Death of a 3-week-old girl in June 2013; coroner classified cause of death as 'unascertained'. Following Child T's death, a home visit found that the family were living in dirty and unhygienic conditions. There had been no previous concerns about the mother's care of her children, and they were not known to children's social care. Issues identified include: confusion across partner agencies about when the Common Assessment Framework (CAF) was open and when it had been closed and a failure to check the room in which the child was to sleep during the community midwife's home visit. Recommendations include: simplify the management system used to track CAFs and introduce as standard a physical check of the room in which the child sleeps in the day and night.
      
 Title:  Overview report of the serious case review concerning the death of Child T. LSCB: Coventry Safeguarding Children Board Author: Felicity Schofield 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.                           1    COVENTRY SAFEGUARDING CHILDREN BOARD SERIOUS CASE REVIEW  This is an Independent overview report of the Serious Case Review concerning the death of Child T  DATE OF SERIOUS INCIDENT: June 2014     Date of report: March 2015 Agreed by Coventry Safeguarding Children Board:  30th January 2015       Independent author: Felicity Schofield                      SCR Chair: David Peplow                                              2                                           Contents                                                                                                Page no. 1. Summary of the case…………………………………………………………………………………..3  2. Terms of Reference…………………………………………………………………………………….3  3. The process……………………………………………………………………………………………….4  4. Involvement of the family……………………………………………………………………………4  5. Background prior to the Scoped Period…………………………………………………………5  6. Ante-natal period……………………………………………………………………………………….5  7. Post-natal period…………………………………………………………………………………………7  8. Examples of Good Practice…………………………………………………………………………..9  9. Action taken since Child T’s death………………………………………………………………………10  10. Findings & Recommendations……………………………………………………………………….11           3     1. SUMMARY OF THE CASE 1.1 The subject of this serious case review (SCR) is Child T, a white British baby girl who died at the age 3 weeks in June 2013. Child T had an older sibling who was 17 months old at the time of Child T’s death. The father had no involvement with the child’s care, his relationship with the mother having ended prior to Child T’s birth.  1.2 The cause of Child T’s death was classified as ‘unascertained’ by the coroner. That is, some abnormalities were found in the post mortem examination and therefore, it was not classified as a Sudden Unexplained Death in Infancy (SUDI). The abnormalities were firstly significant thrush and secondly a congenital viral infection called Cytomegalovirus1. Neither of these factors were considered significant enough to have caused or contributed to Child T’s death. Cytomegalovirus is not associated with poor hygiene. 1.3 There had been no concerns about the mother’s care of either Child T or the older sibling prior to Child T’s death and they were not known to children’s social care. However, when the family home was visited immediately following Child T’s death, it was found to be squalid with dirty nappies, rubbish and food all over the floor. It was very hot and there were flies everywhere. In the police officer’s opinion it was not fit for human habitation. The police investigation concluded that whilst a case for criminal neglect had been established, it was not in the public interest to prosecute.  1.4 This review seeks to analyse the events leading up to Child T’s death, with an emphasis on understanding how agencies worked together and how the organisational context of those agencies may have affected the work of their practitioners. 2. TERMS OF REFERENCE 2.1 The detailed terms of reference are attached at appendix 1. The purpose, framework, agency reports to be commissioned and the particular areas for consideration are all described there. Six agencies contributed to this review. 2.2 It was agreed that the scope of this review would be between October 2012 when it became known that the mother was pregnant and June 2013 when Child T died.  1. Cytomegalovirus (CMV) is a common virus in the Community. It would give most adults nothing more than a cold but can cause problems if it affects an unborn child. It is estimated that one to two babies in every 200 will be born with CMV in the UK. Of these about 13% will have problems when they are born.   4    3. THE PROCESS 3.1 The LSCB’s serious case review sub-committee first considered the circumstances of Child T’s death at a meeting in July 2013 and recommended to the chair of the LSCB that the case met the threshold for a SCR because of the extent of the neglect documented by the police.  3.2 Further advice was sought from both the pathologist and from one of country’s leading experts on death in childhood, Dr Peter Sidebotham. His opinion was that unless there was evidence that the state of the family home was linked to Child T’s death, he would be hesitant to go down the route of a SCR. On this basis, it was decided not to proceed with a SCR. However, the LSCB Chair reviewed her decision in June 2014 and decided that the criteria for a SCR had been met and that a SCR should be commissioned. 3.3 The first meeting of the independently chaired SCR panel was in August 2014. The Chair and Overview Report writer are independent of all professional agencies in Coventry, have had no previous direct involvement with or knowledge of the family who were subject to the review and have had no previous involvement in a professional capacity with safeguarding practice in Coventry. Both are LSCB chairs elsewhere in the country. 3.4 Working Together to Safeguard Children 2013 states that serious case reviews should be conducted in a way which:  Recognises the complex circumstances in which professionals work together to safeguard children; seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did;  Seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight;  Is transparent about the way data are collected and analysed; and  Makes use of relevant research and case evidence to inform the findings. This serious case review has been undertaken in a way that ensures these principles have been followed.  4. INVOLVEMENT OF THE FAMILY Child T’s mother and grandmother are aware that this SCR has been commissioned and were visited in order for the process to be explained. Initially, Child T’s mother agreed to contribute further and arrangements were made for her to meet with the lead reviewer and SCR panel chair. However, she did not attend the meeting. Several subsequent attempts to contact the mother have proved  5  unsuccessful and it must be concluded that, for the time being at least, she has decided against any further involvement. 5. BACKGROUND TO THE SCOPED PERIOD 5.1 The mother became known to community health services when she became pregnant for the first time with Child T’s older sibling, who was born in January 2012. At the time of the birth, the mother was 18 years old and living with the baby’s father. Prior to the sibling’s birth there had been no significant contact by children’s social care (CSC) with either the mother or her partner.  5.2 A Children’s Centre offered support to the family from January 2012 following some missed appointments. A Common Assessment Framework (CAF) was completed in February 2012. The focus of the CAF was keeping the home clean and tidy, benefits advice, the provision of safety equipment and access to Children’s Centre activities. The family engaged appropriately and the health visitor (HV) recorded that at a meeting with the mother in May 2012, it was agreed that the CAF would be closed because the mother and older sibling had moved back to live with the maternal grandmother and the father had returned to live with his parents. However, the CAF was not in fact closed by the Children’s Centre until November 2012.  5.3 Throughout this period, the mother sought appropriate advice from the GP for the sibling regarding a number of minor issues. The GP records did not include information about the CAF. Analysis  5.4 There is nothing significant about the background of this family. Child T’s mother was young and on benefits so she would have been regarded as vulnerable and was appropriately offered support from the local Children’s Centre. She was not always easy to either contact or to find, spending time at her mother’s home as well as her own, and she sometimes missed appointments. There were no concerns about her care of Child T’s sibling. Agencies had different views about when the CAF was closed. This is referred to later in this report. 6. ANTE-NATAL PERIOD (October 2012 – May 2013) 6.1 The mother was booked in for her ante-natal care on 9 October 2012 at around 8 weeks pregnant. Knowledge of the earlier CAF, which was recorded as closed, was evident in both the antenatal and delivery records at the hospital. The midwife did not advise the Children’s Centre of the mother’s second pregnancy.  6.2 At 28 weeks into the pregnancy, concerns arose that the baby was not growing well and a decision was made to provide the mother with consultant led care together with frequent monitoring of the baby. In total the mother attended 27 pregnancy related appointments, which is approximately  6  three times the number for a problem free pregnancy. If she was unable to attend, she always contacted the clinic. It was a bus journey away and sometimes she didn’t have the bus fare. 6.3 The mother was offered a new, unfurnished tenancy in October. It was assessed as being in poor decorative state and vouchers were provided for redecoration. On the basis of a self-assessment, the mother was assessed as requiring a low level of support. This consisted of a telephone call approximately 3 weeks into the tenancy to establish if there were any problems and/or if further assistance was required. Repairs to the boiler, which was not working, were carried out at the end of January after a number of missed appointments. It would appear that the mother and older sibling were living mainly with the grandmother up until then. 6.4 An outstanding home safety check by the Children’s Centre worker was postponed pending the move to the new address. However, it was not carried out because the mother did not respond to the Children’s Centre worker’s phone calls. She had previously advised the Children’s Centre worker that she did not need any extra support because she was managing well and had the support of her family.  6.5 At this point, the HV thought the CAF had been closed in May but it had in fact been kept open by the Children’s Centre because the home safety check was outstanding. The CAF was closed at the end of November 2012. There is no record of this decision being discussed by the line manager. The Children’s Centre were unaware of the second pregnancy. 6.6 The GP contacted the HV at the end of November, advised her that the sibling had been seen in surgery and had a sore bottom and a respiratory tract infection and requested a follow up visit. This took place at the grandmother’s home the following day. The HV had no concerns about the home environment. The sibling looked well and was smiling and interacting appropriately. The mother advised the HV that she was pregnant and that she had been offered a new tenancy. 6.7 The mother took the sibling to the GP twice in November because of a viral infection and nappy rash. Following the second visit, the GP left a message for the HV asking her to visit, expressing some concerns about the mother’s ‘mothering skills’. The sibling was seen the next day by the community staff nurse who subsequently left a message for the GP advising that she had provided advice about nappy rash and that she had no outstanding concerns. 6.8 The sibling attended clinic for a routine developmental assessment at the beginning of December 2012. The sibling was assessed as having age appropriate development with no parental concerns. The child’s bottom was clean and healing and the child was clothed appropriately. The mother advised the nursery nurse that she was pregnant. She was recorded as looking a bit unkempt with grubby clothes and this information was passed on to the HV.  7  6.9 In response, the mother was offered further support from the Children’s Centre but she advised the worker that she did not need it. The Children’s Centre worker then contacted the HV regarding the mother’s request to cancel the CAF. In fact the HV had believed the CAF to have been closed in May. On the basis that the CAF had not been closed, the HV requested that it be kept open until the New Year, when she had visited the mother and sibling in their new home.  6.10 The HV did not manage to see the mother in her new home because there was no reply when she called for a pre-arranged visit. There was no further contact from the HV until after Child T’s birth in May 2013. 6.11 Overall, professionals found it hard to make contact with the mother during this period, but both the Children’s Centre worker and the HV were persistent in making contact. The sibling was not seen in the new accommodation. Analysis 6.12 There were no concerns about the sibling’s welfare during this period and the mother was good at keeping her ante-natal appointments, of which there were many because of the baby’s slow growth. With hindsight, the slow growth is likely to have been due at least in part to the Cytomegalovirus. The mother seemed more willing to see professionals outside the family home. 6.13 There was general confusion between the early support services, the health visiting service and the mother about whether or not a CAF was open and when services were being offered by the Children’s Centre but not under the auspices of a CAF. 6.14 The midwife did not advise the children’s centre that the mother was pregnant with her second child which would have been good practice even though she believed the CAF to have been closed in May. The GP was not involved at all with the CAF process. 6.15 There was a gap of nearly 4 months between the tenancy being signed for and the boiler being repaired. This covered the winter period and the tenant had a child who was only a year old. In this case, it seems likely that the mother was not actually living in the tenancy, however, as part of this review, the housing provider has recognised that this was a potential risk and implemented changes which are described later in this report. 7. THE POSTNATAL PERIOD (16 May – 6 June) 7.1 Child T was born on 16 May 2013 following a normal delivery. She weighed 2.44 kg and, by definition, had Intra Uterine Growth Restriction (IUGR). The mother and Child T were discharged from hospital 2 days later following postnatal checks and the provision of safe sleeping advice. They were discharged to the grandmother’s address, but returned to their own home within a day or so.  8  This unexpected change of address resulted in the midwife having to make additional visits in order to ‘find’ the mother, who proved difficult to contact by phone. 7.2 The mother and Child T were visited by the midwife on 19 and 22 May. At the first visit, Child T was fully examined and was found to be well and alert. The second visit was undertaken by the same midwife who recognised the vulnerability of the situation because the mother was young and living on her own and Child T was so small. The flat was sparse but not dirty or cluttered. There was a Moses basket in the living room which was described as ‘lovely’, with pink surrounds. The baby weighed 2.34 kg, was alert and not jaundiced. Her eyes and mouth were clear. 7.3 The mother had been worried about Child T, who was pale and not feeding very well, since shortly after her birth. On 27 and 29 May Child T was seen firstly at a walk-in centre and secondly by the GP, on both occasions because of bilateral conjunctivitis. Reassurance was given to the mother and no other concerns were identified. 7.4 On 31 May the HV carried out a ‘new birth’ visit at the grandmother’s house. Child T had returned to her birth weight. The mother reported that Child T seemed better and no evidence of illness was observed by the HV, with the exception of a possible fungal infection on the child’s buttocks for which it was suggested that the mother contact the GP. Advice was given on safe sleeping and passive smoking. The mother had been staying with the maternal grandmother but was returning home that day.  7.5 The HV assessed that the mother would need some extra support with practical issues such as engagement with the children’s centre but had no concerns about the children. Her intention was to propose a CAF at the next contact and planned to visit in a week’s time, with an appointment booked for 7 June. Sadly, Child T died before that visit took place. 7.6 The mother, the sibling’s father, the sibling and Child T attended the post-natal clinic at the children’s centre on 3 June. Child T had gained weight and was feeding well. The family registered with the children’s centre and as part of the visit informed the children’s centre assistant that the midwife had advised them to take Child T to the GP because she still had thrush and a sticky eye. 7.7 After Child T’s death, the mother advised professionals that Child T had been very unsettled during the night of 4 & 5 June and that she had tried and failed to get a GP appointment. The GP was surprised to hear this because the practice had a policy that if any patient said they needed to be seen on the day, they would be seen ‘no questions asked’.  7.8 The following night Child T appeared well and was put to sleep in her Moses basket. The mother woke and found Child T dead at 5am on 6 June.   9  7.9 On examination, there was no obvious bruising to Child T’s body and a post mortem did not identify any evidence of injury or overlaying. 7.10 Following Child T’s death a joint visit was undertaken to the family home by a consultant paediatrician and a police officer as part of the rapid response to a child death. The property was found to be squalid. There was rubbish and old food strewn across the floors and every cupboard contained bags of rubbish and dirty nappies. A bottle steriliser was filled with stagnant water. There was an electrical socket just above floor level with wires exposed. There was no bedding on the adults’ bed and in the cot there was milk in a bottle which had solidified and turned green with mould. There were toys on the floor in all the rooms. There were flies everywhere (it was very hot weather). On interview, the mother and her partner accepted that the home was unhygienic. They said that the situation had deteriorated over the previous 10 days. They had put all the rubbish into cupboards in an attempt to tidy up.  Analysis 7.11 The mother was worried about Child T’s health from not long after her birth, seeking medical advice appropriately on two occasions. In addition Child T was seen by health professionals as part of routine post-natal surveillance on 4 occasions. Therefore during the three weeks that she lived, Child T was seen by health professionals on 6 occasions. On every occasion the mother was appropriately concerned about Child T’s health and Child T presented as being well cared for. There is no evidence to suggest that either the mother or those health professionals could have taken any further action which might have prevented Child T’s death. 7.12 Out of those 6 occasions, Child T was only seen once in the family home. That is not unusual, especially when the discharge address was that of the grandmother, which given the mother’s age and circumstances was seen as a positive move which would have offered the mother additional support in the early days after Child T’s birth. 7.13 When the midwife saw Child T in the family home some 2 weeks before her death, the home was not in the condition that was found immediately after her death. However, when the midwife visited, the mother had only just moved back there from the grandmother’s house. It would appear firstly that the mother had attempted to tidy up the room which the midwife would see when she visited and secondly that there was a rapid deterioration in the overall situation, exacerbated by the very hot weather.     8.  EXAMPLES OF GOOD PRACTICE 8.1 The rapid response immediately following Child T’s death  10  A home visit was undertaken jointly by a consultant paediatrician and a police officer from the Child Abuse Investigation Team within hours of Child T’s death. This prompt response enabled valuable information to be gained which subsequently contributed to the criminal investigation and the decision-making regarding this SCR.  8.2 The midwifery & health visiting services Both the community midwife and the health visitors offered good support during the post-natal period. The mother was, and has continued to be, difficult to contact by phone and hard to find at home. This would appear to be caused by her lifestyle and circumstances rather than because she was deliberately avoiding professionals. Nevertheless, both services were tenacious with regard to trying more than one address when she could not be contacted. As a result Child T was still seen very frequently. 8.3 The GP On two occasions the GP followed up low level concerns by asking the HV to offer additional support, which was good practice and was responded to promptly. 9. ACTION TAKEN SINCE CHILD T’S DEATH 9.1 The communication systems between midwives and health visitors have been improved as part of the Acting Early Programme which was introduced during 2014 and which was designed to promote and support integrated working. Specifically, there are now weekly meetings which enable midwives, HVs, social workers and children’s centre staff to share information and discuss vulnerable families. 9.2 The health visiting service now receives notification information from maternity services regarding all antenatal contacts. 9.3 In 2013, CAF practice, processes and procedures were reviewed in order to establish a more consistent approach to service delivery. An eCAF management system has improved case tracking and makes it easier for professionals to establish whether there is a CAF and whether it is open or closed.  9.4 Children’s Centre files are now audited. Between May and July 2014, 43% were judged to be good and 43% to be adequate. 9.5 The housing provider now makes a booking for the boiler test when a tenancy is signed for. They have also commissioned tailor-made safeguarding training for their staff in recognition of their vital role in the protection of children and vulnerable adults.  11     FINDINGS & RECOMMENDATIONS 10.1 The overall findings arising from this SCR are that Child T’s death could not have been either predicted or prevented. There were no concerns about Child T during her short life and her mother sought help and advice appropriately.  10.2 The mother received enhanced ante-natal care as soon as it became known that the baby was growing slowly in the womb and the mother attended the vast majority of appointments, even though they were some distance from where she lived. 10.3 It is likely that being born with Cytomegalovirus contributed to Child T’s vulnerability. CMV is the most common infection at birth, more common than Down’s syndrome, toxoplasmosis or Cystic Fibrosis with as many as 1 in 150 new born babies being born with it. Whilst, the majority of these babies will not have any symptoms, around 1 in 1000 babies born in the UK every year will have permanent disabilities as a result of CMV – around 900 children every year. 10.4 There had been no concerns about the mother’s care of her first born child, Child T’s sibling. As a teenage mother on benefits she had been appropriately offered support from a children’s centre. The mother had accepted the support she was offered and followed the advice she was given. 10.5 There was confusion across partners about when a CAF was open and when it had been closed. It is understood that changes have subsequently been introduced which make the status of a CAF easier to identify. The GP had no record of there being a CAF. Parents and professionals alike need to be clear about when a CAF is in place and, if it is in place, what action is being taken as a result of it. Recommendation 1: The LSCB is assured that the simplification of the ecaf system and processes are having a positive impact on the lives of children and families. Recommendation2: Lead professionals ensure GPs are fully informed of CAF activity in line with existing procedures, which are currently operating within the acting early pilots 10.6 There was a four month gap between the tenancy being signed for and the boiler being repaired. Some of the delay was as a result of missed appointments by the mother. Whilst in this instance the reason was most likely that the mother was staying with the grandmother, the housing provider has recognised that this length of delay could pose a risk to children, had they been living in the property. Steps have been taken to address this issue.   12  10.6 There were no concerns about the care of Child T after her birth and she was seen regularly by health professionals. She was only seen once in the family home, but there had been no previous concerns about hygiene or neglect and therefore there was no specific reason to see Child T at home. 10.7 Safe sleeping advice was given and the place where Child T slept – a Moses basket – was seen by the community midwife, although not the room where she was likely to sleep at night. Two weeks before Child T’s death the home environment was not a cause for concern and there was no information to suggest that it might become so in the future. Recommendation 3: A standard physical check of the room in which the child sleeps in the day and night, and the bed/cot/basket in which the child is sleeping to be undertaken and recorded by UHCW and CWPT.                    13   Appendix 1 Coventry Safeguarding Children Board Serious Case Review – Child T Scope and Terms of Reference Principles for SCR The following principles will govern the review and the role and responsibility of the Lead Reviewer:  Fairness   Impartiality  Thoroughness   Accountability   Transparency  As set out in Working together 2013 - The purpose of these reviews is to identify improvements which are needed and to consolidate good practice. LSCBs and their partner organisations should translate the findings from reviews into programmes of action which lead to sustainable improvements and the prevention of death, serious injury or harm to children.  Plan for SCR Process  The SCR will be carried out by an experienced, independent Lead Reviewer who has a good understanding of interagency safeguarding including health and children’s social care.  The process will include:  The SCR Panel to produce  scoping document and Terms of Reference for the review  Briefing agency report authors on what is required including providing terms of reference   Requests to each agency for information, including summary reports where required and individual management reviews   Focused interviews with staff involved by agency report authors   SCR Panel to receive agency reports and discuss initial findings  First draft of Overview report by Lead Reviewer and mapping of findings within the Learning Summary  Feedback workshop for managers and practitioners on the findings after first draft has been produced   SCR panel to agree final draft of overview report  14   SCR subgroup to agree final draft of overview report  Presentation to LSCB and discussion of action required on findings /  recommendations   Lead Reviewer to deliver final SCR for publication   Follow up learning workshop for managers and practitioners The interviews with managers and practitioners will explore:  critical points in the case   possible reasons for actions taken at the time  the significance of these insights for current practice.  The critical points in the case that will be considered are:   When it was known to agencies that mother was pregnant with Child T   The birth of Child T and discharge home  Visit to mother and children in her own home before and after  the birth of Child T Scope of the Review  The Serious Case Review will be from when it became known mother was pregnant with Child T to her death. Agencies should critically review their contact with the family between October 2012 until Child T’s death in June 2013, and to review any relevant previous contact with the family.  Information gained from the post mortem examination and police investigation which post-dates this date should also be included where relevant.  Terms of Reference:  The agencies involved in the Serious Case Review should:-  a) Summarise all relevant historical information that falls outside of the period under review  b)  Detail agency involvement with the child and family.    c) Provide an accurate chronology (using the provided profoma)and genogram showing the  membership of the family, extended family and household  d) The key relevant points/opportunities for assessment and decision making in the case in relation to the child and family.  Specifically:-     15  - Comment on the quality of assessment and analysis both pre and post birth. Did this include appropriate information sharing and relevant historical information?   - Were previous concerns about neglect or any other risk factors known to agencies, and were they understood and analysed as part of assessments undertaken by agencies in the city  - Were thresholds for intervention understood and applied   - Did actions accord with the assessments and decisions made?  e) Where intervention was delivered were these timely and outcome focused.    f)  How did agencies engage the family in the assessment and decision making process? Were there any difficulties in communication, information sharing or service delivery.  How were these addressed or overcome to meet the needs of the family.      g) Did agencies work effectively together to offer support to the family?  h) Were relevant agency and interagency procedures and guidance, including any joint working protocols followed?  i) When, and in what way were the children’s lived experiences identified and how were these taken account of in the decision making and delivery of services.   j) Where there are examples of good practice these should be highlighted.   k) Did the agencies consider whether the abilities or disabilities, racial, cultural, religious, linguistic identity of the child/ren or the family have an impact on their situation and have any associated implications within the assessment, planning and provision of services?   l) Were adequate supervision and line management arrangements in place and adhered to?    