Revised executive summary of a review into the death of a 4-month-old baby boy in the summer of 2009. Mother and father were arrested in 2009 but later cleared of any criminal offences in 2011. Rrevised executive summary reflects the finding that Child A suffered from rickets, suggesting the possibility of organic, non-inflicted causation of Child A's injuries. Includes recommendations from the original overview report and recommendations from the reconvened case review panel, covering: Islington Safeguarding Children Board, health and police services.
      
 Title:  Child A: a serious case review: executive summary LSCB: Islington Safeguarding Children Board Author: Kevin Harrington Date of publication: 2012  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.                          Page 1 of 7  1                CHILD A  A SERIOUS CASE REVIEW  EXECUTIVE SUMMARY  JANUARY 2010  UPDATED SEPTEMBER 2012                   Page 2 of 7  2 1. BACKGROUND TO THE SERIOUS CASE REVIEW  1.1 This report is the Executive Summary of the confidential Overview Report arising from a Serious Case Review, relating to a child referred to as Child A. Child A lived with his parents (Ms B and Mr C) and his maternal family. He died, aged just over 4 months, in the summer of 2009. It was suspected that he had been deliberately harmed. Ms B and Mr C were charged with and, in 2011, cleared of criminal offences linked to the death of Child A.   1.2 When any child dies, and abuse or neglect is known or suspected to be a factor in the death, Local Safeguarding Children Boards must conduct a Serious Case Review, in line with the government’s guidance, “Working Together to Safeguard Children” (Working Together). In response to the death of Child A a Serious Case Review was initiated in Islington, where the family lived.   1.3 The purposes of a Serious Case Review, as set out in Working Together, are to:  Establish whether there are lessons to be learned from the case about the way in which local professionals and organisations work together to safeguard and promote the welfare of children  Identify clearly what those lessons are, how they will be acted upon, and what is expected to change as a result and  As a consequence, improve inter-agency working and better safeguard and promote the welfare of children  1.4 The Terms of Reference for the Review included various matters which, in the light of the outcomes of the subsequent legal proceedings, are no longer relevant. Consequently the Terms of Reference are not detailed in this report.  1.5 The agencies involved in the Serious Case Review were as follows:  AGENCY NATURE OF CONTRIBUTION NHS Islington (to include General Practitioner, Child & Adolescent Mental Health Services, School Health, Health Visiting Service, Family Nurse Partnership) Individual Management Review (IMR) and Health Overview Report Cambridge Education @ Islington1 (to include school and Education Welfare Service) IMR University College London Hospital NHS Trust (UCLH), ( to include ante natal and midwifery services, Whittington Hospital community and midwifery service, Paediatric A&E) IMR                                             1 Cambridge Education @ Islington is a company contracted to provide a full range of advice and support for schools in Islington. Page 3 of 7  3 Metropolitan Police Service IMR Islington Young People’s Services ( to include Connexions and  Targeted Youth Services) IMR Hackney Learning Trust Background information Great Ormond Street Hospital NHS Trust (GOSH) Background information Camden Children’s Social Care Background information Hackney Children’s Social Care  Background information NHS Hackney Background information Islington Children’s Social Care Background information Hackney Connexions Background information East London Foundation NHS Trust Background information Specialist Service provided jointly by the NHS and Metropolitan Police Background information Alone in London mediation service Background information  1.6 In line with the requirements of Working Together a Panel was established to manage the SCR process. That Panel was chaired by a suitably experienced person independent of all the agencies participating in the Review, Ms Bodil Mlynarska, the Principal Officer (Safeguarding) from the London Borough of Camden. The composition of the Panel was as follows:  Name and Designation Organisation Role Ms Bodil Mlynarska London Borough of Camden Independent Chair Director of Child Protection LB Islington Local agency manager Service Manager, Quality and Safeguarding LB Islington Local agency manager Assistant Director of Children’s Services NHS Islington Local agency manager Designated Doctor for Child Protection NHS Islington Local agency representative Designated Nurse for Child Protection NHS Islington Local agency representative Service Director Cambridge Education Local agency manager Senior Paediatric Nurse UCLH Local agency manager Group Manager, Safeguarding City & Hackney SCB Representative of a Safeguarding Board potentially affected by this review Detective Inspector, Child Abuse Investigation Team Metropolitan Police Service Local agency manager Head of Performance and Equalities Hackney Learning Trust Local agency manager  1.7  Kevin Harrington Associates Ltd is a specialist independent consultancy with extensive experience of conducting and contributing to Serious Case Page 4 of 7  4 Reviews.  Kevin Harrington was appointed to produce the Overview Report from the Review and this Executive Summary.  1.8 Arrangements were made to involve family members in the Review before the criminal trial but, after receiving legal advice, they did not come to these meetings  1.9 That Review was completed in January 2010 but publication of an Executive Summary was kept pending until the legal proceedings were determined.  Ms B and Mr C met with the Review Chair and Overview Report author after the conclusion of the legal proceedings and commented on the Review. This summary takes account of their comments.   2. SUBSEQUENT EVENTS  2.1 The criminal trial of Ms B and Mr C took place over six weeks at the end of 2011.  It was concluded when the prosecution offered no evidence on the charge of murder and the trial judge decided that an alternative charge of causing the death of the child should not be put to the jury.  The jury was directed to find Ms B and Mr C not guilty.   2.2 Ms B and Mr C had a second child, Child P, who, following a court order, had been removed from their care before the criminal case against them was concluded. In April 2012 there was a ruling in the High Courts of Justice, Family Division, in respect of Child P, as a result of which this child was returned to the care of Ms B and Mr C. The judgment (judgementclerks@drj.com 2012049 120934.pdf) in that case sets out in great detail the background to the case and medical matters relating to the death of Child A.   2.3 A key issue was that Child A had been found to suffer from rickets, a medical condition in which the bones become soft and deformed, usually as a result of lack of Vitamin D and calcium. This information suggested the possibility of an organic, non-inflicted causation for Child A’s injuries. The full information from the court proceedings, and its significance, was not known at the time the Serious Case Review was conducted. Had it been known it would have been raised as a significant issue in the process of the Serious Case Review.   2.4 Consequently the Serious Case Review Panel re-convened to consider this new information.  An addendum has been added to the recommendations from this report to reflect the Panel’s views and findings.         Page 5 of 7  5 3. RECOMMENDATIONS FROM THE ORIGINAL REVIEW IN 2010  3.1 Introduction  These are the recommendations from the Overview Report, which arise directly from various matters considered by the Panel in 2010.  The ensuing actions were completed prior to the publication of this summary.  3.2 Recommendations to the Islington Safeguarding Children Board  3.2.1 The Board should examine, and strengthen as necessary, local procedures for implementing the Common Assessment Framework and lead professional arrangements, so as to promote thorough assessment, appropriate sharing of information and effective multi-agency working.   3.2.2 The Board should review and strengthen as necessary the understanding of local agencies of thresholds for inter-agency discussion or referral. This includes circumstances where discussion or referral can be triggered by failure to make progress or achieve engagement.   3.2.3 The Board should continue to strengthen the quality and effectiveness of staff supervision across all relevant agencies.   3.2.4 The Board should seek assurance from all agencies that assessments and work plans take proper account of issues of faith, culture and ethnicity.  3.2.5 The Board should seek assurance from all agencies that they appropriately take account of the needs of fathers in assessments and work plans.  3.2.6 The Board should satisfy itself that the systems now in place are ensuring that records of children or young people coming to the notice of police (known as “Merlins”)  are appropriately risk assessed and shared with partner agencies.   3.2.7 The Board should develop a standardised framework for interviewing and supporting staff who are required to contribute to Serious Case Reviews.   3.3 Recommendation to NHS Islington  3.3.1 NHS Islington must ensure that all child health staff have an appropriate understanding of the arrangements for recording, interpreting and responding to child growth data.    3.4 Recommendations to NHS Islington and the Family Nurse Partnership  3.4.1 NHS Islington and the Family Nurse Partnership should consider the findings of this review in respect of   an appropriate emphasis on safeguarding  Page 6 of 7  6  a more comprehensive approach to assessment and recording  the need to work with whole families, including fathers to determine whether any changes should be made to the scheme’s methodology and implementation, locally or nationally (date to be agreed with the national team).  3.5 Recommendation to the Specialist Service and NHS Islington  3.5.1 The Specialist Service must ensure that they meet agreed standards for follow up care of young people. NHS Islington must ensure that this is monitored and audited in conjunction with London Specialised Commissioning.   3.6 Recommendation to University College Hospital London NHS Trust  3.6.1 The Trust must ensure that communications with partner agencies are clear and timely.   3.7 Recommendation to Great Ormond Street Hospital NHS Trust and the Metropolitan Police Service.  3.7.1 The agencies should review and strengthen as necessary the protocol for managing situations where there may be a tension between the police requirements to investigate a possible crime, and the hospital’s arrangements for supporting the families of children who are seriously unwell.  Page 7 of 7  7  4. RECOMMENDATIONS FROM THE RE-CONVENED PANEL IN 2012  4.1 Recommendations to the Islington Safeguarding Children Board   4.1.1 The Islington Safeguarding Children Board should review local service provision to ensure that current national guidance on the management of rickets in pregnancy and infancy has been implemented, and that public awareness of this issue is promoted.  4.1.2 The Islington Safeguarding Children Board should ask the Department of Health to consider the implications of this case and the possible need for a review of NICE guidance on the management of rickets.  4.1.3 The Islington Safeguarding Children Board should ask the Department of Health to consider the need for national publicity to raise awareness of Vitamin D supplementation for high risk groups and the treatment of Vitamin D deficiency.  4.2 Recommendation to the University College Hospital NHS Foundation Trust   4.2.1 The Trust should re-appraise the Management Review originally carried out in this case, in the light of information arising from subsequent processes, with particular reference to monitoring of carbon dioxide levels, and to record keeping. 