, or the objective assessment of home conditions. Recent recommendations from local reviews include development and publication of a new multi-agency neglect strategy, which itself includes guidance and tools for the early identification of     neglect, how neglect can be indicative of other issues, and pathways of support for families. 7.5 Professionals in this case did have evidence of poor home conditions and potential neglect and by exploring these in more detail may have become aware of other concerns. To support    strengthening of the safeguarding system this review will endorse the recommendations from the CSPR about neglect, and the learning from this case will be shared with the multi-agency steering group currently developing the neglect strategy. Recommendation: 7.6 For the WSCP and the Safeguarding Adult’s Partnership Board to work collaboratively to      develop and publish an integrated multi-agency Neglect Strategy. The strategy must include actions to improve the awareness, understanding, assessment, and response to neglect, and how neglect    interacts with, and is influenced by other factors including parental mental health and substance misuse. Safer Sleep strategy 7.7 Unsafe sleep is the main issue in this case which led to the death of Child Ollie. The report has already described how safe sleep safe messages are already bound in practice in Wirral, but how—cases such as this—suggest that they are not as successful as they need to be in encouraging safe sleep.  7.8 The ‘Out of Routine’ review includes a proposed ‘prevent and protect’ practice model for safe-Wirral Safeguarding Children Partnership                Page 16 guarding partnerships to adopt to help them develop a strategic framework to reduce the risk of the sudden and unexpected death of infants (SUDI). The framework includes a strategy to promote positive safe sleep messages as part of a more holistic public health strategy. Recommendation: 7.9 The report recommends that the WSCP reviews its approach to safe sleep messaging and SUDI prevention and creates an updated practice model based on the ‘prevent and protect’ model     suggested in the Out of Routine: A Review of SUDI in Families with Children at Risk report. The new model must be multi-agency and holistic in its nature and include the commissioning of        services to promote safer sleeping, a review of the current thresholds of need, review of relevant local processes, and development of the workforce Parental substance misuse 7.10 There was regular parental substance misuse taking place in the house by Ollie’s father, and Ollie and his siblings all had traces of cocaine in their systems. Ollie’s father could not explain why the children tested positive for cocaine but theorised that perhaps Ollie came into contact with it via his dummy if he had put it in his own mouth when using cocaine for toothache. It was also sug-gested that perhaps the other children came into contact with traces of cocaine on their father’s clothes. 7.11 It is clear that neither parent saw the use of cocaine as a potential safeguarding issue because it was never used when the children were around. It is also clear that agencies were not aware that Ollie’s dad was using cocaine around the time of his death and it was not something he had raised with services. Recommendation: 7.12 For the WSCP to work with substance misuse services to create awareness raising materials aimed at parents/carers warning them of the dangers of their own social drug use to their children and others in the same environment. The WSCP to also ensure that the wider workforce are aware of the issue through its substance misuse training. Testing of understanding by professionals should take place through the Section 11 process.   Hidden Harm and the legacy of the Covid-19 pandemic 7.13 The review strongly suggests that the issues facing this family were, to a lesser or greater     extent, hidden due to the lockdowns caused by the Covid-19 pandemic. As previously stated the Covid pandemic led to changes being made to the wider delivery of services, including health      services, resulting in the replacement of routine home visits with virtual visits and telephone     conversations. Families could also tell services that they were self-isolating (whether they actually were or not), and avoid face-to-face visits.  7.14 During the Covid period this family were struggling, as indicated by the decline in home     conditions, but services were not as sighted on the impact of the additional stresses brought by Wirral Safeguarding Children Partnership                Page 17 Covid than they would have been under ‘normal’ circumstances. It is impossible to say whether the Covid pandemic and resultant lockdowns indirectly contributed to the death of Ollie, but it is clear that with additional support the issues facing the family may have been able to be addressed. Recommendation: 7.15 For the WSCP to undertake a wider piece of local research to determine the impact that the Covid-19 pandemic and lockdowns has had on families with young children, and to consult with families to ensure that the universal and early help and prevention offer to families includes support for issues identified in the research and by families. Recommendation: 7.16 For  the WSCP to deliver a series of locality centred events for families including a market place of local services and access to advice and guidance, and for the WSCP to evaluate the impact of the events. Single agency learning 7.17 Each agency involved in the review should examine their own learning and ensure a robust plan is in place to improve their own policies, practice, procedures and guidance. Recommendation: 7.18 For individual agencies involved in the review to develop their own learning action plan and to share regular progress with the WSCP case review committee until all actions have been          completed.                   Wirral Safeguarding Children Partnership                Page 18 Summary of Recommendations  8.1 Six recommendations are made to the WSCP as a result of this review:  1) For the WSCP and the Safeguarding Adult’s Partnership Board (SAPB) to work         collaboratively to develop and publish an integrated multi-agency Neglect Strategy. The strategy must include actions to improve the awareness, understanding, assessment, and response to neglect, and how neglect interacts with, and is influenced by other    factors including parental mental health and substance misuse 2) For the WSCP to review its approach to safe sleep messaging and SUDI prevention and creates an updated practice model based on the ‘prevent and protect’ model suggested in the Out of Routine: A Review of SUDI in Families with Children at Risk report. The new model must be multi-agency and holistic in its nature and include the commission-ing of services to promote safer sleeping, a review of the current thresholds of need, review of relevant local processes, and development of the workforce 3) For the WSCP to work with substance misuse services to create awareness raising ma-terials aimed at parents/carers warning them of the dangers of their own social drug use to their children and others in the same environment. The WSCP to also ensure that the wider workforce are aware of the issue through its substance misuse training. Testing of understanding by professionals should take place through the Section 11   process.   4) For the WSCP to undertake a wider piece of local research to determine the impact that the Covid-19 pandemic and lockdowns has had on families with young children, and to consult with families to ensure that the universal and early help and prevention offer to families includes support for issues identified in the research and by families 5) For the WSCP to deliver a series of locality based events for families including a       market place of local services and access to advice and guidance, and for the WSCP to evaluate the impact of the events 6) For individual agencies involved in the review to develop their own learning action plan and to share regular progress with the WSCP case review committee until all actions have been completed.         Wirral Safeguarding Children Partnership                Page 19 Appendices 1. Partner organisations involved in the review 9.1 The following agencies participated in this rapid review: • Local Authority Children’s Services • GP  • Merseyside Police  • North West Ambulance Service • Wirral University Teaching Hospital NHS Foundation Trust • Wirral Community Health and Care NHS Foundation Trust • Grove Street Primary School (in respect of siblings)  9.2 A chronology of involvement, including key questions was submitted by each agency including analysis, identification of learning, and an assessment both of their involvement, and the effective-ness of multi-agency working. The minutes of the Acute Life Threatening Event (ALTE) meeting held shortly after the incident also informed the review.  2. References 9.3 Documents and resources referenced in the review: • Developed by the Social Care Institute for Excellence (SCIE), the Learning Together Method-ology provides a framework for undertaking Child Safeguarding Practice Reviews where the identification of learning to strengthen    safeguarding arrangements is key: https://www.scie.org.uk/publications/reports/report19.asp   • Out of routine:  A review of sudden unexpected death in infancy ( SUDI ) in families where the children are considered at risk of significant harm. National Child Safeguarding Practice Review Panel July 2022: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/901091/DfE_Death_in_infancy_review.pdf  • Pan Merseyside SUDIC Protocol: https://www.wirralsafeguarding.co.uk/wp-content/uploads/2020/07/SUDiC-0-18-YEARS-FINAL-23.6.2020.pdf  • Working together to safeguard children (2018): Statutory guidance on inter-agency working to safeguard and promote the welfare of children. https://www.gov.uk/government/publications/working-together-to-safeguard-children--2   David Robbins April 2023 Wirral Safeguarding Children Partnership                Page 20 