Unexplained injuries to an 11-week-old baby in March 2014. Baby N was moved to a place of safety before being placed with the maternal grandmother. The father, JB, had a child from an earlier relationship who was also removed from his care following injuries. Following the injuries to Baby N, JB was charged with neglect/ill-treatment. Father had a history of domestic violence and involvement with childrens services due to concerns about neglectful and abusive parenting. Issues identified: the failure of childrens services to conduct a pre-birth assessment based on concerns reported by the health visitors; significant delays in childrens services conducting an initial assessment once Baby N was born; health professionals seeing their safeguarding role as primarily passing on or responding to information from childrens services and an over willingness amongst professionals to accept what they were told by the parents. Uses a systems methodology to analyse practice. Recommendations include: frontline practitioners should be reminded of unborn baby procedures and specifically told that where a previous child of either partner has been made subject to child protection procedures a pre-birth assessment is required for all subsequent pregnancies; where Initial Assessments are undertaken, referring agencies should be informed in writing of the outcome of referrals so there is clarity between agencies about the rationale for the decisions taken and referral forms and guidance should make clear the expectation that referring agencies gather background information from their own records.
      
 Title:  Serious case review: Baby N. LSCB: Sunderland Safeguarding Children Board Author:  Date of publication: 2015  This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC.  This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above.                                      Serious Case Review    Baby N (The SSCB has used a pseudonym to protect the identity of the child and family)        Publication date  26 November 2015              Contents           Page   1. Decision to hold a Serious Case Review  (SCR)       3  2. Statutory Guidance          3  3. The approach used          3  4. Parallel Proceedings          4  5. Local Context           5  6. The Family’s Perspective         5  7. The Family as known to Agencies        6  8. Analysis of Practice         12  9. Summary          25   Appendix 1: Single Agency learning        26 Appendix 2: Recommendations for Sunderland Safeguarding Children Board    28 Appendix 3: Progress Report         30          1 Decision to hold a Serious Case review (SCR) 1.1 Baby N was born to parents JB and ST in December  2013. 1.2 In March 2014, when Baby N was 11 weeks old, unexplained bruising was found on the child’s abdomen. A skeletal survey revealed three healing fractures on ribs and another mid-clavicle fracture, possibly about 6-8 weeks old. Child Protection procedures were followed and Baby N was moved to a place of safety before being placed with the maternal grandmother.   1.3 JB had a child from an earlier relationship who, nine years previously, had been removed from the care of JB and his partner, following similar injuries to those found on Baby N. The view of the ‘Learning and Improvement in Practice’ Sub Committee was that the criteria for undertaking a Serious Case Review (SCR) were met and the Independent Chair of LSCB concurred with that view.  2 Statutory Guidance 2.1 A Serious Case Review 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.’ Regulation 5 of the Local Safeguarding Children Boards Regulations 2006 require LSCBs to undertake reviews of serious cases in these specified circumstances and to ‘advise the Authority and their Board partners on lessons to be learnt’  2.2 Statutory guidance requires SCRs to be conducted in a way that: • 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.   2.3 The guidance also stipulates that when undertaking reviews, LSCBs should ensure that frontline practitioners are fully involved in the process and are invited to contribute their perspectives without fear of being blamed for actions, which they took in good faith. Boards should also consider ways of involving family members and sensitively and appropriately managing their expectations.  2.4 The guidance is also clear that reports should be written in plain English and in a way that can easily be understood by professionals and the public alike.  3 The approach used 3.1 The review has used systems methodology supported by the use of short reports, and an integrated chronology from the agencies involved. An independent reviewer with experience of using a systems methodology and an internal reviewer from the LSCB were commissioned to lead the SCR process.    3.2 A Review Team of senior professionals representing the agencies that were or had been involved with the family was established. Their role was to provide a source of high-level strategic information about their own agency and their involvement with Baby N’s family through their contributions to the SCR process and through the submission of an Agency Learning Report. The Review Team, listed below, gathered and analysed data, appraised practice and agreed the content of this report.  Linda Richardson   Independent Lead Reviewer Lynne Thomas    Business Manager-SSCB Deanna Lagun   Head of Safeguarding Sunderland CCG                           (2nd Reviewer) Lay Member    SSCB    Lead Nurse Safeguarding   South Tyneside NHS Foundation Trust   (STNHSFT) Named Midwife  Safeguarding  City Hospitals Sunderland (CHS)    Strategic Manager  Sunderland Children’s Services1    Deputy Head of Safeguarding  Northumberland Tyne and Wear NHS Foundation      Trust    Detective Inspector   Protecting Vulnerable Persons Northumbria Police    Education and Schools Lead   Sunderland Council  3.3 Members of the Review Team also identified frontline practitioners and first line managers who were known to, or had worked with Baby N’s family.  These practitioners formed the ‘Practitioner’s Group’ and they met on three occasions. They offered important details about the family and also provided a rich source of information about local systems and multi-agency procedures and processes. In addition, they helped the Review Team consider the extent to which the findings from this review were typical of practice elsewhere across the authority.  3.4 Data was collected through the examination of single and multi-agency records and individual conversations with practitioners and their managers.  3.5 Taking a systems approach encourages reviewers to begin with an open enquiry rather than a pre-determined set of questions from terms of reference. This helps the data to lead the key issues to be explored as opposed to the preconceptions of managers or a review panel. However, key lines of inquiry for this review quickly emerged around the central importance of quality assessments and how these are monitored; how significant information is collected, analysed and shared between agencies and the extent to which professionals understood the link between past and future harm.  3.6 This review examines practice and decision making of key agencies between May 2013 when ST first became pregnant to March 2014 when Baby N was admitted to hospital and injuries to the baby were observed.  4 Parallel Proceedings 4.1 JB was convicted of the offence of Neglect and ill treatment in August 2014.                                                     1 Children’s Services membership of the Review Team changed three times during the review period, an issue picked up later in this report   5 Local Context 5.1 The Review Team were aware that this was the fifth Serious Case Review in Sunderland which related to the death or injury to a child under the age of 1 year old.  Multi-agency learning looking at frontline practice between 2012 – 2014 centred around:  a. The absence of good quality and robust assessments including assessments of parental abilities b. The lack of managerial oversight in Children’s Services  c. An absence of critical thinking when key decisions were made d. Evidence that frontline practitioners especially in Children’s Services, repeated errors previously highlighted in research and local reviews e. The impact on frontline practice of poor leadership and ineffective supervision practice  f. The absence of any robust performance management systems within Children’s Services g. Concerns that senior managers in Children’s Services did not ensure active and sustained participation by managers in SCR processes and how this impacted upon the depth and breadth of learning for that agency.  5.2 The Review Team shared concerns that the same lessons were being identified from each SCR with little evidence that changes were being embedded, quickly enough into frontline and managerial practices. As this SCR was nearing completion, Children’s Services was subject to an inspection by Ofsted and the findings from that inspection were of particular relevance to the findings identified in this SCR and which were related to that particular agency. Where the findings and required actions are similar these are noted and reflected in the report where appropriate.  6 The Family’s Perspective 6.1 The SSCB Business Manager and the 2nd Lead Reviewer met with Mother, ST, and Maternal Grandmother when the SCR began. They were keen to participate in the process but at the first meeting were unable to say how they could have been provided with any further support or advice from professionals. 6.2 Further attempts were made to make contact with these family members but they did not respond to letters or phone messages and so their perspective is sadly missing from this report.  6.3 The Lead Reviewer did however make telephone and email contact with the Paternal Grandmother who expressed distress at the fact that her son JB had not been given access to Baby N despite assurances by Children’s Services that supervised contact would be arranged. The Paternal Grandmother however felt she was unable to comment on professional involvement during the period under review. JB declined to meet or communicate with the Lead Reviewer and this again is a significant omission in this report.       7 The Family as known to Agencies 7.1 The Family2 Mother     ST  Father    JB (and also father to Child D) Baby N   11 weeks  (at the time of injury)  Child D Half-Sibling  (lives with Paternal Grandparents) under a Special Guardianship Order Mother of Child D   FL  Paternal Grandmother  PGM  Background Information prior to review period  7.2 Child D was born to parents JB and FL in September 2004.  7.3 At three months old, Child D was taken to baby clinic by JB. A bruise on the cheek and another on the baby’s arm was noted. The following week, the health visitor discussed the injuries on a home visit. FL said perhaps one bruise had been caused by a dummy and the other when the baby was being bathed.  The health visitor then noticed another mark - an elongated bruise on the arm and she immediately made a child protection referral. The child was admitted to hospital where a bruise on the child’s left ear was also noted. A skeletal survey showed healing fractures to the forearm and old fractures to the lower end of both shinbones.   7.4 Child D was placed with the Paternal Grandmother on a voluntary basis in December 2004 and following a child protection conference, was made subject to a Child Protection Plan under the categories of Neglect and Physical Abuse. In 2006, the Paternal Grandmother, was granted Special Guardianship3 of Child D and Sunderland City Council obtained a 12 month Supervision Order in respect of the child.   7.5 The CAFCASS report presented to the Review Team stated that both parents accepted they were the primary carers of Child D and as such neither could be excluded as the perpetrator of the injuries. The CAFCASS report also identified that concerns were raised at the time about domestic violence within the parental relationship, the lack of routines and Child D being cared for by multiple carers. In addition there were some concerns noted in relation to JB’s learning needs. 7.6 The specialist reports filed for court included the findings from a Consultant Paediatrician which stated that Child D’s injuries ‘occurred as a result of pulling and twisting forces applied to a limb and these injuries rarely follow accidental injury’.  The report concluded that the ‘infant had sustained repeated injury over time in the form of ……fractures and bruises’. A Psychological report was also filed which concluded that Child D would not be at risk in the care of JB ‘for short periods of contact’ but did not comment upon the risks of                                                  2 Names, dates of birth and some family details have been changed to preserve anonymity. The ages given are the approximate ages at the time of the injury to Baby N.  3 A Special Guardianship Order (SGO) is an order made by a Court appointing one or more individuals to be a child's 'Special Guardian'. It is a private law order made under the Children Act 1989 and is intended for those children who cannot live with their birth parents and who would benefit from a legally secure placement.   him sharing the same household as his child. At the time of the Final Hearing, JB was living with his parents who agreed to monitor his contact with his child. 7.7 Information recorded on Children’s Services information system (CCM) indicates that JB was later the subject of a Multi-Agency Risk Assessment Conference (MARAC) in 2008 and had a conviction for domestic abuse.   7.8 The Review Team specifically asked Children’s Services to review what was held on file regarding Child D and were informed that the same information as that provided by CAFCASS was on their system. Period under review: May 2013 – March 2014 7.9 In May 2013, ST presented for an antenatal booking appointment when she was 9 weeks pregnant. A ‘Vulnerability Assessment’4 was undertaken. ST advised that the father of her baby, JB, had “mild Aspergers”. There were no safeguarding concerns noted. 7.10 The ‘Vulnerability Assessment’ was received by the Health Visiting Team in late May and by ST’s GP in early June. Later that month, ST, at 16 weeks pregnant, was seen for a routine antenatal appointment and shortly after referred to the Family Nurse Partnership (FNP)5.   7.11 Despite contact with, and encouragement from, the FNP practitioner, ST was unwilling to engage with the FNP programme. The Review Team was told that not all parents agree to the intensive support offered, so this was not particularly concerning and health professionals did not consider that any additional agency involvement was required. ST attended for a routine antenatal scan in late July 2013. No safeguarding concerns were documented.  7.12 JB attended his GP in August 2013 with concerns about excessive sweating and weight gain after giving up smoking. This was a different GP practice to that of his partner ST. He was given smoking cessation advice and referred to a weight management and exercise programme. The GP records refer to JB as suffering from ‘anxiety/stress’ and although he rarely attended the practice, when he did, he was usually accompanied by his Mother, which the GP noted was unusual for a man of his age. The GP was aware of the previous child protection concerns related to Child D, but was unaware that JB was to be a father again.    7.13 In September 2013, ST attended a routine antenatal appointment with her midwife. No safeguarding concerns were documented.  7.14 After two no access home visits, in October, health visitor 1 (HV1) saw ST at home in early November 2013 for an antenatal assessment.  ST was excited about her pregnancy, despite it being unplanned. JB was present at this visit and the couple discussed the support they had from extended family members. They reported that they lived apart but that JB spent most of his time with ST when he wasn’t working. During this visit JB disclosed how he was bullied at school and labelled as ‘slow’ but was later diagnosed with ‘Aspergers Syndrome’.  He then disclosed that this had made it difficult to cope with Child D and the child had  later been placed in the care of his mother (PGM) as a result of being injured by  FL.  JB explained he had been too young to care for his child and had remained living with his parents. HV1                                                  4 These assessments seek to identify the potential needs of pregnant women who may be vulnerable and require additional services or support.  5 The Family Nurse Partnership is a voluntary home visiting programme for young mothers. A specially trained family nurse visits the parent on a regular basis, from early in pregnancy until the child is two years old.   explained to the couple that she had a responsibility to share this information with Children’s Services and JB said he understood why this information should be shared.  7.15 HV1 telephoned Children’s Services later that day and spoke to an ‘assistant social worker’, (ASW1). She was advised that there was information on the CCM system, which confirmed that JB currently had supervised contact with Child D and there were also references to domestic violence towards a previous partner. ASW1 confirmed she would discuss the information with the Operational Manager (OM1) and a strategy meeting would be convened. HV1 followed up this conversation with a formal Child Protection referral, which was faxed through to Children’s Services and copied to the Safeguarding Team in STNHSFT.  7.16 Following her referral, HV1 contacted the Delivery Suite at CHS and advised the Midwifery Team of her referral to Children’s Services and that if ST should attend the hospital over the weekend the Duty Social Work Team should be contacted before discharge was considered. HV1 did not have a verbal conversation with the Community Midwife regarding this referral, she did however copy her referral to the Safeguarding Team in CHS. 7.17 Later that day CHS Midwifery Services received a fax, out of hours, from SW1 indicating that a Section 476 investigation was to be undertaken. A partially completed birth plan was included. This advised that should ST’s baby be delivered over the weekend mother and baby should be kept in hospital until the Monday, when the Section 47 investigation would continue.  The fax advised that JB had a history of violence and was a risk to both mother and baby and also stated that Mother was to be informed that JB would only be allowed contact with the child under supervision by hospital staff.    7.18 Following her Child Protection referral the Health Visitor attempted to contact JB to discuss the referral. A message was left requesting he make contact with her. When he phoned back he was advised that a SW would be making contact with the couple to complete an assessment. During the conversation with the HV, she recalled that JB accepted that this would need to happen and he asked whether he would be assessed ‘like he was with his older child’.   7.19 Children’s Services records document that a few days later a   no -access visit was  made by SW1. This was followed up with a phone call to JB who advised that the Court Order related to Child D stated he could have unsupervised contact with his child. JB also informed SW1 that Child D had been injured not by himself but by the child’s mother, FT.  The SW arranged to meet ST and JB the following day. SW1 received a telephone call from Paternal Grandmother later that day which confirmed she was the carer of Child D, via a Court Order and there were no concerns regarding her son having unsupervised contact with Child D.  7.20 SW1 visited the family home and both JB and ST were present. The home was reported to be clean and warm. The couple were documented as being prepared for the birth of their baby and had support from their families. No concerns were documented regarding drug/alcohol misuse or domestic abuse. SW1 recorded that ST was aware of the circumstances regarding Child D, and JB confirmed the injury was caused by the child’s mother.  JB reported that he had regular contact with his child. According to Children’s Services records, the parents were informed that SW1 would contact the Police and if there were ‘no concerns to note’ there would be no further involvement by Children’s Services.                                                     6 Under the Children Act 1989, a section 47 investigation takes place where there is reason to believe a child or young person may be suffering or is likely to suffer significant harm.   7.21 ST saw her midwife for a routine antenatal assessment the following day. There is no record of any safeguarding concerns.  7.22 The chronology from STNHSFT recorded repeated telephone calls and emails to SW1 from the HV1. Although she was able to speak with SW1’s colleagues, she did not manage to discuss the progress of her referral with SW1 until the end of November.  Once contact was established, SW1 told HV1 that Children’s Services would not be taking any further action and the case was to be closed. She was advised that it was Child D’s mother who had caused the injury to Child D and JB had then assaulted the mother.  HV1 records state that SW1 said  that there was no risk to the baby and that ST was a protective factor. 7.23 HV1 accepted the decision of SW1, believing that the full history of Child D’s injuries had been accessed. She did not seek any advice or support from her safeguarding supervisor, as she had no reason to doubt that a thorough assessment had been undertaken.  She shared the information from SW1 with the midwifery team and also with ST’s GP later that day.  She reported that ‘SW1 has assessed the family and is taking no further action, but that health may need to offer additional support as necessary.’  7.24 In early December 2013, there was a review of the Children’s Services case file by a temporary Operational Manager (OM2). The records state that SW1 had undertaken one home visit and concluded that there was no role for Children’s Services.  OM2 however noted the health visitor’s concerns, contained in her November referral on 1.11.13 and decided that he and SW1 would prepare a genogram showing family relationships and SW1 would complete the Initial Assessment to ensure “that the correct conclusions are being drawn”. Children’s Services records show at this point, the Initial Assessment was already out of timescale.   7.25 ST did not attend a hospital appointment in December 2013, in relation to her anaemia.  The Community Midwife attempted telephone contact with both ST and JB to advise of the need to attend the Midwifery Day Unit for review and although several attempts at contact were unsuccessful, ST did eventually attend hospital and was successfully transfused. The midwifery involvement at this point focussed on clinical presentation with no safeguarding concerns identified.  7.26 In late December 2013, ST went into labour. The Midwife contacted the Children’s Services Out of Hours Team to advise that ST had been admitted and queried whether JB could be present for the birth. She was advised that the unborn baby was not subject to a Child Protection Plan and there was nothing on the system to suggest that JB could not attend the birth. As they had not been notified of any concern, the duty officer said there was no information to suggest JB could not be present at the birth.  7.27 Baby N was born the next day, following a normal delivery and bottle-feeding commenced. The 24 hour Postnatal Vulnerability Assessment was completed by ST’s Midwife and this was sent to ST’s GP and HV.  This document was not easy to read and was of poor quality, but it stated that Baby N could go home with Mum, but JB was not allowed unsupervised access, due to ‘previous concerns of violence’.  7.28 On the 21.12.13 prior to discharge, the Midwife contacted SW1 to clarify discharge arrangements. She was advised that mother and baby could go home, and although JB was not allowed unsupervised access, ST was considered a protective factor for Baby N. Mother and Baby N were subsequently discharged home.    7.29 ST and Baby N were seen on six occasions by the Community Midwife between postnatal day 3 and 11, five of these visits took place at home and one visit took place at clinic. Baby N was noted to be well, although slightly jaundiced. Both parents were present during the day 8 visit and were reassured about Baby N’s general development. No safeguarding concerns were identified.  7.30 On day 11, HV1 contacted SW1 requesting clarity on supervision arrangements regarding JB after receiving information from the hospital about the birth and JB not to have unsupervised contact; she was advised that he was allowed unsupervised access and SW1 was reported to state she didn’t know why  hospital midwives thought otherwise.  7.31 Baby N was seen again by the Community Midwife on day 13, no concerns were recorded. HV1 undertook her primary visit to mother and Baby N on the same day. JB was feeding Baby N in the bedroom when she arrived. Both parents were noted to interact well with Baby N. JB questioned the HV about safe handling as he felt he had to be careful after what had occurred with Child D.  The HV appropriately advised the parents about safe sleep arrangements and highlighted the risks and dangers of shaking babies. It was agreed that she would return in 2 weeks. The family were noted to be ‘level 2’ which meant they required  additional support from health services. 7.32 In January 2014, a new and permanent Children’s Services Operational Manager (OM3) joined the team and found that despite SW1 being instructed to complete and close the Initial Assessment, it was still showing open and incomplete on the system. In response to concerns about work with this and other families, SW1 was made subject to disciplinary proceedings and was later dismissed from the authority. OM3 then instructed a SW (SW2) to prioritise the completion of the Initial Assessment and report back the following week to ensure that closure of the case was still the correct option. The Review Team was informed that due to a back log of open cases, Operational Managers were being told by their service leads, to review the open cases and where it was ‘safe’ to do so, close as many as possible on the system. The instruction to SW2 was in line with this strategy.  7.33 Baby N was seen at 18 days old by the Community Midwife and reported to be well and gaining weight.  ST was documented as looking pale; however she said she was feeling healthy and felt well supported by JB and extended family. The Midwife arranged to return in one week. 7.34 HV1 visited ST at home mid April.  Baby N was described as ‘clean and well-dressed’. JB was also present and described as responding to the baby well.  The couple informed the HV that they were looking for a new home together.  JB also advised that he was looking for a new job, as he wasn’t being treated fairly in his current position.  HV1 advised that Baby N should be taken to see the GP regarding a rash and ST took Baby N to the GP 6 days later.   7.35 At the end of January 2014, Baby N was seen by the Out of Hours GP when parents were concerned that the baby was unsettled all day and crying more than usual. Colic was thought to be the problem and the parents were advised to use gripe water. Baby N was taken to the Baby Clinic the following day where the baby was stripped and examined which is usual practice, and was noted to be gaining weight. No concerns were identified. 7.36 HV1 undertook a 6-8 week assessment at the end of January 2014. ST was noted to handle her baby gently and was documented as having increased confidence with her baby, reporting that she ‘loved being a mam’. ST discussed the consultation with the OOH GP a few days earlier, stating she had used the gripe water and that Baby N had settled after a bowel movement. HV1 reinforced previous advice on safe sleep; recording that Baby N   slept in a Moses basket. No safeguarding concerns recorded.  The parents were invited to ‘baby days’ and a referral was made to the nursery nurse for baby massage. The HV reviewed her assessment of the family’s needs and downgraded the support needed to level 1 – universal services.  7.37 In early February 2014, ST attended her GP for her 6-week postnatal check and she was referred to the practice nurse for a contraceptive injection. No concerns were identified.  7.38 HV2 saw Baby N at the baby clinic in mid-February. Advice was given about increasing the amount of formula feed offered. HV2 contacted the named HV, HV1, regarding the clinic attendance. Nothing of concern was noted. From mid-February the nursery nurse visited the family at home to demonstrate baby massage techniques and support both parents in using these techniques.  ST advised that they had found a new home and would be moving house in the next few weeks. 7.39 In mid–February, SW2 contacted HV1 by telephone and was updated on the progress that had been made by Baby N and both parents. The HV confirmed she had no concerns about the care of Baby N and agreed to the case being closed to Children’s Services. On the same day Baby N was taken to the GP surgery and the first vaccinations were given. 7.40 In early March 2014, the nursery nurse visited the family home, and saw Parents and Baby N. They were advised to talk and sing to their baby, and leaflets were left with them.  The nursery nurse noted that Mum maintained good eye contact with her baby.  The Parents were still awaiting the keys for their new property. 7.41 The following day a case note was entered onto the CCM system by OM3 in Children’s Services, stating that the previous SW had not completed an Initial Assessment as advised, so SW2 had been in contact with professionals involved with the family and as there were no concerns, the case would be closed.  7.42 On the 6th March 2014, the day after the above was recorded, Baby N was taken to the Baby Clinic by ST early morning, accompanied by a female friend. The HV at the clinic (HV3) noted an unusual bruise to the baby’s abdomen. ST could not explain how this might have occurred but wondered if the marks could have been caused by her nappy or by her acrylic nails.  ST advised nobody else lived in the family home and that they had no pets. HV3 advised ST that as Baby N was immobile she would have to refer the baby to a Paediatrician and to Children’s Services. ST became upset at this point and said she would not ‘batter her baby’. HV2 tried to contact Children’s Services but the phone kept ringing out and then cutting off. A verbal Child Protection referral was eventually made to a call handler and HV3 requested an urgent response.  7.43 HV3, who did not know the previous history of this family, recognised that Baby N needed to be seen by a Paediatrician, because of a possible ‘non-accidental injury’. Due to the difficulty in contacting the duty SW, she requested that ST take Baby N straight to hospital and explained the need for a paediatric assessment with a Consultant Paediatrician. ST cooperated and took Baby N to hospital by public transport, accompanied by her friend and PGM. HV3 advised the Paediatric Emergency Department that she was sending Baby N in for a paediatric assessment and subsequently spoke to the Paediatric Liaison Nurse to ensure that the baby had been brought into hospital.   7.44 The Consultant Paediatrician, after examining Baby N also made a Child Protection Referral to Children’s Services. A strategy discussion was held between Police and Children’s   Services and a Section 47 Investigation commenced. A SW  (SW4) subsequently attended the hospital where the baby was seen in the care of ST, JB and PGM.   7.45 Baby N was admitted to a paediatric ward where further investigations showed multiple healing rib fractures, and a healing fracture of the left clavicle. The injuries were not compatible with the explanations offered by parents. Hospital staff were advised by the SW that Baby N should not be removed from the hospital by any family member and should they try, then security or police and Children’s Services should be informed. 7.46 During subsequent enquiries, JB questioned whether the harness of the car seat being too tight could have caused the bruising. He again stated that the injuries sustained by Child D were caused by Child D’s mother. Police records indicate that Police Powers of Protection were taken in early March and Baby N was discharged from hospital into a foster placement.    7.47 In mid-March 2014, SW4 contacted HV1 with an update; JB said he had fallen over when holding Baby N and the baby had fallen onto the arm of a chair. ST was reporting that she knew nothing of JB’s previous history and that the couple had subsequently separated. HV1 advised that ST had been present when JB had disclosed the circumstances around the injuries to his first child.   7.48 The Crown Prosecution Service took a decision in April 2014 to charge JB with neglect/ill-treatment. 8 Analysis of Practice   8.1 It is important to recognise how much hindsight can distort our judgement about the predictability of an adverse outcome.7 It should be appreciated that the prediction of events is not a straightforward matter; nevertheless it is important for any review to examine what happened and why actions and decisions may have made sense at the time.  8.2 The examination of single and multi-agency working leading up to the injuries sustained by Baby N has identified some single and multi-agency learning alongside some important reflections about partnership working. The analysis is structured around three specific areas of practice (ASP) listed below and further details follow.  ASP1:  The response of Children’s Services to the Health Visitor’s referral and the Initial Assessment undertaken in November 2011  ASP 2:  The extent to which professionals understood their safeguarding responsibilities  ASP 3: Supervision and Managerial Oversight ASP4: The SCR process  8.3 ASP 1:  The response of Children’s Services  to the Health Visitor’s concerns  The information provided to Children’s Services by HV1 on November 1st 2013 should have prompted a pre-birth assessment in line with the Unborn Baby Procedures. This would have highlighted that the injuries sustained by Child D as a baby indicated a potential risk to Baby N. A pre-birth assessment was not however undertaken.  8.3.1 The Unborn Baby procedures in Sunderland clearly state that where a previous child has been made subject to child protection procedures, a pre-birth assessment is required for all                                                  7 Munro (2011: 1.14)   subsequent pregnancies. This is to ensure that any known or perceived risks are properly analysed and assessed within a multi-agency context, so babies who may be vulnerable are better protected and support can be targeted to parents who may be struggling.    8.3.2 The information in the Child Protection referral from HV1 to Children’s Services clearly highlighted information about past history, and this was corroborated by ASW1 when she accessed the Children’s Services system. This information stated that Child D had sustained unexplained injuries whilst a baby and had been removed from the care of JB and his then partner, FT.  HV1 was told ‘the referral would be passed to her team manager and there would be a ‘strategy meeting’. Although this decision was one which should have been taken by a qualified social worker and not an ASW,  the  course of action, proposed by ASW1 was correct and in line with the SSCB multi-agency procedures.   Her response to HV1 indicates that she had been able to access historical information relating to previous events with Child D.  8.3.3 HV1 appropriately contacted maternity services and was advised that should ST give birth over the weekend, the Duty Social Worker in Children’s Services should be contacted in order that a discharge meeting could be held. The midwives who attended the Practitioner’s meetings informed the Review Tea that where concerns about a baby have been identified, this would be their usual practice.   8.3.4 Children’s Services records indicate that the referral was passed to a locality team but despite the information given and the procedures in place at the time, no strategy meeting or pre-birth assessment was discussed or initiated. SW1 was allocated the case and asked to undertake an Initial Assessment. The Review Team could find no evidence that SW1 accessed Children’s Services records relating to Child D, either  before or after her meeting  with JB and ST and consequently, the significance of historical information was lost.   8.3.5 Clearly, there was concern on the part of Children’s Services and given that ST was then about 34 weeks pregnant, the need to act quickly was recognised. Although not documented in Children’s Services records, the labour ward received a fax from SW1 advising that a ‘s47 Enquiry’ was underway. The fax included a partially-completed birth plan advising that should the baby be born over the weekend, JB should not be allowed unsupervised contact and mother and baby should be kept in hospital until Monday morning. The Review Team was of the view that SW1 was unclear about what type of assessment she was being asked to complete and why, but as both she and the Operational Manager (OM1) have now left the authority, the Review Team was unable to explore this further and were left to examine the details through records made at the time. 8.3.6 The partially completed birth plan was not discussed with any health professional and the ‘instruction’ was unhelpful; hospital staff have no authority to insist that a mother and baby stay in hospital. The Review Team were informed that there is often a misconception by social workers that staff on maternity or neonatal wards generally ‘supervise’ parent/child interaction, but unless this part of an agreed multi-agency  ‘safety plan’, they have neither resources nor capacity to undertake this role over a longer period.     8.3.7 The fact that such a direction ‘in relation to an unborn baby’ needed to be given should have alerted professionals to the Unborn Baby procedures and also reminded health professionals of their own agency guidance in place at the time.8  Although aware of the procedures, neither SW1, OM1 or any of the health professionals were familiar with the detail of these procedures and they did not refer to them to support their actions and decisions.  8.3.8 The reference to ‘s47 enquiries’ and ‘strategy meeting’ gave the impression to midwives on the delivery ward and to HV1 that child protection enquiries were underway. The Review Team was advised that the health professionals believed any concerns about risk to the unborn baby would be encompassed in those enquiries  ‘in line with SSCB procedures’  and so they did not challenge the absence of a pre-birth assessment.  8.3.9 The fax from Children’s Services to the labour ward was received outside normal working hours and the ‘incomplete birth plan’ was not shared with the Named Midwife or the Community Midwife as is normal practice during ‘office hours’. It would be expected that existing communication protocols would refer to the importance of the timely sharing of information with key personnel as soon as possible on the next working day. This did not happen. Neither did staff on the labour ward seek any support or guidance from the Named Midwife who has considerable experience in developing or challenging the content and appropriateness of birth plans. The Review Team was informed that as staff believed that Children’s Services were involved there was no further action required on their behalf.  The procedure for sharing information received by the labour ward including that received out of hours has now been reviewed and strengthened. Finding: Children’s Services staff and health professionals were unaware of the specific detail of the Unborn Baby procedures and the failure to follow these led to a single agency assessment which had unintended consequences.  Recommendation 1 a. SSCB should seek assurance from partner agencies that frontline practitioners have been reminded of the Unborn Baby procedures and specifically informed that where a previous child of either partner has been made subject to child protection procedures, a pre-birth assessment is required for all subsequent pregnancies. (See 5.2.d of the Unborn Baby Procedures) b. SSCB should ensure that this message is clearly conveyed in multi-agency training programmes, where appropriate.   8.3.10 The Review Team was unable to evidence that Child D’s records were accessed before or after the home visit undertaken by  SW1 in early November and it is assumed, therefore, that JB’s narrative of what happened to Child D, was accepted without question by SW1. The Review Team has not received any information to indicate that the police information was                                                  8 Joint Guidance for the Supervision or restriction of Parental/Carer Contact to Babies and Children Admitted to Paediatric Wards where there is Actual or Suspected Deliberate Harm to a Child. (Revised 2015)    requested to support the assessment being undertaken. There does not appear to have been any discussion between SW1 and her Team Manager (OM1) regarding the Unborn Baby procedures and there is no evidence to suggest there was any managerial oversight by OM1  at the time, in relation to the assessment  undertaken.     8.3.11 OM1 left the authority and was replaced by another temporary operational manager (OM2). Almost 4 weeks later, OM2, reviewed the information gathered for the assessment and noted the details of HV1’s referral, Children’s Services records state that he  wanted to be sure that ‘the correct conclusion had been drawn’. Records indicate that he and SW1 would prepare a genogram and SW1 would complete the assessment, which was already well outside the 7-day timescale. This work was however never completed. The Review Team commented that even if SW1 had not understood the significance of historical information or the need for a pre-birth assessment, her manager should have been aware of their importance and the need to follow SSCB procedures.  OM2 was an interim manager but nevertheless should have been aware of the Unborn Baby procedures.    8.3.12 Following her referral, HV1 made several unsuccessful attempts to contact SW1 to find out the outcome of the assessment, but she was unable to make contact until the end of November. She accepted without question, the decision that there was no role for Children’s Services, believing that  information about Child D’s injuries had been accessed and a full  assessment  had been undertaken  by SW1 to inform the decision taken.  HV1 was not however given  information about the circumstances of the injury to Child D; the age when injured, or the injuries sustained by the child  as a baby and neither did she ask for this information.  The Review Team was told that HV1 had no reason to doubt that a thorough assessment had been undertaken and there was therefore no need for any discussion with her Safeguarding  Team and she did not inform them of the outcome of her referral.  8.3.13 At this point, the only information given to HV1 was what she was told by SW1 and she  did not receive any written confirmation relating to the outcome  of her referral. The Review Team was told that despite statutory guidance,9 it is not common practice in Sunderland for referring agencies to be sent  copies of Initial Assessments or to be given detailed feedback in writing. The Review Team concluded referring agencies need to be informed in writing about decisions taken in response to their referrals so they can better understand and where necessary, challenge,  the rational behind the decisions taken.   Finding: If the outcome of Children’s Services assessments and the decisions taken are not confirmed in writing to referring agencies, then the rational and understanding for those decisions is diminished. Even with busy schedules and increasing workloads, it is not only good practice to communicate key decisions in writing; it enhances partnerships working and engenders a sense of collaboration between professionals.10                                                      9 Working Together to Safeguard Child 2015 10 http://www.scie.org.uk/publications/guides/guide34/   Recommendation 2  SSCB should ensure that where Initial Assessments are undertaken, referring agencies are informed in writing of the outcome of referrals so there is clarity between agencies about the rationale for the decisions taken.   8.4 ASP 2: How professionals understood their safeguarding responsibilities   In a non-collaborative, stressful working environment there is always a risk that professionals defer too readily to colleagues in other agencies who they believe have greater knowledge or more experience than them and this makes challenges more difficult and less likely to take place.   8.4.1 The need for effective multi-agency working and information sharing in order to secure improved safeguarding outcomes is clearly stated in a number of reviews, policy documentation, and statutory guidance.11   8.4.2 Whilst the midwife noted at the booking appointment information regarding JB’s diagnosis of Aspergers there was no exploration of how this may impact on his parenting capacity, nor was any contact made with his GP (his GP details had not been recorded at this appointment). At this time there was no requirement for midwives to link with paternal GPs or share vulnerability antenatal or postnatal assessments. JB’s GP held relevant information about his previous involvement with Children’s Services, MARAC and his medical history - generalised anxiety disorder - and having met the criteria for an autism spectrum disorder. Following this review, midwives now routinely contact a father’s GP where the father’s details are  provided and/or asked about. The Review Team were informed further work is being undertaken with GPs to improve partnership arrangements with midwives.   8.4.3 JB shared details with HV1 about Child D and the circumstances under which the child was removed from his care, several years previously. HV1 understood the significance of what she had been told and appropriately contacted Children’s Services, but did not pursue enquiries within her own agency to find out what had happened, for example by contacting the School Nurse for Child D or her Safeguarding Supervisor.  School Nursing records  held substantial information about Child D but HV1 did not consider the need to access this information as she  was referring  relevant information to Children’s Services and later,  when informed that a strategy meeting was to take place,  she saw no need to access the health information held by her own agency. HV1 also reflected that she had believed that JB was being truthful and had given her accurate details and therefore saw no need to be ‘curious’ about what she had been told.    8.4.4 There was some discussion in Practitioners’ Meetings about the extent to which health professionals should check out what was known in their own agency about what had happened to Child D. It was acknowledged that their own systems, had they been accessed, would have produced relevant background information  as  Child D was a Sunderland child. The view was expressed again that knowing Children’s Services were undertaking an                                                  11 http://www.nfer.ac.uk/publications/MAD01/MAD01.pdf   assessment reassured health professionals that background information would automatically be checked, although how health information would have been accessed without their assistance remains unclear.   8.4.5 The Review Team was told there is still confusion about what information can be shared and when, and accessing information from GPs remains a particular challenge. There was a helpful discussion about gathering information from pregnant women about fathers and this is reflected in the single agency learning identified by STNHSFT and CHSFT. In relation to JB, his GP had information that was very relevant to the Initial Assessment, but this was not accessed by health professionals and neither, significantly, by SW1.  Finding: If professionals do not access their own agency records for background information when informed that a child known to them is the subject of a child protection or  a child in need referral, important information can be lost or not accessed and this can leave children vulnerable.  Recommendation 3 SSCB should review how the existing referral forms and guidance notes make clear the expectation that referring agencies gather background information from their own records to support child protection/ child in need referrals or the assessments that follow.  8.4.6 It became clear in individual and group discussions that health professionals in this review saw their safeguarding role primarily as passing on or responding to information from Children’s Services, as the “lead” statutory agency. They were of the view that they had fulfilled their safeguarding responsibilities in terms of sharing information, following up the outcome of the Initial Assessment and being persistent in pursuing Children’s Services for information  8.4.7 Once they had been informed that the assessment had been  undertaken and no risks to Baby N were identified, the health professionals acknowledged, that they saw no need for them to take any additional actions to safeguard unborn Baby N. It is at this point that the training and experience of health professionals, should have led them to be more curious about the outcome of the assessment given that a previous baby had been injured whilst in the care of a parent with whom they were currently working.   8.4.8 Whilst HV1 and later, midwifery services, repeatedly contacted Children’s Services regarding outcome of the assessment  and  the contact/supervision arrangements, neither agency raised the issue of non-compliance with the procedures with their Named Professionals. The Review Team was told that the midwives and health visitors were unaware of the details of these procedures but assumed that if they were relevant Children’s Services, as the ‘lead’ agency would have advised them accordingly.   8.4.9 The question was asked about what stopped them being more curious about what had actually happened. Health professionals explained that competing demands for time and   heavy workloads did not always allow them times to be ‘curious’, other than for families where there were emerging concerns or where safeguarding was already an identified issue. Health professionals described significant staffing issues during the period under review and the need to respond to a growing number of families with child protection concerns. These factors were felt to significantly impact on their workloads and influence what tasks they addressed and what they felt should be undertaken by partner agencies.   8.4.10 It was questioned in the Practitioners’ Group whether Children’s Services should be challenged given they were the ‘experts’. It was felt that they had to ‘trust’ their social work colleagues if they were told by them that checks had been undertaken and assessments concluded. The Review Team acknowledged these comments but are of the view that this approach clearly places the responsibility for ‘safeguarding children’ onto Children’s Services and did not reflect current thinking that every agency has a role to play in keeping children safe. Whilst the health professionals acknowledged this, it was pointed out that had there been safeguarding concerns noted, i.e. new or emerging issues, their practice may have been different.   8.4.11 Health professionals saw no reason to be concerned when told the assessment had been concluded and Children’s Services would have no further involvement. Careful parenting had been observed and the parents were engaging with professionals. Nevertheless, this was a family where a previous baby had sustained unexplained injuries and professionals needed to be both mindful and probing about that fact. Whilst it is not the responsibility of health professionals to do the ‘job’ of their social work colleagues, they are experienced practitioners and their knowledge and expertise should at least have led them to ask more details about the injuries to Child D and the role of JB. Had they questioned, sought appropriate advice they may have been supported to question the view that ‘there were no risks’ to Baby N, and the poor practice of SW1 and lack of managerial oversight might have come to light much earlier. However, in times of increasing workloads and busy schedules, the views were passionately shared in the Practitioners’ Group that the responsibility for challenging and addressing poor practice lay within the management structures of Children’s Services.  8.4.12 Between November and December, information from Children’s Services to HV1 and the Midwifery Team was confusing and contradictory but ST and Baby N were sent home without a discharge planning meeting. This was a missed opportunity, which could have been used to clarify the position regarding JB and supervised contact.  It was apparent that midwifery were still concerned about the information contained in their hospital records and contacted SW1 to check that it was safe for baby to be discharged home with Mum, however no support was sought from the Named Midwife.   8.4.13 The Community Midwife did not question information about contact when the Mother and baby returned home and, despite JB being present during at least one of the post-natal visits, did not clarify or discuss how ST was supervising her Partner’s contact with their child. There   was no meeting or telephone contact between the Community Midwife and Health Visitor around the supervision arrangements and no contact made with either ST’s or JB’s GP.  8.4.14 The confusion and misinformation around ‘supervision and access’ did not spark any concern from health professionals nor did it signal a need to refer this issue onto their Safeguarding team. HV1 did clarify supervision arrangements prior to her primary visit and again was reassured by Children’s Services that none were required; this was not shared with the Named Nurse or her team within STFT.  8.4.15 During later meetings with practitioners there was discussion about roles and responsibilities. Practitioners shared with the Review Team their frustration with colleagues in Children’s Services who did not return calls, meet timescales, or respond appropriately when they raised concerns. They were aware of how busy everyone was but stressed they too were working under pressure and could not spend their time always tracking progress of referrals or concerns.   Finding:  What is seen as consistently poor performance of Children’s Services has resulted in a loss of confidence by professional colleagues and this has a significant impact on partnership working and seriously compromises multi-agency working. This issue was identified in the recent Ofsted report.  Recommendation 4  SSCB should consider how it might facilitate improvements in working relationships between professionals  and so  enhance multi-agency practice.   8.4.16 Whilst there was an acceptance that all agencies had safeguarding responsibilities to ensure that practice within and across agencies was robust and to challenge where accepted standards were not met, health professionals in the practitioner’s group continually stressed that they had no concerns about the care of Baby N. Children’s Services was not however  the only agency holding information about what actually happened to Child D; whilst the facts surrounding the unexplained injuries on Child D were not shared by SW1, the information would have been available  from the school health Child Records had the HV1  liaised with her School Nurse colleagues. It was not until much later the review process that health professionals recognised the similarities between the injuries of Child D as a baby and Baby N.  8.4.17 The decision to allow the Baby to be taken from the clinic by her Mother was potentially unsafe and a Consultant Paediatrician appropriately advised HV3 that she should have ensured that the Baby remained in clinic until a SW arrived. Later that day the HV discussed the day’s events with a Safeguarding Supervisor and understood that she should have considered alternative arrangements to transport Baby N to hospital, for example by discussing with the police, given she was unable to speak to a SW. It is unfortunate that she did not consider liaising with her Safeguarding Supervisor or the Named/Lead Nurse in STFT at a much earlier point about the difficulties she was having in contacting Children’s Services.   HV3 accepted these comments and shared the difficulty in managing such a sensitive issue in a clinic full of other parents and with no easy access to a private room. During the individual conversation with HV3, she advised she was relatively new to the Sunderland area and did not have access to the SSCB procedures in the clinic setting. She had to arrange support from her colleagues to relieve her from her clinic responsibilities and returned to her office to complete the necessary paperwork and fax it to Children’s Services. She had reflected on her actions and recognised earlier support from the STFT Safeguarding Team should have been sought to ensure all aspects of the referral and medical management were safely considered.  8.4.18 SW2 advised the Review Team that she saw her responsibility as responding to her Manager’s instruction to check with the Health Visitor before closing the case and she did just that and no more. She did not check the background files for Child D and clearly did not access the incomplete Initial Assessment. She described how the Team were under considerable pressure at the time and she just did as she was told. The Review Team were concerned at this response from SW2 as it suggested a lack of confidence in being able to challenge her Manager about what she was being asked to do, but it also highlighted that from a professional perspective, SW2 demonstrated poor practice in closing a case on file without reviewing records or checking that all that should have been done to ensure the safety and welfare of a child had been done.   8.4.19 The case was closed without any challenge from HV1, although it is difficult to determine on what grounds HV1 could have argued for it to remain open. Although the couple were moving house to live together, HV1 did not share this information with SW2 and clearly did not think of it as the ‘significant’ event it was.  The Review Team were of the view that this information would have been highly unlikely to have impacted on the decision to close the case, given the circumstances under which that decision was taken.    8.4.20 HV1 did identify that she could recall having a ‘gut’ feeling about ST and Baby N. In conversation, HV1 said she couldn’t clearly identify what was troubling her and knowing that Children’s Services were closing the case, felt she had no strong evidence for her ‘feeling’. She therefore agreed to the case being closed. Had she been aware of the circumstances  and nature of the injuries sustained by Child D, HV1 said she would have pursued  this  instinct further. HV1 also indicated that with hindsight, it would have been useful to share her feelings with her safeguarding supervisor as this may have offered an objective pair of eyes to help her step  back and review her thinking.  In practitioner meetings, the challenge of knowing when  and whether to seek support for concerns which don’t meet the child protection threshold was acknowledged and views expressed that this was often made more difficult by the fragility of relationships and lack of confidence  in  other agencies.   8.4.21 The Review Team were left with a sense that professionals in this review had a narrow view of their safeguarding responsibilities. In the present climate,  however health professionals found it difficult to accept that their safeguarding responsibilities extended beyond sharing or responding to information or in the case of SW2, doing more that they were told. This   perspective can leave children vulnerable but also highlights the vulnerabilities of a multi-agency system designed to safeguard children.    8.5 ASP 3: Supervision and lack of effective management oversight;  During this review it was revealed that there was not a thorough understanding by frontline professionals and managers of the Unborn Baby procedures. The initial child protection referral was shared with the safeguarding  team  in STNHSFT and  CHSFT  but neither they nor the Operational managers in Children’s Services picked up the significance of the information shared.   8.5.1 Whatever the state of their work environment, frontline practitioners must constantly assess situations and make judgements while working on their own or in teams. However, supervision sessions should both support and challenge practitioners - helping them to avoid the temptation to slip uncritically into either an analysis skewed by bias and unfounded assumptions, or simply defaulting to an entrenched ‘agency view’.   8.5.2 The Review Team were informed that the experiences of supervision and managerial oversight varied across agencies; in health settings high caseloads often meant only higher risk (i.e. Child Protection) families were discussed, whilst in Children’s Services, supervision depended on other pressures and too often sessions, at that time, were cancelled or led by agency workers who were not familiar with local procedures. The lack of robust supervision arrangements for social workers and concerns about management oversight were highlighted in the recent Ofsted report.  8.5.3 In the professionals’ meetings, health professionals were varied in their responses to  when and under what circumstances  they would  contact their Safeguarding Team s or Named leads where concerns did not reach the child protection threshold.  The Named  Professionals provide a statutory role for their employing organisations and are expected to function at level 4 competency as outlined in the Intercollegiate Guidance, 12Health Visitors and Midwives must demonstrate safeguarding children competency at level 3 and this requires them to use their professional judgment  when making safeguarding decisions. The Health Visitor complied with her agency’s safeguarding procedures by copying the Safeguarding Team, Midwifery, and the GP into her child protection referral in November, she did not however advise  the outcome of that referral.   8.5.4 It is usual practice that when a child protection referral is copied into the  Safeguarding Team at  STNHSFT, a safeguarding advisor reviews the information and  checks for any additional information  on the system which may support the frontline professional.  Using a tracking tool, there is usually a follow up with the referring professional after 5 days  to monitor progress if they have not been informed by the referring professional. Where a referral remains  outstanding with no recorded outcome,  the tool  is used to alert the safeguarding advisor/referring professional for the need  for  remedial action. It became evident in this                                                  12 /Safeguarding Children Roles and Competences for Healthcare Staffed    review that the absence of any follow  up from the safeguarding team in  STNHSFT in relation to the  referral  was directly linked  to capacity issues. The safeguarding team  consisted of  three and then later two safeguarding  advisors, the original team having been composed of seven and this appears to have impacted upon the team’s ability to respond to STNHSFT procedures for routine safeguarding practices.  The Review Team were informed that this issue is currently being addressed  as a matter of some urgency through a ‘Business Continuity Plan’ for the Safeguarding Team.   8.5.5 The Named Professionals  and safeguarding advisors were unaware that no further action was being taken by Children’s Services and  this clearly was a missed opportunity to challenging procedural non-compliance and  the decisions taken by Children’s Services.    Finding: This review highlighted that the roles and responsibilities of Named Professionals and their respective teams would benefit from clarification and dissemination amongst health professionals. Finding:  Where  capacity issues impact on the ability of these teams to respond effectively to the material passed to them, important information can be overlooked.   Recommendation 5 SSCB should seek assurance that the Named Professionals and their safeguarding teams are well equipped to  effectively monitor and respond to safeguarding  information forwarded to them.     8.5.6 The review team were made aware that the STNHSFT Safeguarding Team still do not have an electronic system to support the Named Nurse and the supervisors in their daily work – this was a recommendation in the Child X SCR in 2010, and reportedly remains high on the STNHSFT Risk Register. Some health information on Child D will have been archived off-site by the Safeguarding Team, but could have been requested when the initial child protection referral was reported to them when ST was pregnant. It has been acknowledged that the School Nurse  would  have been able to provide the historical information regarding the incident and subsequent events with Child D.  Additionally if the outcome of the referral had been shared by the Health Visitor, with her Safeguarding Team, the absence of pre-birth would have likely been identified and  support  offered to the  HV  to ensure  procedural compliance.    8.5.7 The STFT Agency Learning Report advises that the above should have been the core response from the safeguarding team, but highlights that in addition to  capacity issues  mentioned previously , the team at  STNHSFT also became responsible for Safeguarding Adults which was also not without impact on  practice.   8.5.8 Clearly, there were significant and concerning shortcomings in the quality of the Initial Assessment, which by January was several weeks outside of timescale. A new Operational Manager (OM2) appointed in January instigated disciplinary proceedings against SW1 in relation to her work with this and other families and she was subsequently dismissed her by   the Local Authority. OM2 instructed SW2 in February 2014 to contact other professionals and if they had no concerns about Baby N to complete a summary and close the case. SW2 placed a closure note on file in March 2014, having been informed by HV2 that she had no concerns about the care of Baby N.   8.5.9 The Review Team requested additional information on what SW2 had been asked to do and were clearly informed she had been asked to just check with the professionals involved, i.e. the HV, whether there were any current issues. She was not asked to review the files held by Children’s Services on Child D or revisit the Initial Assessment itself. SW2 advised the Review Team that the records indicated that the historical files had had been checked by SW1 so she saw no reason to revisit previous records for Child D. The Review Team have learnt that the Initial Assessment although ‘open’ on the CCM system, contained no details at all. Whilst the records relating to the home visit were on the Family’s file, there was no analysis to support to the judgement that there was no risk to Baby N. The Review Team was unable to explore why historical records were not accessed and how the decision was made that there were no risks involved. No supervision records for SW1 have been located. The ‘warm and comfortable home’, the disclosure, and self-reported history by JB together with his willingness to engage appear to have influenced SW1 and highlight a level of professional naivety/professional optimism when faced with what was likely disguised compliance by the family.  8.5.10 The Agency Learning Report from Children’s Services described drift and delay, resulting from sickness, change of SWs and the involvement of 3 Operational Managers, the first being a temporary agency worker. The very evident poor practice of SW1 was compounded by a lack of management oversight and supervision; and although the Review Team were assured that an appropriate review of her caseload was undertaken, it is clear that the shortcomings related to the  ‘Baby N’ assessment was not picked up.   Finding: Organisational restructuring, inadequate IT systems,  increasing workloads and reduced staffing are significantly impacting  upon the work of frontline professionals and their managers  and  compromises their capacity  to safeguard children effectively.  Recommendation 6  SSCB should establish a system whereby the board is kept informed  on a regular  basis by  partner agencies  about any organisational constraints which impact or are likely to impact on their safeguarding  responsibilities.    8.6 ASP 4: The SCR Process  8.6.1 This review has been delayed in completion due to a range of factors: change in Review Team membership, incomplete individual agency learning reports and action plans,  rescheduled meetings due to the Ofsted Inspection and other review processes impacting on managers, the SSCB Business Unit and the 2nd reviewer.  The number of SCRs being undertaken in Sunderland has a significant bearing on the  extent to which  practitioners and   managers  from all agencies can  realistically sustain their active involvement in multiple SCRs.   8.6.2 The Review Team recognised the significant pressures influencing Children’s Services and the  challenging climate in which both managers and practitioners are currently working.  The number of temporary leadership posts within Children’s Services has been commented upon  by partner agencies and there has been a consequential impact of these on this and other SCRs. During the process of this review, 4 different Children’s Services Managers attended at various times, as members of the Review Team and were not always well prepared to contribute  to discussions.  This compromised the ability of the Review Team at times to work effectively but it also created tensions as managers from other services attended regularly and met the required deadlines for information  and action plans.   This issue has been raised in previous SCRs.      8.6.3 It is clear that when managers in temporary positions attend as team members of a Review Team, they struggle to commit to the SCR process, as they were not in post during the period under review, and they are often unable to account for practice in their service at that time. Neither, however, can they always reassure the Review Team, that the necessary changes will be introduced and embedded.   Finding Partners have expressed their frustration at what they regard as a continued lack of commitment by senior and middle managers within Children’s Services  to SCRs and are of the view that their failure to ensure continuity of membership compromises the learning from, and the integrity of, the SCR process.   8.6.4 Sunderland LSCB has completed a number of case and serious case reviews over the past 3 years and there are many common themes emerging from these reviews. This would suggest that whilst lessons are being learnt, they are not being embedded quickly enough into frontline practice. The challenges highlighted by the recent Ofsted report in respect of Children’s Safeguarding Services and the LSCB clearly compound this issue even further. The following recommendations are respectfully offered to assist the LSCB to move forward in learning from SCRs in the light of improvement plans already identified.   Recommendation 7 The single agency action plan template used in SCRs is reviewed so the Board can more easily audit and monitor progress of single agencies in implementing agreed actions.  Recommendation 8 The Board reconsiders the way in which operational and strategic learning from SCRs is disseminated across the workforce and between Board partners.       Recommendation 9 SSCB should review the capacity of the SSCB Business unit to respond to and manage existing and future SCRs especially given its increased responsibility to also support the Adult Safeguarding Board.   9 Summary    The  historical information  relating  to a  previous child  of the father  should, in line with Sunderland’s Unborn Baby procedures, have led to a  multi-agency pre-birth assessment once it became known that  the male  was to become a father again. Whilst this may not have prevented the injuries sustained by Baby N, it would have identified the potential risks posed to a vulnerable baby and allowed agencies to consider how or if these risk could be managed and the need for protective action agreed.    Health and social work professionals observed careful and sensitive parenting and had no concerns about the safety or welfare of Baby N, although they were aware of some concerns with a previous child several years previously.   Their willingness to accept what they were told by both parents highlights how, without good supervision, a measure of curiosity and a degree of healthy scepticism, professionals can be influenced and to some extent disarmed, by parents and grandparents who appear helpful and persuasive.    This review is also a stark reminder to professionals of the importance of not only sharing information, but also questioning what is being shared and on what basis decisions and actions are undertaken. This requires the continued acceptance that safeguarding children is a responsibility shared by all agencies.   During the period of 2013 -2014 a number of case and serious reviews in Sunderland have highlighted the impact of workforce instability and poor managerial oversight in Children’s Services on staff morale, both within the organisation and on other agencies. This SCR again reinforces the importance of clear direction from managers and safeguarding supervisors in all organisations and illustrates how a variety of factors can result in procedural non-compliance which can lead to unintended consequences.     Appendix 1   Single Agency Learning  (Information below is taken directly from the Agency Learning Reports which were endorsed by the Chief Officers in each agency)   City of Sunderland Children’s Services  All Front Line Staff in Children’s Social Care must be supported to deliver high quality practice:  Children’s Services have developed a new framework for supervision to ensure that all front line practitioners and managers receive regular (4 weekly), good quality supervision. Supervision is monitored through regular reporting to both Children’s Services and the monitored and reported to the improvement board on a monthly basis.  The caseloads of all social workers are monitored and reported weekly.  Ensuring front line practitioners are aware of and understand the Unborn Baby Procedures.  Children’s Services staff have been reminded of these procedures through briefings and the procedures will be part of the induction for new staff.   Management information to assist front line manager to manage workloads will be developed.  A weekly and monthly performance management data set has been developed and this is available to all front line managers and staff. This will enable Managers to have oversight of all the work of their team, including assessments out of time. There is a weekly Improvement meeting with all Managers chaired by Head of Safeguarding. The Performance Information Team which supports Children’s Services is being strengthened and Children’s Services are commissioning a new Recording System which will enable managers and practitioners to have access to a range of performance information.     Ensuring that all staff in Children’s Services have access to statutory guidance and procedures. Children’s Services have commissioned TriX which will give all staff access to online statutory guidance and procedures. The system will be operational in January2016.           Ensure that referrers are informed of the outcome of assessments Children’s Services has undertaken a range of work to strengthen and improve the process for managing and responding to referrals. New processes to ensure that referrers are informed in writing of the outcome of referrals and assessments are being developed will be fully operational as of 1.12.15  Sunderland Clinical Commissioning Group • Where a father to be or father is known to be registered with a different GP to the other family members information will be shared with them about any safeguarding concerns by midwifery and health visiting services • GPs have been requested to consider the parenting/caring role of men when taking histories from male patients to ensure they can liaise with other practitioners involved in safeguarding children to prevent issues about “hidden/invisible fathers”     • The SSCB will ensure that all safeguarding procedures are explicit regarding information sharing with GPs for males who are Fathers or carers  South Tyneside NHS Foundation Trust   (STNHSFT) • STNHSFT should ensure that all baby clinics have Children’s Services contact numbers and body maps accessible frontline professionals • The awareness of the ‘masking’ influence of tidy, well presented and appropriately responding parents on the perceptions of health professionals should be revisited through supervision and training • STNHSFT Safeguarding Procedures should be amended to reflect the process for safe transfer of a child to the local hospital when a paediatric assessment is required • STNHSFT new starters safeguarding supervision should reinforce how to deal with suspected NAI within the community settings • The use of STNHSFT tracking tool, which has been recently reviewed, should be audited within 6 months • The role of the Safeguarding team and the information they may hold should be highlighted to all front line health professionals • Staff will be reminded of the importance of promptly escalating concerns to, or seeking advice from, the Safeguarding Team  at STNHSFT City Hospitals Sunderland • A more holistic discussion should be undertaken by Midwives with both parents including the completion of a genogram to provide a robust risk assessment and analysis • The Vulnerability assessment needs to be updated to include key factors for inclusion including who is present at booking, name of fathers even if not currently in a relationship, contact made with GP • Contact should be made with the father’s GP to ascertain any unknown risks to improve information sharing between agencies regarding ‘invisible’ fathers  • Midwives need to escalate cases where safeguarding procedures are not being followed  • The maternity safeguarding Team need to have oversight of all cases  • Internal processes for sharing information received OOH needs to be robust  • In view of the lack of birth arrangements and concerns raised by the midwives a discharge planning meeting should have been held. This is particularly important where post- natal arrangements needed a multi - agency approach.  During this time period pre discharge planning meetings were not robustly embedded in practice • Capacity issues within the Maternity Safeguarding team need to be addressed    Appendix 2   Recommendations for Sunderland Safeguarding Children Board  Recommendation 1 a. SSCB should seek assurance from partner agencies that frontline practitioners have been reminded of the Unborn Baby procedures and specifically informed that where a previous child of either partner has been made subject to child protection procedures, a pre-birth assessment is required for all subsequent pregnancies. (See 5.2.d) b. SSCB should ensure that this message is clearly conveyed in multi-agency training programmes, where appropriate.   Recommendation 2  SSCB should ensure that where Initial Assessments are undertaken, referring agencies are informed in writing of the outcome of referrals so there is clarity between agencies about the rationale for the decisions taken.  .  Recommendation 3 SSCB should review how the existing referral forms and guidance notes make clear the expectation that referring agencies gather background information from their own records to support child protection/ child in need referrals or the assessments that follow.  Recommendation 4  SSCB should consider how it might facilitate improvements in working relationships between professionals and so enhance multi-agency practice. (See SCR Baby A and Child C)   Recommendation 5 SSCB should seek assurance that the Named Professionals and their safeguarding teams are well equipped to effectively monitor and respond to safeguarding information forwarded to them.     Recommendation 6 SSCB should establish a system whereby the board is kept informed on a regular basis by partner agencies about any organisational constraints which impact or are likely to impact on their safeguarding responsibilities.    Recommendation 7 The single agency action plan template used in SCRs is reviewed so the Board can more easily audit and monitor progress of single agencies in implementing agreed actions.  Recommendation 8 The Board reconsiders the way in which operational and strategic learning from SCRs is disseminated across the workforce and between Board partners.     Recommendation  9 SSCB should review the capacity of the SSCB Business unit to respond to and manage existing and future SCRs especially given its increased responsibility to also support the Adult Safeguarding Board.                                                       `    Appendix 3 PROGRESS REPORT   Outlined below is some of the improvement work undertaken by individual agencies and by the SSCB partnership:  Sunderland Clinical Commissioning Group  Where there are Safeguarding concerns about an unborn baby, GPs to share appropriate and proportionate information about fathers to assist in information gathering by midwives and enabling appropriate referrals to Children’s Services  • Ongoing work continues with the Head of Midwifery to develop a plan to ensure patient confidentiality is respected and Safeguarding concerns in respect of the father of the unborn baby are shared; this will inform the risk assessment process.  • Risk assessment and referrals in respect of the unborn baby are undertaken in a timely manner in the antenatal period.  • The pre-birth assessment will include father’s information.   • The impact of this will be reflected in such cases being discussed at MDTs which will improve information sharing.  GPs have been required to consider the parenting/caring role of men when taking histories from male patients to ensure they can liaise with other practitioners involved in Safeguarding children to prevent issues about hidden/invisible fathers.  • This recommendation is being covered in the GP locality training sessions which began in November 2015; dates have been planned until March 2016.  • GPs recognise the importance of understanding the relevance of sharing Safeguarding concerns in respect of fathers in order to safeguard the unborn baby  City Hospitals Sunderland NHS Foundation Trust  • Ensuring robust, respectful challenge when safeguarding procedures are not followed. • The Unborn Baby Procedures have been highlighted with Midwives. • Midwives will be aware of the timescales for actions under the procedures and   understand the key points where challenge may be required.  The role of the Maternity Safeguarding Team and the need to escalate any delays to the team has been reinforced.  • From October 2015 there are now 5 teams with dedicated community midwives who will provide continuity of care to the women ensuring that the midwives have a robust understanding of the case.  Where drift and delays are highlighted the Midwife will be able   to challenge and escalate as required.  Impact to date has been evidence through challenge by Midwives.  An audit will be undertaken in December 2015 to further evaluate impact.   Strengthened oversight by the Maternity Safeguarding Team The Maternity Safeguarding Team should have an oversight of all safeguarding cases and where there are concerns in respect of the case they are reviewed by the Team.  All referrals are quality assured by the Maternity Safeguarding Team and concerns are feedback to the referring Midwife and discussed in supervision.  This ensures improved professional quality of referrals, challenge as required.    Improving information sharing during Out of Hours (OOH) Arrangements for secure transfer of information via secure email have been strengthened.  Staff are aware of the requirement to prioritise information sharing and a more robust recording system is in place.  These processes are closely scrutinized and any issues are raised with the Maternity Safeguarding Team.  This ensures robust management oversight.  Improved capacity of Maternity Safeguarding Team Additional resources have been provided that is 0.5wte dedicated admin.  This has enabled a robust process for internal procedures to be implemented.  A further 1.0wte is being considered.  An additional temporary Safeguarding Midwife has been appointed and a further 1.0wte Named Midwife is being considered.  Both posts will strengthen the capacity of the team.    Strengthen Pre discharge planning meeting  CHSFT and Children’s Services have strengthened the use of the pre-discharge planning meetings.  This ensures a robust secure discharge home and is evidenced through minutes etc.  Embedding Learning and Improvements into every day practice All actions from this SCR have been considered and will be implemented from January 2016.  These improvements will strengthen the continuity of care for women and their babies from dedicated Midwives who have knowledge of the safeguarding concerns regarding the family.  Sunderland Safeguarding Children Board   The SSCB has instigated the following improvement work:  • Reviewed and updated the Safeguarding the Unborn Baby - to strengthen the requirement for the Pre-Birth Child in Need Assessment to include information from other professional assessments including the Vulnerability Assessment Protocol.  The assessment will therefore be multi-agency and include the expertise of partners.  The Pre-birth Child in Need Assessment must also be copied to all professionals working with the family to ensure a shared understanding of what the child’s plan is based on • Reviewed and updated the SSCB Vulnerable Baby Training  - This is delivered to multi-agency staff and includes the learning from SCRs    • Raised awareness of the learning from the SCRs - developed SCR briefing sheets and delivered  multi-agency learning and improvement workshops.  Staff attending the sessions report that they have learnt from the sessions and are applying this to their practice.  The impact of this learning will be audited through a further post course evaluation audit • Reviewed and agreed a robust action plan format for future SCRs which will require agencies to demonstrate what improvements they intend to make and how they will measure the impact of the improvement work on children and their families • Reviewed and updated the Child Protection/Child in Need  Referral form  - To strengthen the requirement to access and consider historical family information prior to submitting referrals - To remind professionals that their responsibility does not end once they have made a referral  - To remind professionals that they have a professional responsibility to challenge drift/delay using the SSCB Escalation and Challenge Process when required - To require referring professionals to identify fathers and/or any other adult male in the child’s life and clarify their role in relation to the child   The intended impact  of the improvements is to ensure that referrals to Children’s Services  contain robust historical information and a full outline of the family of a child including any adults they have contact with, remind multi-agency staff of their responsibility to continue to work with families even if they have made a referral to Children’s Services and when multi-agency professionals don’t receive a response to their referral or they don’t agree with the action taken in response to their referral they must escalate issues to ensure children and young people are safeguarded.    • Reviewed and updated the SSCB Escalation and Challenge Function and highlighted the process to multi-agency staff   - The impact of this is to ensure that multi-agency frontline staff and managers are aware of their responsibility to escalate issues of concern, the process is put into action when required and use of the process safeguards children and young people   