Executive summary of a review into the serious injury of a baby girl in late 2011. Child F was stabbed by her father who was described as suffering a severe psychotic episode at the time. Father was arrested and subsequently received psychiatric care in a secure setting. Father had intermittent contact with mental health services from his late teens onwards, which included episodes of drug-induced psychosis. He received a four year prison sentence for a serious violent crime prior to the birth of Child G. Issues identified include: lack of access to significant history contained in court and prison psychiatric reports and prison health records; pattern of agency involvement with the family by two distinct sets of professionals, focusing separately on the father and on mother and children; overreliance on self-disclosure in assessing risk; and lack of agency knowledge about degree to which father was involved in care of children. Identifies learning, including: the need for GPs to 'think family'; and the need for the probation service to improve its approach to notifying social care of the birth of children to supervisees. Makes various recommendations covering GPs, probation services, accident and emergency services, mental health and health services. Review was undertaken using elements of a systems approach.
      
   Serious Case Review No:  2014/C5018  Published by the NSPCC On behalf of an unnamed local safeguarding children board      This report was written by an independent author and is owned by the commissioning LSCB.  This report is published by the NSPCC with the agreement of the National Panel of Independent Experts.  Publication of this report by the NSPCC does not constitute endorsement of the contents. Copyright of this report remains with the commissioning LSCB.      1 (TEXT REDACTED) Safeguarding Children Board  Serious Case Review  EXECUTIVE SUMMARY  Services provided for Child F and Child G and members of their family           Serious Case Review Overview Report Author Keith Ibbetson       2 1 Background to the SCR and the reasons for carrying it out 1.1 Between November 2011 and June 2012 (TEXT REDACTED) Safeguarding Children Board (LSCB) conducted a Serious Case Review (SCR) of the services provided to an infant (who is referred to as Child F) and her older sibling (referred to as Child G). Child G was aged 2 and Child F was under 1 in late 2011, when Child F was stabbed by her father. Forensic psychiatric opinion is that he was suffering from an acute but severe psychotic episode at the time. The children lived with their mother and other members of her family in (TEXT REDACTED). Their father lived at this address for some of the time and also at the home of his parents, which is also in (TEXT REDACTED). 1.2 Child F was stabbed a number of times before her father was restrained and arrested by police officers who had been sent to the family home following a 999 call. After the incident the children’s father received psychiatric care in a secure setting. The criminal proceedings have now been concluded.  1.3 The parents of both children are both Black (born in the UK) and in their late 20s. The couple do not have any other children.  1.4 The SCR was carried out in order to fulfil the requirements of Chapter 8 of the statutory guidance Working Together to Safeguard Children1. The Working Together guidance states that the LSCB in the area where the child lived should consider conducting a SCR when a child sustains a life threatening injury and the case gives rise to concerns about the way in which local professionals and services worked together to safeguard and promote the welfare of children (Section 8.11). Initial reports indicated that the injuries were life threatening and so the LSCB decided to conduct a SCR. It is part of the function of the SCR to judge whether there are concerns about the way in which agencies and professionals had carried out their child protection responsibilities.                                              1 HM Government, Working Together to Safeguard Children – 2010.   3 1.5 In reaching the decision to conduct the SCR the LSCB noted the following background information which would require attention in the review: • The children’s father had been in intermittent contact with mental health services for a number of years – both in (TEXT REDACTED) and prior to this when he was in prison  • He had a number of criminal convictions and he had been supervised by the probation service between 2008-2010 • A number of agencies and professionals had been involved with the family but had not identified any concerns about the children • The father and members of his family had sought help from a number of local health services about his mental health in the days prior to the incident. 1.6 Prior to the injuries to Child F there had been no significant child protection or welfare concerns about the children. Neither had ever been referred to the local authority nor had either child been the subject of a child protection investigation or child protection plan. Nevertheless the SCR was conducted in order to establish whether any indicators of risk had been overlooked by professionals and to establish whether – regardless of the injuries to Child F – the history pointed to wider lessons that could be learnt or opportunities to improve services to safeguard and promote the welfare of children.  1.7 The decision to hold the SCR was made on 21 November 2011 by the Independent Chair of the LSCB. The review covers the period from 2009 until the incident in which Child G was wounded. The father experienced significant adversity in his childhood. He had had intermittent contact with mental health services and he had a number of criminal convictions pre-dating the birth of his children and the SCR has taken account of these events and the contact that he had with agencies at this time. 1.8 The findings of the SCR and the multi-agency action plan were accepted by the LSCB at its meeting on 2 July 2012. This is the Executive Summary of the findings. The SCR overview report has also been published. No individuals are identified in   4 the published documents and information that could have led to the identification of the children or could lead to an unnecessary intrusion into the privacy of family members has been removed from the published version of the full SCR overview report. The publication of documents has awaited the completion of criminal proceedings and further work to remove information from the SCR overview report that might lead to an unnecessary intrusion into family members’ privacy. 2 Arrangements for the SCR  2.1 The SCR reviewed the work of the following agencies who were involved with the family during the period under review. All are based in (TEXT REDACTED) or are linked to the LSCB because they provide a significant range of services to children and families in the borough:  (TEXT REDACTED) NHS Trust (which provides community health visiting services (TEXT REDACTED))  (TEXT REDACTED) NHS Foundation Trust (which provided community mental health services)  (TEXT REDACTED) NHS Trust (TEXT REDACTED)  NHS (TEXT REDACTED) (in relation to GP services)  (TEXT REDACTED) NHS Trust (antenatal services in relation to Child F)  Police Service   Probation Trust  2.2 A number of other agencies had very limited involvement in the case history and were therefore either asked to provide chronologies, background information and reports or to contribute via additional discussions with SCR panel members:  Ambulance Service  A substance misuse service involved with the father  Limited information was also obtained from the father’s school records and Connexions records.    5 2.3 The review was conducted by a SCR panel which included senior representatives of LSCB member agencies who have expertise in safeguarding children and detailed working knowledge of the professional standards relevant to all of the services involved. The SCR panel was chaired by (TEXT REDACTED). The SCR overview report was prepared on behalf of the LSCB by Keith Ibbetson. Both the SCR panel chair and the report author are independent of the agencies involved and have expertise in children’s safeguarding and substantial experience in conducting Serious Case Reviews.  2.4 The work of the SCR panel was supported by the (TEXT REDACTED) Safeguarding Children Board Manager and the LSCB Administrator. A health overview report was prepared by the Designated Doctor for Safeguarding on behalf of NHS (TEXT REDACTED) which commissioned the health services involved with the family. 2.5 The purpose of the SCR is set out in Working Together as follows:  to draw together a full picture of the services provided for the children and their family  to establish what lessons are to be learned from the case about the way in which local professionals and organisations work individually and together to safeguard and promote the welfare of children  to identify clearly what those lessons are both within and between agencies, how and within what timescales they will be acted on, and what is expected to change as a result  to improve intra-agency and inter-agency working and better safeguard and promote the welfare of children 2.6 Given the specific circumstances of the case the SCR considered whether lessons could be learnt in the following areas:  Was there evidence of risk factors from the period prior to January 2009? Did information about them inform later professional contacts with the family?   6  What assessments were undertaken and what was the quality of those assessments?  Were plans made to provide services consistent with assessments and were they fully implemented?  Did agencies respond appropriately to any risk factors identified in the course of their work with the family?  Did the activity of agencies focus on the needs of children?  What was the quality of information sharing and joint working within and between agencies?  Did any issues arise in the work with the family that prompted, or should have prompted, agencies to seek information from agencies involved before the start date of the review?  Were the specific racial, cultural and religious needs of the family recognised and responded to? Were any other matters relating to diversity addressed?  Did staff have the knowledge, skills, and experience to respond to the needs identified in the case?  Were staff appropriately supervised and supported in their work with the family?  Did lack of capacity or other organisational issues limit the ability of agencies to meet the needs of the family? The SCR overview report provides comprehensive information on all of these matters. The Executive Summary sets out the most important findings of the SCR. 3 Family involvement in the SCR 3.1 Although there was continuing police investigation into the circumstances surrounding the stabbing of Child F it was agreed that in this case it would be possible to seek the views of family members and that this would not prejudice any criminal trial.   7 3.2 It has not been possible to obtain the views of the father because it was judged that during the course of the review he remained too ill to understand the purpose of the SCR and to contribute to it in a meaningful way.  3.3 Individual meetings were held between the SCR overview author and three family members (one of whom was assisted by a close family friend). The purpose of these meetings was to seek the views of family members about the services that were provided and to seek additional information from family members in order to understand the involvement of professionals more fully. The SCR is grateful that family members were able to make a positive contribution in relation to a traumatic, recent event that continues to have a severe impact on their lives. The views of family members are reflected at a number of points in the SCR overview report and have influenced its findings. 3.4 It was apparent that family members were dissatisfied with a number of aspects of the services that were provided and family members have expressed the view that the father was badly let down by professionals and that this has had a devastating effect on the family.  4 Key events in the case history  Events prior to the period under review 4.1 None of the background information about the children’s mother or members of her family gives any indication of potential risk to children.  4.2 The children’s father experienced significant adversity in his childhood and adolescence, including problems in health, mental health, substance misuse and education. From age 17 - 21 the father was convicted for a series of offences including six drug offences (including the possession and supply of drugs), driving offences and two assaults.  4.3 The father had intermittent contact with mental health services from 2004 onwards. The pattern of contact established at that point was repeated later in   8 the case history. His parents or other family members sought help for him when his mental health deteriorated. Assessment did not identify any psychotic symptoms or underlying mental illness. He did not engage with mental health services offered. He was not referred to substance misuse services. His family remained motivated to help him and keep up his treatment by collecting prescriptions and medication. 4.4 In mid-2006 the father violently assaulted another person following a confrontation in the street and he received a four year prison sentence. He explained his actions as being the result of threats from the victim linked to his own involvement in criminal activity. When he was sentenced a report prepared by a consultant forensic psychiatrist set out the history of the father’s involvement with mental health services and concluded that the father’s actions might have been influenced by his mental state. The report pointed to the potential for the development of a ‘severe and enduring mental illness such as schizophrenia’. In July 2008 the father was released on licence at mid-point of his sentence under the supervision of a probation officer. The probation service referred the father to the community mental health service where he was assessed by an experienced psychiatrist. At this point the assessment did not reveal any signs of psychosis or any underlying psychiatric illness. The probation service supervision continued until mid-2010.  4.5 For most of the period 2008 - 2010 the father had no contact with the police suggesting that he had made successful efforts to change his lifestyle. He appears to have been genuinely motivated to remain drug free.  Key events during the period under review 4.6 In April 2009 the mother booked for antenatal care in relation to Child G. She did not mention the identity of the father or the problems that he had experienced in his life. The antenatal care and delivery of the baby were straightforward. No subsequent concerns were raised about the care of Child G. He experienced   9 ordinary child health problems and his mother dealt with them by seeking professional advice in an appropriate way. The health visitor was not aware of the father’s history. 4.7 The father told his probation officer that he was going to be a father shortly before the birth of Child G. The probation service made a check which confirmed that the family was not known to the local authority. At this point there was no reason for the probation officer to have concerns about the care of the child and the recent reports were that the father had no mental health or drug problems. 4.8 From January 2010 onwards the father started to come to the attention of the police, although he was not arrested or charged with any offence. In mid-2010 the father reported to his GP that he had recently restarted using cannabis and that this was causing a deterioration in his mental health. He was prescribed antipsychotic medication and referred to the mental health trust but he did not keep the appointment. Nor did he keep a review appointment at the GP surgery some weeks later, so his prescription was not renewed. Neither the GP records nor the referral letter make any reference to the father being a parent. 4.9 Child F was born in March 2011. Once again the antenatal care and delivery were uneventful. The mother did not provide details of the father or his history to the health professionals she was in contact with. Child F’s health and development were subsequently monitored by health professionals and gave no cause for concern. Events leading up to the wounding of Child F 4.10 Four days before Child F was stabbed the father’s mother contacted his GP to say that he was smoking drugs again and as a result behaving oddly. The father saw a GP later that day and told him that he had no paranoid thoughts. However his own description of his behaviour and thinking suggested that his mental health was deteriorating. The father agreed to be referred to the mental health trust Primary Care Liaison Team. The GP requested an ‘urgent’ appointment within the   10 next two weeks, but he sent the referral by post. It arrived on the morning that Child F was stabbed and it did not contain any information to show why it should be considered as urgent. As a result an appointment was offered for a date four weeks later. 4.11 Two days after the GP appointment the father’s mother telephoned his GP again because her son was not sleeping at night and she said that ‘his mind was racing’. This was 36 hours before Child F was stabbed. A different GP agreed to prescribe the father sleeping tablets for the next seven days. The father’s mother went to the surgery to collect this prescription urgently and it was agreed that she would also call the father’s own GP the next day to explain the circumstances and ask the GP to chase up the referral that had been made to the Primary Care Liaison Team by phoning the on call mental health worker. Subsequent records show that the father’s partner did go to the GP the following morning. No contact was made with the mental health trust to hurry up the appointment. 4.12 That evening the father presented at A&E at (TEXT REDACTED)Hospital, initially with his mother. They were joined shortly afterwards by his partner. This episode began approximately 30 hours before Child F was stabbed. The father was seen by a triage nurse, then by an A&E doctor who recognised that the father had a chest infection. This doctor also referred him to see the duty psychiatrist because of his account that he had been exhibiting paranoid, angry and erratic behaviour. The A&E doctor noted that the father had suffered from ‘induced psychosis in 2004’ and that he had been treated with Olanzapine for two years. The medical record states that he ‘denied hearing voices or seeing things’ and the risk assessment recorded was that he was ‘no risk to others’, no risk to self – not suicidal’ and ‘no risk from others but paranoid’. The father attributed his condition to smoking too much ’weed or skunk’. According to his mother, he had had similar episodes earlier in the year (2011). She reported that ‘when he is like this’ he could smoke up to 40 cigarettes a day and drink large amounts of alcohol, ‘but not most days’.    11 4.13 The duty psychiatric service to the A&E department on this evening consisted of an experienced mental health worker on rota who had access to advice and support on call from a junior doctor in her second year post qualification. The father was seen shortly after midnight by them both which was the practice of the service in relation to new patients. Prior to seeing the father the mental health worker checked for records of the father on the mental health trust’s information system and recorded basic details of the referral.  4.14 The record check showed that the father had been a trust patient in the past but did not give details of contacts, assessments or diagnosis. This was because records of the father’s earlier contacts had not been transferred when the trust had adopted a new electronic recording system. This was because his previous contacts with the trust had only been very limited and because as far as the mental health trust was concerned his mental health had not previously posed a risk of harm to himself or to others.  4.15 The junior doctor and the mental health worker carried out an assessment of the father’s mental state and presentation. The professionals both recollect firstly briefly interviewing the father alone, then seeing him with his mother, until she left the interview and then with his partner. The father’s aunt (a very close family friend) arrived separately but was not interviewed as part of the assessment. Family members told the SCR that they do not recall the father being seen on his own.  4.16 The father gave a very frank account of his heavy use of drugs and alcohol. He said that he felt his symptoms were due to his drug use and that he did not suffer from any mental illness. It was noted that in the past he had been diagnosed with drug induced psychosis on three occasions and treated with antipsychotic medication. The assessment was not able to elicit any symptoms of psychosis or other mental illness (such as depression) arising either from the father’s recent drug misuse or from an underlying mental illness. The record of the mental state examination indicates that there was no evidence of formal thought disorder or of auditory or   12 visual hallucinations. According to the medical record the father showed no evidence of thoughts of harming himself or others. He was noted to have ‘full’ insight, suggesting that at this point there was a rational connection between his explanation for his symptoms and his account of his own behaviour. His mood was recorded by the doctor to be ‘objectively slightly paranoid and anxious’ but ‘subjectively paranoid’ (which is taken to mean that the father said that he felt paranoid but that in psychiatric terms he was not experiencing paranoid delusions). The assessment noted that his paranoia was ‘exacerbated by weed use’ and that the basis for his fear and suspicion of others was in good part grounded in reality. 4.17 The outcome of the assessment was that the father was believed to be experiencing symptoms consistent with heavy drug and alcohol use but that he had no thoughts of harming himself or others. The judgement was that there was no indication that he presented any immediate risk to himself or others and that he had very good family support at home. He was believed to have had ‘full insight’ into his circumstances (i.e. he himself had a very clear idea what it was that was making him feel paranoid). The management plan was for the father to be allowed home and discharged back to the care of his GP who had already made a referral to the (TEXT REDACTED) Primary Care Liaison Team. The father and the family were given up to date information leaflets about local drug and alcohol services. The clinicians state that they felt that this plan had involved the father and his family and that they were in agreement with it. The father was given one tablet of Diazepam in order to help him sleep that night and the mental health worker agreed to expedite the referral that was already in place to the mental health service. Family members say that they questioned whether more needed to be done. 4.18 The assessment was documented on the trust electronic record system. The mental health trust risk documentation was not fully completed at the time of the   13 assessment. Family members state that the father took both of the medications prescribed to him that evening. 4.19 For their part family members have expressed frustration and disappointment to the SCR about this assessment (and also directly to the mental health trust). They have expressed concerns about some remarks made by the doctor and the mental health worker which they feel conveyed a negative attitude towards their work with the family. The father’s partner did not think that there was sufficient probing in depth of his mental and emotional state and how he was feeling. The close family friend has expressed surprised at how short a time the assessment lasted. With hindsight all family members feel that too much emphasis was placed on the father’s self-reported misuse of cannabis and alcohol. They now state that they find the extent of his reported consumption to be implausible and feel that this detracted from a fuller exploration of his mental health needs. Family members state that the father was willing to be admitted to hospital and that this is what they think should have happened.  Assessment of risk to the children 4.20 The A&E doctor recorded that the father lived ‘with girlfriend and children’. The duty psychiatrist recorded that the father had two children and noted their ages. No specific information was recorded about exactly where the children lived or the nature and extent of the father’s contact with them or his caring responsibilities.  4.21 No one perceived there to be any risk at all to the children or stated any concern in relation to this. The doctor and the mental health worker say that they were reassured about the welfare of his children because the father was not being aggressive or violent, he was affectionate to other family members and because he spoke about his children in a very positive way specifically citing his desire to be a better father as his main reason for wanting to stop taking drugs and drinking. They were reassured by the presence of key members of the extended   14 family who they felt mitigated any potential risk –both in relation to the father’s mental health and in relation to the care of the children. The mental health trust provides a format for recording the risk assessment in relation to patients and service users who have contact with children. This was not completed at the time of the assessment. 4.22 Later the following day the father’s partner telephoned the father’s GP surgery who prescribed additional medication in order to help the father sleep. This was the last professional contact with any family member before Child F was stabbed.  4.23 The following morning the father woke in the early hours. After a few minutes it was clear to his family that he was becoming agitated and behaving and speaking in a very odd way. The children’s mother called 999 reporting that the father had mental health problems and was ‘going mad in the house’. Child F was stabbed before anyone could intervene. Because of the urgency of the circumstances Child F was conveyed immediately to the nearest A&E department (a very short distance from the family home) in the police car. This was with the agreement of her grandmother who accompanied her. Child F was subsequently moved by the Helicopter Emergency Medical Service to a hospital better equipped to treat major paediatric trauma. 4.24 Descriptions of the father’s behaviour from the evidence of those who were present indicate that there had been a significant change in his mental state in the 24 hours since he had been seen at A&E. At this point all of the witness accounts indicate that he was floridly psychotic. 5      Conclusions of the SCR and key lessons learnt  The overall pattern of professional involvement with the family 5.1 The preceding narrative shows that all of the factors associated with risk to the children were associated with the father’s drug misuse and associated mental illness. However most of the professionals who were involved with the family   15 were not aware of his difficulties. This is because there were two distinct groups of professionals who were involved with different family members and consequently had very different information.  5.2 The first group of professionals worked with the father. The father’s family GP knew him well and had treated his mental health problems during 2004 – 2006. The father was seen again at the surgery in 2010 and in 2011. The GP knew that the father had become a parent but did not record this on the medical notes or refer to this in any referrals or correspondence.  5.3 The father was under probation supervision for two years from 2008 – 2010. During this period Child G was born.  5.4 The father had also had a number of contacts with mental health services, described above. 5.5 This group of professionals shared information about the father with one another at appropriate points.  5.6 A separate group of professionals were in contact with the children and their mother. This group included midwives, health visitors and the mother’s family GP. Prior to the incident that triggered this review there had been no child protection concerns about either of the children. The children were in good health and developing well without any need for additional services. The health visitors knew the identity of the children’s father but neither of them had any background information about him. The children’s mother did not disclose this to the professionals who were working with her. No professional knew how much involvement he had in the lives of his children.  5.7 As a result of this pattern of involvement the assessment of those professionals who were working with the children could only be based on their own observations of the health and development of the children and the care provided to them by their mother, which was always observed to be positive. No account could be taken of the potential risk that the children’s father might pose   16 if his substance misuse triggered a deterioration in his mental health or started to impair his parenting capacity.  5.8 The professionals who were in contact with the mother and the children and those who were working with the father did not communicate with one another. This was because there was no cause for concern about the children and no need for professionals to be in touch with one another. The probation officer ceased to be involved with the father before the birth of Child F and the mental health service was only intermittently involved. Could the assault on Child F could have been anticipated or prevented? 5.9 The weight of all the evidence is that the father’s cannabis use began again and increased after his probation supervision ended in mid-2010. This led his family to be concerned about the deterioration in his mental health as a result of which his GP referred him to the community mental health service for assessment in 2010 and in 2011. The outpatients assessment arising from the second referral had not taken place at the time when Child F was injured.  5.10 24 hours before she was injured the father was assessed in the accident and emergency department. His anxiety, agitation and paranoia were attributed to his heavy cannabis and alcohol use and linked to his involvement in criminal activities and there was no sign of any serious mental illness at that assessment.  5.11 There is a clear contrast between the view of the case history that it is possible to obtain looking back with the benefit of hindsight and the knowledge that professionals had of the case as it unfolded. Regarding the case with the benefit of hindsight it is apparent that the health professionals who were in contact with the children and their mother would have benefited from knowing more about the background history of the father and the risks that he might pose if his mental health deteriorated. However following the case history as it unfolded it is easy to understand why separate groups of professionals worked with different family members and why there was never any reason for them to   17 communicate to one another about potential risks.  5.12 When there is no evidence of risk or additional need there is no system that enables all professionals who are working with children to know everything about the involvement of other professionals with other members of the family. This relies entirely on family members sharing this information. They may not understand why this could be useful and they may not choose to. In this case the mother had some knowledge of her partner’s history of mental health problems and drug misuse but did not consider that it was relevant to discuss it with professionals because she did not believe that he presented a risk to the children. From the professional perspective it means that there are cases - such as this - where professionals will not know some information that later turns out to be significant. 5.13 Even if they had had background information about the father the health visitors or other health professionals may not have acted very differently. Prior to the deterioration in the father’s mental health there were no concerns about the children and the other family members were viewed as competent and supportive and it would have been assessed that they would have protected the children if there had been any problems. There might have been a higher level of health visitor involvement in the family, but there would never have been sufficient concern to trigger a child protection investigation or any other form of social care intervention. The professionals who were involved would not have been able to anticipate the very sudden and dramatic deterioration in the father’s mental health. In particular it would not have been possible to predict that as his mental health did deteriorate he would immediately pose such a serious risk of harm to his child. Neither the family nor the professionals had ever seen the slightest hint of this before. 5.14 The father had been referred for a community-based mental health assessment, four days before he injured his daughter. The GP asked for an urgent assessment, but did not provide the sort of information that would have   18 triggered an urgent response or communicate the referral quickly enough to the mental health trust. 5.15 The psychiatric evaluation of the father that took place in the A&E department 24 hours before the father injured his daughter was a critical point. Some shortcomings in this assessment have been identified. It would have been better if family members had had an opportunity to speak to the professionals without the father being present. There was no systematic assessment of potential risk to the children. However the SCR has found that there was no indication of psychotic illness shown during the assessment. The SCR is confident that if there had been evidence of psychosis or overt indicators of risk to the children they would have been recognised. The assessment of risk to the children was based on the observation that the father was not psychotic and not acting in an aggressive way and that he did not pose a risk to his children. If that assessment had been completed in a more comprehensive and systematic way it is very likely to have come to the same conclusion. There was no reason for the professionals involved to believe that the children might be seriously harmed by the father because of the active concern and the level of involvement and engagement of the family.  5.16 24 hours after this assessment the evidence is that the father was in a severely psychotic state and suffering from delusions. So far as the SCR can establish he had never been in such a condition at any point before in his life and prior to this there was no reason to believe that he posed a risk of serious harm to his children. 5.17 In his review of services to safeguard children in England in March 2009 Lord Laming recognised that it is not always possible to prevent the serious abuse of a child, noting that serious injuries and even deaths can arise from ‘the sudden and unpredictable outburst by an adult towards a child’. He notes that such circumstances are ‘entirely different from the failure to protect a child or young   19 person already identified as being in danger of deliberate harm’. 2 The evidence is that this is such a case and that there was no indication to any professional (or indeed to members of the family) that the children were at risk of serious harm. 5.18 Although there is no indication that the injuries to Child F could have been anticipated or prevented a number of additional learning points arise from the evaluation in this report and in the individual management reviews.  Obtaining information about fathers and engaging them in work 5.19 None of the health professionals involved saw it as their responsibility to challenge the mother to provide more information about the father or to seek background information from other sources. This was consistent with the prevailing practice and culture of all health agencies and this is a pattern in practice that goes beyond the individual case, despite recent government guidance which places great stress on identifying fathers and encouraging the involvement of fathers in the care of their children.  5.20 At present it is clear that there is a gulf between the guidance produced by government and the implementation of this aspiration by many front line staff. Guidance sets very high expectations about the involvement of both resident and non-resident fathers in work with young families highlighting the value of direct communication with fathers, assessment of fathers and arranging appointments at times when fathers can attend. 3 Many practitioners aspire to achieve this but know in practice that in many settings contacts will usually be with the mother and practitioners will rely on the information that the mother provides. The reasons for this will be shaped by different reasons in different health settings and in work with different communities. In practice it will often be most difficult to engage the fathers and other male carers who most need to                                             2 The Lord Laming (March 2009), The Protection of Children in England – a Progress Report., HC330 Stationery Office 3 Department of Health (2009), Healthy Child Programme – pregnancy and the first five years of life Page 26     20 be engaged - because they are less likely to be cooperative. 5.21 To be successful the work to engage fathers requires a significant change in culture, expectations and working practice. Guidance alone will not achieve these changes. Training will be beneficial because it is clear that many practitioners find it hard to broach the issue of father’s involvement with mothers and to find out more about fathers in a way which does not appear to be intrusive and threatening. However it is unlikely that in isolation training will make a significant difference and it is recommended that health trusts need to provide a much more comprehensive approach. This could include: issuing clear guidance; offering training; and monitoring the extent of engagement with fathers and the effectiveness of contacts. Staff will need to be consulted so that there is a shared understanding of why this aspect of practice is so difficult and to have an opportunity to contribute their own ideas. Many of the ideas suggested in national government guidance (such as offering appointments when it suits fathers) have resource implications. Trusts need to decide at a senior level whether they are prepared and able to commit the necessary resources and to ask staff to prioritise this area of activity. This needs to be addressed by all health trusts providing midwifery and health visiting services. Other opportunities for learning 5.22 The SCR has highlighted opportunities for better information sharing between the prison and criminal justice system and community based health professionals, both through the sharing of prison health records and court reports and through the greater engagement of health agencies in the multi-agency risk assessment arrangements (MAPPA).  5.23 The SCR has highlighted the complexity and difficulty of undertaking mental health risk assessments within the A&E service, particularly noting the difficulty of assessing potential risk to children when they are not present, contact with professionals who know them is not possible and there are often no records   21 available. The mental health trust review has made a number of recommendations in relation to this and the LSCB will closely monitor its implementation since this is a point of vulnerability within current services. 5.24 The probation service has recognised the need to refine and improve the approach taken in notifying the birth of children to probation service supervisees to local authority social care services. Consideration needs to be given to making this more sensitive to individual circumstances and also to providing channels of communication to GPs and other health professionals. 5.25 The case history underlines the need for GPs whose patients have mental health problems to actively ‘think family’. That means specifically: 1) asking whether their patients are parents or have substantial caring responsibilities towards children; 2) recording this in medical notes so that all members of the primary health care team have access to the information; and 3) mentioning and emphasising it in all referrals and correspondence about the patient. 5.26 In this case the father’s GP and the mental health trust had a completely different understanding of whether the father’s circumstances merited an ‘urgent’ Additional recommendations from individual management reviews 5.27 These findings and recommendations stand in addition to the recommendations made in individual management reviews prepared by agencies that had direct involvement with the family. Additional recommendations have also been made in the health overview report prepared on behalf of commissioners of health services. These are set out in full in the multi-agency action plan that accompanies this report. They deal with the following areas. (TEXT REDACTED) NHS Trust (TEXT REDACTED)  The use of the Family Health Assessment  The implementation of the ‘did not attend’ policy in child health services (TEXT REDACTED) NHS Foundation Trust    22  A consistent trust wide operational policy for mental health assessments undertaken in A&E departments  A revised safeguarding children programme tailored to staff working within A&E  In future all junior doctors will have information about safeguarding children and adults as part of their induction.  Clearer procedures for staff about documenting risk assessments and management plans  Improved access to records of service users with a historic history of severe risk that had been documented on previous recording systems   Better information sharing protocols between agencies involved in mental health services (such as the prison health service) to ensure that all relevant information and reports are shared NHS (TEXT REDACTED) (in relation to GP services)  The family focus of GPs  Information sharing between GPs working with different members of the same family  The need for GPs to seek information about drug and alcohol use  GP working arrangements with the health visiting services (TEXT REDACTED) NHS Trust  Improving compliance with the audit of postnatal discharge documentation 6 Learning the lessons of the SCR and the implementation of recommendations 6.1 The findings of the SCR and the recommendations that flow from them have been adopted by (TEXT REDACTED) LSCB and the member agencies directly involved. Many of these recommendations have already been fully or partly implemented. The LSCB will oversee implementation over the coming months to ensure that lessons are learnt and practice improves.  