Executive summary of a review into the serious injury of 6 1/2-week-old twin babies, who were admitted to Somerset hospital and found to have serious head injuries and body bruising. Father was convicted of unlawfully and maliciously inflicting grievous bodily harm and received a sentence of 45 months' imprisonment, Mother was found not guilty of any offence. Mother and Father known to have had troubled childhoods and history of paternal mental ill health and conviction for violent offences. Family had contact with a number of services, including 7 local authority areas, 29 health agencies, 3 police forces and 7 housing authorities/agencies. A strategy discussion had been held by Somerset children's services and plans were in motion for a child protection conference at the time of the incident. Considers issues of: pre-birth assessments and rights of the unborn child; the role of police welfare checks; the need for professionals to challenge each other appropriately; working with mobile families who regularly cross organisational boundaries; and the use of research to inform practice. Makes interagency and various single agency recommendations covering children's social care, housing services, legal services, GPs and NHS Trusts and the police.
      
Title: Serious case review: overview report: executive summary: in respect of Baby A and Baby B LSCB: Somerset Local Safeguarding Children Board Author: Jane Wonnacott and Gillian Earl Date of publication: 2013 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. Executive Summary 21.03.13 Page 1 of 27 Somerset LSCB Serious Case Review Overview Report EXECUTIVE SUMMARY In respect of Baby A and Baby B  Report Authors Jane Wonnacott  BA MSc MPhil CQSW AASW Director In-Trac Training and Consultancy Ltd Gillian Earl RGN RHV MA Associate In-Trac Training and Consultancy Ltd Executive Summary 21.03.13 Page 2 of 27 1.INTRODUCTIONCircumstances leading to this serious case review 1.1  Twin babies aged six and a half weeks were admitted to a Somerset hospital and found to have serious head injuries and body bruising. The babies had moved to Somerset from Nottingham with their parents eleven days previously and were living with family in the area. Both parents were arrested and charged with Grievous Bodily Harm. The result of the criminal trial was that Father was convicted of unlawfully and maliciously inflicting grievous bodily harm and received a sentence of 45 months’ imprisonment. Mother was found not guilty of any offence. 1.2  Mother and Father had received services in seven different local authority areas and had been in contact with a significant number of health providers, both during the pregnancy and following the birth of the twins. 1.3  In view of these circumstances, the chair of Somerset Safeguarding Children Board decided that the case met the criteria for a serious case review under statutory guidance1, which requires that a review should be considered where a child sustains a potentially 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. 1.4  In line with national guidance, Somerset LSCB took the lead in convening the review since the babies were resident in Somerset at the time of their injuries. As information emerged that there had been significant prior involvement by agencies in other areas of the country, information was sought from the relevant organisations and they were invited to participate in the review process. This included attending panel meetings and commenting on drafts of the report. 1 HM Government (2010) Working Together to Safeguard Children London: DCSF. Chapter 8, paragraph  8.11.   Executive Summary 21.03.13 Page 3 of 27 2. THE SERIOUS CASE REVIEW PROCESS   2.1  John Snell, Somerset Safeguarding Children Board Independent Chair, was appointed to chair the serious case review panel and oversee the process.   2.2  Members of the serious case review panel were: Somerset LSCB Co-ordinator  Somerset LSCB Deputy Chair Service Director, Safeguarding and  Care Designated Doctor Somerset and North Somerset Local Safeguarding Children Boards  Designated Nurse Somerset Local Safeguarding Children Board Detective Inspector Avon and Somerset Police Principal Educational Psychologist Somerset County Council LSCB Audit Officer     2.3  Independent authors Jane Wonnacott and Gillian Earl were appointed to prepare the overview report. The authors attended panel meetings in order to ensure that the views of the panel were taken into consideration in the preparation of the final report.   2.4  Following careful consideration of the facts, full individual management reviews were requested from: • Oxfordshire County Council. • Oxfordshire General Practitioner Services. • Avon and Somerset Police. • Nottingham CityCare Partnership (Health). • Nottingham City Children’s Social Care. • Northern Lincolnshire and Goole Hospitals NHS Foundation Trust. • Derby Hospitals NHS. • Nottingham University Hospitals. • Somerset Social Care. • Somerset GPs. • Somerset Partnership NHS Foundation Trust (formerly Somerset Community    Executive Summary 21.03.13 Page 4 of 27 Health). • Derbyshire Social Care. • Somerset Health Overview Report.  2.5  Supplementary information and reports for information from organisations who had limited contact with the family were received as requested by the panel.    2.6  During the latter stages of the review process information was received from Somerset County Council Legal Department regarding the estimated timings and nature of the injuries to Baby A and Baby B. This information noted metaphyseal fractures present in both babies that were likely to have occurred sometime prior to the final serious injury.    Terms of reference and scope of the review 2.7  The terms of reference for the review were agreed by the panel chair. The timescale for the review was established as beginning when Mother met Father, moved to North Somerset, and became pregnant, and ending following the twins’ admission to hospital with serious injuries and non accidental injury was established to be the most likely cause.   2.8  It was agreed that the overall aim of the serious case review process would be as described in Working Together to Safeguard Children 2010 Chapter 8, section 8.5. In addition, authors were asked to consider the earlier childhood history of each parent in order to understand the attributes they brought to parenting.  Each author was also asked to assess whether any information their organisation held about either parent, outside the prescribed timescale, was relevant to any issues raised and lessons learnt.   Family involvement 2.9  The Serious Case Review Panel was advised by Somerset Police that family members should not be contacted until after criminal proceedings had been completed. Letters were sent to both parents and paternal grandmother outlining the serious case review process, explaining that they could immediately submit any comment in writing to the serious case review panel.  This letter was copied to the family social worker as a point of contact should the family request further explanation. Following conclusion of the trial Mother, grandmother and Father were contacted and asked whether they wished to contribute to the review. Father did wish to see the overview author and he was    Executive Summary 21.03.13 Page 5 of 27 therefore visited in prison and his views sought about the help offered to the family.       3. FAMILY AND PROFESSIONAL CONTEXT   3.1  Both parents of Baby A and B are White British. Father lived in the south west region until moving to Oxfordshire and Nottingham following his relationship with Mother. Mother grew up in Derbyshire, moving to North Somerset once she began the relationship with Father; together they then moved to Oxfordshire, Nottingham and most recently Somerset.  3.2  Mother, following a troubled childhood, was living in a hostel in for vulnerable young women in Derbyshire immediately prior to meeting Father. She has several siblings, one of whom lived in the Oxfordshire area. There have been frequent suggestions that the Mother may have a learning disability but there is no evidence of any formal testing to confirm this.   3.3  Father’s childhood was also troubled, having spent time in the care of Somerset County Council as a young person. There is some evidence of mental health problems and he was also known to the police following violent incidents resulting in a number of criminal convictions.   3.4  Father met Mother when she was visiting North Somerset on holiday; she moved in with him a week later and shortly afterwards it was confirmed that she was pregnant with twins.   3.6  Following confirmation of Mother’s pregnancy in North Somerset: •  Mother moved to Oxfordshire to stay with her brother, citing domestic violence from her partner. Mother reconciled with Father, was evicted from her brother’s home and moved with Father into a tent in Oxfordshire. Health, Children’s Social Care, Police and housing agencies had contact with the family at this point.  •  Mother and Father moved to Nottingham, moving in with a friend until they obtained their own accommodation. Nottingham Children’s Social Care, housing organisations and health agencies were all involved with the family during this pre-birth phase. Children’s Social Care completed assessments but at no time    Executive Summary 21.03.13 Page 6 of 27 was the case considered by them to meet the threshold for child protection enquiries. • Mother went into premature labour ten weeks before her estimated date of delivery and was admitted to hospital in Nottingham before being transferred to hospital in Grimsby (where the twins were born) due to lack of Neonatal Intensive Care cots in Nottingham.  • The twins (together with both parents) were transferred to Derby hospital’s Neonatal Intensive Care Unit, then back to Nottingham where they were discharged into the community. During their time in hospital concerns were expressed to the social worker by hospital staff about the parents’ care of the twins, however, the case continued to be assessed as falling below the threshold for child protection.   • Within forty eight hours Baby A was re-admitted to hospital in Nottingham and discharged the following day. Nottingham Children’s Social Care continued to be involved at this point and liaised with Somerset Children’s Social Care once they were aware that the family were planning on visiting Paternal Grandmother in the Somerset area. • A few days later, the family moved to Somerset without telling professionals that they were leaving. According to Father, their intention at this point was to find somewhere to live where they felt safer than they did in Nottingham.  • During the eleven days the family spent in Somerset a strategy discussion was held and plans were set in motion for a child protection conference. Daily visits were set up and they were visited by professionals from three services (Police, Health and Social Care) on seven occasions. A number of planned visits to the family were unsuccessful. The babies were also seen by the GP and were taken to Accident and Emergency on one occasion prior to their final admission with unexplained injuries.  3.7  As demonstrated by the above history, Mother and Father have had contact with a number of services beyond universal provision, both prior to and during the period covered by this review. This has therefore been an extremely complex review involving seven local authority areas, twenty-nine individual health agencies, three police forces and seven housing authorities / agencies.        Executive Summary 21.03.13 Page 7 of 27                                                 4.  SUMMARY OF LESSONS LEARNT     Protecting babies’ pre-birth. 4.1  Many of the lessons from other reviews, in relation to babies under one year, apply in this case, particularly in the pre-birth period. An important factor appears to have been a lack of understanding of the implications of a multiple birth, the likelihood that the babies would be premature and the possibility of medical complications making the babies more vulnerable.  The delay in completing a robust pre-birth assessment was therefore particularly significant and resulted in over-optimism that the parents would be able to provide safe, appropriate care. Caring for twins provides a number of challenges and for these parents, with their own vulnerabilities and needs, a comprehensive pre-birth assessment should have highlighted the risks and resulted in a coherent multi-agency plan before they were born.   4.2  The issue of the right of unborn babies to protection is fundamental here. The legal and statutory definition of a child does not include the unborn and there is, therefore, a case to consider amending this definition in order to protect the rights of the unborn child.     Using professional knowledge to inform assessments 4.3  There is evidence that assessments failed to identify the interaction of a number of known risk factors that should have concerned professionals.  These included mental health problems, a history of violence, substance misuse, possible domestic violence and parents who had received compromised parenting themselves. These were not properly assessed and did not result in a coherent plan to protect the babies.   4.4  At no time, particularly pre-birth, were professionals explicitly utilising any frameworks to assist them in identifying risk. The PAM (Parenting Assessment Manual) assessment’s primary focus was on parental functioning and, in conjunction with a good core assessment, may well have contributed to an understanding of risk.   4.5  However, there was no core assessment and the PAM assessment was unfinished. Ward et al (2010)2 suggests that utilising a simple methodology developed by Jones et  2 Ward, H., Brown, R., Westlake, D., and Munro, E. (2010) Infants suffering, or likely to suffer, significant harm: A prospective longitudinal study. DfE Research Brief DFE-RB053    Executive Summary 21.03.13 Page 8 of 27                                                                                                                                                                  al (2006)3, and underpinned by research evidence, has proved a useful means of identifying which children are at greatest risk of suffering significant harm in the future.  Another useful framework both pre- and post- birth is the signs of safety approach4. The explicit use of such frameworks might have assisted in the consideration within Nottingham and Somerset as to the level or risk and whether the threshold for legal intervention had been met.   Daily Visiting 4.6  One response to the concerns in the case was to set up a daily visiting schedule both in Nottingham and Somerset. Any plan for daily visits needs careful consideration as, unless the purpose and limitations of the visits is clear, it may result in a false sense of security across the professional network. As this case demonstrates, it is likely that the babies had suffered during the period that visits had occurred and the visiting schedule did not prevent the final severe head injuries.  In fact, it is possible that the visits themselves raised the parents’ anxieties. Where daily visiting is taking place, it is important that the purpose is made explicit to families and the professionals who are carrying them out and there are clear contingencies in place if visits are not achieved.   Police Welfare Checks 4.7  Linked to daily visiting is the issue of ensuring the right people with the right qualifications and experience are carrying out tasks.  For example, the police officer asked to carry out a welfare check had limited operational experience. They were asked to undertake a potentially complex task and to offer an opinion as to the health and welfare of the babies, an opinion that was likely to have been given considerable weight by others. As a result of this case and others, Avon and Somerset Police are working on a protocol which will clarify the role of welfare checks and who should be charged with carrying them out.    Attendance at meetings 4.8  Other issues have emerged concerning roles within the system, including ensuring that the right people (i.e. those with direct knowledge of the parents’ capabilities) attend discharge planning meetings and the need for strategy discussions to include health personnel, particularly where there are young babies with medical issues.  3Jones, D., Hindley, N., and Ramchandani, P. (2006) ‘Making Plans: Assessment, Intervention and Evaluating Outcomes, in Aldgate, J., Jones, D., and Jeffery, C. (eds) The Developing World of the Child. London: Jessica Kingsley Publishers 4Buffa, J., and Podesta, H. (2004) ‘Partnership and Risk Assessment in Child Protection Practice Protecting Children 19 (2) 36-48    Executive Summary 21.03.13 Page 9 of 27  Professional Challenge 4.9  The need for professionals to challenge each other appropriately has been a feature of many serious case reviews. In this case there appear to have been a number of factors that prevented constructive challenge at various points, most notably during the time the twins were in hospital, post-birth. The overriding impression is that there was a reluctance to challenge social workers who were perceived to have more expertise in child protection matters. This reluctance was compounded by the communication style of one social worker. This was particularly crucial at the point of the discharge planning meeting, when it is now known that despite escalation polices within the LSCB, the disquiet of nursing staff was not conveyed to the chair. LSCBs, therefore, need to take steps to move beyond policies and procedures in this area and to examine the health of interagency relationships on a regular basis.       Working with mobile families  4.10  This case has clearly highlighted the challenges associated with working with mobile families who regularly cross organisational boundaries. As well as the practical issues relating to information transfer, the review has also identified that mobility needs to be treated as information in its own right. In this case, for example, it is possible that the sudden move to Somerset may have been triggered by the parents becoming aware that there were developing concerns about their parenting. The reason for mobility therefore needs to be questioned and understood within the context of an assessment of risk.    4.11  Professionals also need to be careful not to increase mobility inappropriately, such as when Mother was encouraged to move from North Somerset to her brother’s home in Oxfordshire.  Additionally, in this case, the lack of suitable neonatal intensive care cots resulted in these vulnerable babies moving through three hospitals in the first few weeks of their life. The number of moves immediately following their birth appears to have reflected the mobility of the family generally, and may have reinforced this behaviour and led them to believe that practitioners were not robustly managing the case and therefore that they should move to one (Somerset) which could meet their needs.     Working with complexity 4.12  The importance of reflecting, throughout any assessment on the dynamics of family/    Executive Summary 21.03.13 Page 10 of 27 professional interaction, is evidenced throughout this review. At times the parents appeared to be engaged with professionals, drawing them in as a source of support, mainly with practical matters. On other occasions they were openly hostile although there is also evidence that they gave clear warnings to professionals that they did not feel able to cope with the babies and would have agreed to s20 accommodation. In Nottingham this option was not considered, as the focus was on the inappropriateness of using section 20 for what was perceived to be housing rather than a child protection issue. This option was again not considered in Somerset, this time because the parents were not requesting it and appeared to be coping, with support.  The importance of listening to parents who, through their behaviour, are giving clear warnings that they are not coping needs to be recognised, as a failure to respond at that point may mean the opportunity for intervention is lost.  4.13  Relationships between professionals and the family were therefore complex and there is little evidence that supervision in any agency enabled professionals to reflect on the dynamics of the relationship they had with the family and the meaning of their behaviour.   Staff supervision 4.14  The need for effective supervision is therefore a key lesson from this review. Effective supervision would have enabled professionals to stand back from the day to day case management, focus on the risk factors present in this case and consider their likely impact on outcomes for the babies.  Effective supervision would also have focussed, whilst the babies were in Nottingham, on the dynamics of family / professional relationships as well as relationships between professionals and the impact these might be having on outcomes.   4.15  One important lesson particularly relevant within health agencies is the need to use consultation with named and designated professionals, combined with escalation processes if necessary, when there is concern regarding the actions or decisions of others within the professional network and constructive challenge has not resulted in the desired outcome.          Executive Summary 21.03.13 Page 11 of 27 5. CONCLUSION   5.1  In this case, Baby A and Baby B were injured whilst living in a family situation which, when all the facts are taken into account, could have predictably led to a less than optimal outcome. Whilst the severity of the injuries could not have been predicted, there were clear signs that Mother and Father were struggling to provide the care needed by two vulnerable, premature babies. An important issue is therefore whether there were opportunities to prevent the injuries.   5.2  The most obvious opportunity was during pregnancy in Nottingham, when a comprehensive pre-birth assessment would have revealed family histories indicative of parents who, at best, would need a great deal of support to care for twins. The combination of a twin pregnancy, two vulnerable parents, Father’s history of violence and few support structures should have led to a structured assessment of risk prior to the birth.  5.3  The second opportunity to prevent the injuries was during the immediate post-birth period when both parents were giving clear signals that they were finding it difficult to cope, with the father at times being especially vocal about his concerns. A combination of a discharge planning meeting that did not include information from concerned health professionals, and a failure to really listen to what the parents were saying, both verbally and through their actions, meant that there was a focus on practical issues such as housing, rather than potential risk. Health staff remained concerned, but failed for whatever reason to escalate their concerns to senior management.  5.4  The final opportunity was following the parents’ sudden move to Somerset, when the earlier failure to conduct a full assessment resulted in a paucity of relevant information being passed to Somerset. Although the case at this point was immediately identified as high risk, again historical information that should have been available about Father, including his criminal background involving violence, was not integrated into the ongoing assessment, nor did it inform a discussion with the legal team regarding whether the threshold for legal intervention had been met.  5.5  Although there was well co-ordinated professional activity providing intensive visiting to the family at this point, it is likely that both babies had already received some injuries. It    Executive Summary 21.03.13 Page 12 of 27 is possible that the final serious injuries could have been prevented by greater clarity regarding the purpose of the welfare visits and a more intrusive approach by professionals. In addition, a greater recognition and acknowledgement of the risk posed by Father might have resulted in a more proactive management of risk action plan.  5.6  The preventability of the final injuries through a differing approach to visiting in Somerset is by no means certain. The main conclusion from this review must be that the failure to prevent the injuries stemmed from the cumulative effect of a number of organisations over time, failing to: • Integrate all known information about the family. • Recognise risk, including the particular issues relating to a multiple birth. • Fully assess the impact of a parent’s own life experiences on their parenting capacity. • Work together effectively across professional and area boundaries.   5.7  It should be noted that this was a particularly challenging situation due to the number of moves, some of which were precipitated by organisations themselves. Managing such cases requires strong, effective management, supervision and support for professionals to enable them to stand back, reflect and identify risk whilst working with constantly evolving complex situations on a day to day basis.  5.8  The most important element of any review must be whether it has a positive impact on future practice. Individual management review authors have considered their involvement in this case and made many recommendations for practice improvement which have been accepted by senior managers and are in the process of being addressed. A number of additional recommendations are made by this overview report that require either a multi-agency approach to service improvement or a shared vision of good practice across LSCB member agencies. These relate to pre-birth assessment practice, staff supervision, inter-professional relationships and use of research to inform practice. It is the view of the serious case review panel that these recommendations address key issues which are at the heart of practice in this case.        Executive Summary 21.03.13 Page 13 of 27 6. OVERVIEW REPORT RECOMMENDATIONS    All LSCBs involved with this review are asked to consider the recommendations from the overview report, health overview report and individual management reviews relevant to their area. The chair of Somerset Safeguarding Children Board will write to the chairs of Nottingham, Derbyshire, North East Lincolnshire, Oxfordshire and North Somerset, in order to bring to their attention the findings of this review and invite them to develop and monitor action plans which will address the lessons learnt.  6.1  LSCBs should review their pre-birth assessment guidance to ensure that it highlights the particular risks that need to be considered in the case of multiple births and the need to gather and analyse all relevant historical information.   6.2  LSCBs should ensure that an audit of pre-birth assessments takes place, in order to ascertain whether they are fit for purpose, in line with the guidance and adequately analyse the potential risk to the unborn child.    6.3  LSCBs should review supervision arrangements across the partnership and establish, implement and audit a core standard for safeguarding supervision. The standard should:   • Focus on the quality of supervision delivery. • Take account of differing governance arrangements, supervision cultures and organisational structures for the delivery of supervision. • Take account  of Working Together to Safeguard Children (2010 para 4.51) and promote a style of supervision which: � Keeps a focus on the child � Avoids drift � Maintains a degree of objectivity and challenges fixed views � Tests and assesses the evidence, based on assessments and decisions � Addresses the emotional impact of work.  6.4  LSCBs should ask agencies to review their internal escalation and resolution processes and ensure that policies are combined with regular activity to evaluate and review the health of relationships at the front line and first line manager level.   6.5  LSCBs should review and monitor single agency or multi-agency safeguarding training strategies to ensure the promotion and embedding of relevant research, in relation to the assessment of risk and young babies, the importance of cumulative histories in    Executive Summary 21.03.13 Page 14 of 27 analysing risk and working with resistant and/or mobile families.   6.6  Somerset LSCB should raise with the appropriate Government department the issue that unborn children currently do not have the same right to protection in law as children post-birth, and ask that Government child protection guidance should adequately address the rights of the unborn child.        7. HEALTH OVERVIEW RECOMMENDATIONS    It is recognised that only the Somerset Local Safeguarding Children Board and partners can implement an action plan; however, it is highly recommended that these recommendations are disseminated to all NHS Clusters and Local Safeguarding Children Boards for both their consideration and implementation as standards of good practice.  7.1  NHS Somerset Director of Nursing will write to the Strategic Health Authorities Directors of Nursing to request them to recommend that NHS Trusts have in place, a policy for multi-agency pre-birth planning between 18-20 weeks gestation, where there is recognition of parental risk factors and/or safeguarding concerns to the unborn/newborn child • Early identification of high-risk families must include a holistic evaluation of any risk factors to unborn children, particularly where there is known domestic violence and parental mobility.   • There should be recognition of the likelihood of early delivery for all pregnancies but particularly when the mother is expecting twins.  • Safeguarding concerns to the new born child should be identified through holistic assessment by 18-20 weeks gestation and a multiagency pre-birth planning meeting held to develop a pre-birth plan with additional measures in place in the event of premature birth.  • GP record keeping policies should require all vulnerable families’ records to be ‘flagged’ with born/unborn children. Record keeping policies should be amended    Executive Summary 21.03.13 Page 15 of 27 to include unborn child in line with the Children Act 1989 despite foetuses having no legal status.   7.2  NHS Somerset Director of Nursing will write to the Strategic Health Authorities Directors of Nursing to request them to ensure that all health provider services have a Did Not Attend/Missed Appointment policy with reference to children where there are safeguarding concerns across all health specialities, including where children and pregnant mothers may attend.   • All NHS Providers to have in place a Did Not Attend/Missed appointment policy for all health services accessed by antenatal mothers and children  7.3  NHS Somerset Director of Nursing will write to the Strategic Health Authorities Directors of Nursing to request them to recommend that all Obstetric/Neonatal health services should review policies to ensure clinical need, vulnerability and safeguarding concerns are included in the decision making for hospital transfer and discharge, ensuring both family history and documentation are provided in a timely manner, and there is clarity of purpose for discharge planning and strategy meetings.  • When unborn infants are transferred out of area in order to access specialist neonatal care, further transfers must be limited to transfer back to the local area to promote continuity of care, information sharing and child protection planning. All transfers should be made on the basis of clinical need only.  • Unborn babies/children should not be transferred to other hospitals out of area when there is no identified clinical need for this transfer. Where transfers are required for a clinical need proper documentation and transfer of full ‘social information should be made by direct telephone communication to the receiving on-call Community Paediatrician/Paediatric Consultant. If this is not received, it should be ‘chased up’.  • Where there are safeguarding concerns, weekend/bank holiday discharges should be avoided if possible to minimise the involvement of staff that are unfamiliar with highly complex families, avoiding ‘start again’ assessments. There must be clarity of the status of all professional and discharge meetings with appropriate attendance from all agencies. Professionals with key    Executive Summary 21.03.13 Page 16 of 27 information who consider they should attend should request an invitation. The meeting should incorporate: • good preparation • practitioners prepared and empowered to challenge decision making • good minutes including appropriate and timely distribution   7.4  NHS Somerset Director of Nursing will write to the Strategic Health Authorities Directors of Nursing to ask them to recommend that NHS Trusts review information sharing pathways and escalation policies to ensure health professionals are clear about their duty to share information when there are child protection concerns, and the process to escalate these concerns, to include the secure and prompt transfer of information when families move out of area.   • Health professionals must be clear about their duty to share information, escalate cases and refer to Children’s Social Care, if necessary, without the consent of parents where the welfare of children or UNBORN children is likely to be compromised. Designated and Named professionals should facilitate this if necessary.   • There must be careful and concise sharing of concerns about parenting ability and risks to the unborn child between agencies and health services when families move areas.   • All practitioners are accountable for their practice and must challenge other agencies’ decisions when required. Designated Professionals must be accessible for advice and support to assist staff to use the escalation process where there are appropriate concerns.   • There must be consideration of a clear policy for prompt and secure transfer of children’s health records to the receiving authority for both children in need or subject to a child protection plan. Transfer of information through Named Nurses should also be used.  • When new services are set up to provide urgent care services such as the    Executive Summary 21.03.13 Page 17 of 27 acute care GP, there must be consideration of the pathways for information sharing to health visitors on attendances by children.  7.5  NHS Somerset Director of Nursing will write to the Strategic Health Authorities Directors of Nursing to ask them to recommend that early identification of high-risk families must include a holistic assessment, targeted history taking and the evaluation of the risks and protective factors to the unborn children. • Sufficient consultation time for all health professionals should be allowed for holistic and complete history taking especially at first contact, and ‘patterns’ of behaviour and risk factors noted where there are concerns. Every effort should be made to confirm information given in a history independently and to contact/receive information from previous health workers responsible for parents, unborn babies and children, where they may be parenting concerns.  • Nursing observations as to parental management skills and their behaviour is an important CONTRIBUTION to a “Parenting Assessment” but because of the artificial environment of a hospital setting cannot replace it. There needs to be clarity that such information does not form a complete formal parenting assessment as understood by other agencies.  • There should be consideration of the appropriate policy for admission of children with faltering growth/neglect in specialist children hospitals to an appropriate ward with due regard to safeguarding concerns  • Where parents are recorded as having “learning difficulties” early “baby handling” teaching skills should be instigated with sufficient time for reinforcement of lessons.  •  Professionals should expect to see and check vulnerable children and not be inhibited by parental excuses to not disturb, particularly when ‘serious neglect’ issues are identified.          Executive Summary 21.03.13 Page 18 of 27 7.6  NHS Somerset Director of Nursing will write to the Strategic Health Authorities Directors of Nursing to ask them to recommend that all NHS Trusts review their training materials and give consideration to the need to be amended such that the learning points which have emerged are clearly embedded in professional training.     8. INDIVIDUAL MANAGEMENT REVIEW RECOMMENDATIONS    Derby Hospitals 8.1  That medical and nursing staff are supported and developed by a programme of further specific training in identification of attachment issues in the NICU environment, adult risk issues, parenting assessment, recording and communication of concerns.  8.2  Safeguarding team to facilitate involvement of learning disability liaison nurse or safeguarding adult officer with LD background in cases of concern where parents have a learning disability   8.3  That Derbyshire County Council Children and Younger Adults Department review the protocol for sharing information with other Local Authorities to ensure a timely response   North Lincs and Goole Hospital 8.4  To review the protocol and name of the child protection care pathway   8.5  To review the current level 3 safeguarding training to increase course content in relation to recognition and impact of parental learning disability   8.6  Develop specific child development training for staff groups working on neonatal units across the hospital sites   8.7  Develop a formal communication process for transfer / handover of care from midwifery to neonatal units ensuring the inclusion of all family / social history   8.8  Develop a timely records transfer process between midwifery and neonatal unit to ensure no loss of information    Executive Summary 21.03.13 Page 19 of 27  8.9  Develop a process of parental assessment for parents of children on neonatal units    NHS North Somerset  8.10  Safeguarding Training for all GPs to encompass their role as gatekeepers of information, and that they need to take a more holistic view of patients as parents.   8.11  GP training is audited on an annual basis   8.12  Pre-birth planning arrangements are audited    Nottingham Support Service 2 8.13  All Access Point staff undertake in house safeguarding training    Nottingham Support Service  8.14  Work between agencies to be further examined internally and areas for improvement identified   8.15  Handling of complaint: there is evidence to indicate that communication between the social worker and manager was good through the investigation and the complaint was resolved to everyone's satisfaction. However, records of the contact could be better, which needs to be addressed with manager of Nottingham Support Service 1.   8.16  Contact following on from the complaint was with the manager but records are not clear. This will be addressed with manager    Nottingham University Hospitals NHS Trust 8.17  Complete the planned update of the existing Trust policies (Safeguarding Vulnerable Adults; Mental Capacity Act)   8.18  Update the In-utero Transfer Guideline to include safeguarding   8.19  Update the Trusts Transfer & Discharge policy to include safeguarding   8.20  Have a debriefing meeting between NUH and Social Care once the SCR is completed    Executive Summary 21.03.13 Page 20 of 27 to identify lessons learned regarding the interagency relationship   8.21  At that meeting it should seek solutions to the need for formal communication regarding risk issues, particularly category and severity, between Social Care and NUH   8.22  Produce guidance clarifying roles and responsibilities for ward staff regarding parenting observation and assessment   8.23  Ensure that all staff attend safeguarding training according to Trust Policy   8.24  Ensure that the nature of the individual’s safeguarding responsibility is reviewed at annual appraisal (appraisers therefore need to be trained accordingly)   8.25  Re-emphasise the need of internal escalation to the responsible consultant when there are safeguarding difficulties   8.26  Ensure that the staff who attend Discharge planning meetings are the appropriate staff and that they understand their role and understand that the organisation should support discharge only when it is satisfied that a satisfactory plan is in place   8.27  Ensure that where care is provided at home by NUH staff that there are clear roles and responsibilities in place for escalating safeguarding concerns   8.28  Ensure that the staff of the Family Health Directorate, have Learning Disabilities training   8.29  Continue its current work on Information Governance and address this issue particularly with the Family Health Team   8.30  The Family Health Directorate should work with their neonatal consultant team to review how they discharge their responsibility on the postnatal wards for babies with social concerns which are often outside the overview abilities of medical registrars   8.31  The Family Health Directorate should ensure that the feeding charts identify who has fed and provided care to babies on our wards     Executive Summary 21.03.13 Page 21 of 27  8.32  The Family Health Directorate should emphasise to its ward managers their oversight role in cases of complex social issues, in particular where non-registered staff have been involved   8.33  The Family Directorate should re-emphasise the importance of adhering to policy for parents being resident of the wards   8.34  The Family Health Directorate should work with the Obstetric team to review how the outcome of referrals to the perinatal mental health team is communicated to the mother’s NUH record   8.35  The Family Health Directorate should re-emphasise to its staff the importance of adhering to its In-utero transfer policy with respect to completing incident forms   8.36  The Safeguarding team should address training issues in those areas where communication with them was not timely   8.37  The Safeguarding documentation should be reviewed to ensure that the paperwork supports ready access to the correct “Risk”  Information  8.38  ED should explore what processes they have in place to deal with patients who present with complex social issues and are not already known to Social Care locally   8.39  The Family Health Directorate should ensure that there is appropriate advise/support given to the Safeguarding Team should issues arise that they cannot manage.    Nottingham CityCare Partnership 8.40  Nottingham CityCare Partnership will arrange training for frontline staff in relation to Parents with Learning Disabilities and the impact upon children.   8.41  The Nottingham CityCare Partnership Named Nurse for Safeguarding Children will ensure that all the Safeguarding Children Nurse Specialists and the Domestic Abuse Nurse Specialist in the Safeguarding Children Service are fully aware of the Escalation Process where there may be immediate concerns for the safety and well being of a    Executive Summary 21.03.13 Page 22 of 27 baby, child or children and know what immediate action to take   8.42  A review of the Escalation Process by Nottingham City Safeguarding Children Board    Nottinghamshire Healthcare NHS Trust 8.43  That the ‘trilogy of risks’ are added to the screening tool for post natal depression   8.44  That the Trust’s DNA policy is used in all directorates   8.45  All Perinatal Mental Health Practitioners have a knowledge of the usage of the CAFs    Nottingham City C&F 8.46  Where families have been known to previous local authorities, Social Care Team managers will ensure that background information is sought from those authorities prior to authorising a Core Assessment   8.47  In the case of pre-birth assessments where there are identified safeguarding risks / indicators, an initial planning meeting to commission the assessment must be chaired by a CTM or a CSCTM. This meeting should allocate key tasks, record risks and identify the timescale and review process.   8.48  All contact with a Service User, even via text message, will be recorded and form part of the child’s case file   8.49  An electronic recording system is developed for the Family Community Teams which complements and has a clear interface with the social Care Carefirst and Castle systems.   8.50  Supervision case discussion records will be amended to include a section on ‘current assessment of risk, if any’.   8.51  All discharge planning meetings will consider a current assessment of risk   8.52  Social Care will develop a policy regarding highly mobile families      Executive Summary 21.03.13 Page 23 of 27 8.53  The outcome of a CRIMMs check will be copied directly to the team manager who must make a written acknowledgment on the file that he/she has read the contents and a managerial view of risk.   8.54  Training is developed in respect of pre-birth planning and rolled out across social care and family community teams.   8.55  Concerns about individual issues of competence should be addressed within the appropriate line management arrangements.    Oxfordshire Health NHS Foundation Trust  8.56  To improve the level of knowledge regarding Child Protection processes for General Practitioners   8.57  To improve communication between Midwifes, General Practitioners and  Health Visitors  8.58  To formalise the process to follow up complex / high risk pregnant women who do not attend appointments / move out of area  8.59  Social Services telephone calls to be managed by the respective Named General Practitioner   8.60  Improved use of General Practitioner codes and flagging system   8.61  To ensure that all staff working in a PHCT have received a commensurate level of Safeguarding training  8.62  To ensure that the correct advice is given to patients who present as ‘homeless’     Oxfordshire County Council: Children, Education and  Families Directorate 8.63  Domestic Abuse training and guidance is reviewed to ensure that the cycle of abuse and reconciliation is adequately reflected and that an understanding of reactions to abuse are included.  8.64  The ‘pre-birth referrals’ procedures and protocol for children moving across boundaries are reviewed and updated to ensure that pre-birth cases are referred quickly and not    Executive Summary 21.03.13 Page 24 of 27 held open without active assessment or support being provided . 8.65  Where a third party moves in to a household where there is active CEF involvement guidance is developed to assist practitioners in knowing when to refer to the assessment team.  8.66  An audit and dip sample of referral recording and address checks is undertaken . 8.67  CEF to explore how the relevant aspects of the course ‘Principles of learning disability support’ can be delivered to CEF staff.    Thames Valley Police 8.68  Thames Valley Police to review the initial training of PCSOs to ensure the inclusion of guidance on how to correctly record and refer (internally) safeguarding concerns.   8.69  Thames Valley Police to circulate a bulletin to PCSOs containing guidance on how to correctly record and refer (internally) safeguarding concerns.   8.70  Thames Valley Police to review their Domestic Abuse Policy and Operational Guidance to ensure sufficient guidance is provided in relation to what may constitute an ‘incident’. (Any changes to be published)   8.71  Thames Valley Police to issue a bulletin to the Domestic Abuse and Child Abuse Units reminding them to create a CEDAR record whenever an intelligence report results in further Police action and in particular a referral to another agency.   8.72  Thames Valley Police to review the management of intelligence reports once received within the Child Abuse Investigation Units, Domestic Abuse Units and by the Vulnerable Adult Co-coordinators to ensure compliance with the ‘Management of Police Information’ guidance in terms of creating an audit trail.   8.73  Thames Valley Police to review their Child Abuse Investigation Policy to ensure it contains reference to the importance of considering the welfare of unborn children. (Any changes to be published)      Executive Summary 21.03.13 Page 25 of 27  Somerset County Council Children and Young People’s Directorate 8.74  If another local authority or agency requests a welfare visit or other task, expectations for this visit or task should be agreed and sent out in writing.   8.75  Somerset Direct (SD) should always advise the caller of the secure email facility.   8.76  Somerset Direct should always clearly identify advisors by their full name, whilst ensuring personal security.   8.77  Somerset Children's Social Care should have clear guidance relating to failed home visits including contingency and reporting arrangements.   8.78  Somerset Children's Social Care, in conjunction with LSCB partners, should set out clear criteria relating to welfare visits specifying roles and responsibilities.   8.79  Somerset Children's Social Care should in consultation with partners clarify:   ●When a strategy meeting must be face to face   ●When it is appropriate to have a telephone conference  ●When a respective specified agency (e.g. health) must be included in the strategy.   8.80  Somerset Children’s Social Care, through the Somerset LSCB, to share the above with the South West procedures group as examples of good practice.    Avon and Somerset Constabulary 8.81  All ‘Welfare checks’ should be carried out be qualified Child Protection professionals with police attendance reserved for occasions only where police powers are required.  8.82  Where 5.1 is not possible, by virtue of the fact an emergency check is required, a strategy discussion should take place between a CAIT supervisor and the agency before the checks are carried out. The risks can then be analysed and a considered plan agreed prior to the visit taking place. The officer attending should ideally be a CAIT officer; if another member of staff attends they should receive a briefing direct from the CAIT supervisor. The results of the visit should then be subject of a further strategy discussion.      Executive Summary 21.03.13 Page 26 of 27 8.83  Protocol agreed between Social Services and police to reflect procedures to follow in the event of emergency checks being required by police.   8.84  ISO procedure to be introduced into Force Communications to reflect an appropriate response to such requests in the future.   8.85  All Avon and Somerset Constabulary staff likely to come into contact with the public to receive appropriate child protection training, including risk indicators of abuse. This should be by delivery of the existing NCALT training module in the first instance.   8.86  Where a need for an Initial Child Protection Conference is highlighted there should be ability to fast track those where children are at most risk.   8.87  All police contact with children about whom there are concerns should be reflected in a comprehensive intelligence report that should be submitted in a timely manner and shared with CAIT staff for analysis.    Taunton and Somerset NHS Foundation Trust 8.88  Clinical case to be used in the Trust ongoing Safeguarding training programme.   8.89  Recommendations from this SCR to be incorporated into Trust Safeguarding procedures and audit programme as appropriate.  8.90  Learning from this SCR to be used Trust ongoing Safeguarding training programme.    Somerset County Council Legal Services 8.91  Submit e-mail to every lawyer within the Social Care team, strongly urging them to maintain a record of any conversation with client(s) where it could be construed that legal advice has been given (even if no matter subsequently arises as a result of that advice).   8.92  Message to instruct that where such records are created, they should be added to the Norwel case management system on every occasion in the event that a legal matter does arise (i.e. the Service is formally instructed to take further action).      Executive Summary 21.03.13 Page 27 of 27 8.93  The format of any such record is to be at the discretion of the lawyer providing the advice, provided that it clearly details any recommendations provided, even if that recommendation is to take no further action at the time. The recommended (but not mandated) format is an e-mail to the recipient of the advice as soon as is practicable after the event.    Somerset Partnership NHS Foundation Trust 8.94  A review of the processes currently in place to ensure professional records of high risk cases are transferred swiftly between organisations must take place. Consideration must be given to how information from outside Somerset is obtained in order to guarantee the seamless provision of key services to families; consistently delivered, ensuring children remain safeguarded.   8.95  A Significant Event Audit meeting should take place with the health visitor team involved in this case. The Area Manager, Locality Safeguarding Children Nurse and Named Nurse should attend to discuss all the issues in this case and to identify any individual learning required from the individuals involved.   8.96  The lessons learnt from this review must be disseminated to the individuals concerned, the health visiting team and the wider organisation, illustrating the concerns identified and reiterating best practice processes. The relevant local and national policies and guidelines should be referenced and their usage reiterated to all staff.    