Malnutrition of a 3-year-old girl in 2020. Child C was admitted to hospital due to breathing difficulties requiring cardiopulmonary resuscitation, where it was discovered that she had severe anaemia and was malnourished. Learning includes: health visitors must ensure that the correct level of need is recorded on case management systems; work needs to be undertaken to ensure that all heath visiting staff understand the levels of need set out in procedures and understand how to apply in practice; there is a need to remind GP staff to contact health visitors directly regarding children that raise concerns; GPs are able to weigh children and spot a malnourished child and to recognise the need for urgent referral; professionals need to be reminded of the need to effectively coordinate and manage case transfers; hospital staff need to be trained to understand the significance of safeguarding, the processes for referral and the respective roles of agencies; processes for case handover within the hospital need to ensure that safeguarding is considered at each handover point; professionals have an active responsibility to seek information from strategy and other planning discussions to which they have been invited but didn't attend. Makes no recommendations but the serious incident report and root cause analysis completed as part of this review identify actions to address concerns.
      
 Title:  Child safeguarding practice review: a learning report concerning Child C. LSCB: Ealing Safeguarding Children Partnership Author: Ealing Safeguarding Children Partnership Date of publication: 2021  This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC.  This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above.                            1    Ealing Safeguarding Children Partnership  Child Safeguarding Practice Review   A learning report concerning Child C.   This report is strictly confidential and must not be disclosed without discussion and agreement with the ESCP prior to publication   The disclosure of information beyond that which is agreed, will be considered as a breach of the subjects’ confidentiality and a breach of the confidentiality of the agencies involved     2  Contents   1. Context.  2. Introduction to the case and summary of learning.  3. Process.  4. Family structure.  5. Background prior to the incident.  6. Analysis of key practice episodes and the identification of learning.  7. Conclusion and next steps.                                    3  1.Context   1.1 The history and timeframe of this case relate to the period immediately before an incident that occurred on the 10/01/20 when the above child was transferred to West Middlesex Paediatrics requiring CPR.   1.2 This report focuses on the learning for the wider children’s system as a result of the individual agencies contributing to a serious incident and management information request.   2. Introduction to the case and summary of learning   2.1 This review is in respect of a female 3-year-old child, known as Child C. Child C came to the attention of the Ealing Safeguarding Children Partnership,  initially as an item of any other business and without any clear  details; this was chased by the partnership but delayed because of other pressures in the health system at the time. The child had attended a routine mental health appointment with her mother on the 10th January 2020. This appointment had been with a counsellor at a GP practice venue. Whilst there, Child C had become distressed and developed breathing difficulties; she required cardiopulmonary resuscitation and was successfully resuscitated by the GP and surgery staff. Both she and her mother were taken by ambulance to West Middlesex Hospital.  2.2 At the point of admission the child had severe anaemia and was reported to be malnourished due to her poor diet. She received a blood transfusion and was started on oral iron. She was discharged on 13th January 2020.   2.3 The learning identified from this Review is in relation to the following, these have been identified from single agency reports and discussion. They include:  • The importance of health visiting staff correctly recording the levels of support to families based on levels of identified need and risk, in line with the London Continuum of Need threshold  • The importance of all professionals understanding the impact on children that familial mobility, particularly in the early years, has on access to services. GPs, ED & hospital staff and community paediatricians should liaise with the child’s local health visiting team so that further support and assessment in the community may be implemented • All staff must be aware of the continuum of need and use it appropriately.  • Health staff must contribute to meetings, particularly important with children in the early years.  • The importance of all involved agencies being proactive in liaising with appropriate partners following incidents of concern. The importance of effective multi-agency assessment in informing planning.  • The importance of effective discharge planning following a stay in hospital where the presenting incident has caused concern. • The importance of understanding the impact of adverse experiences for adults and the effect this may have on successful parenting.  • The importance of effective and timely information exchange.       4  3. Process   3.1 The process of reviewing this case has not been easy given the number of organisations involved pan London; this, together with the mobility of the family, has created some challenge in coordinating and exchanging information. Given that the family have moved away from Ealing and into another London Borough, we are assured that information has been shared appropriately and we will share this learning report relating to the specific incident. The review has been conducted locally and is a proportionate response to identify learning at a multi-agency level. It seeks to build on individual agency reports and to consolidate the learning for dissemination across the whole system.   3.2 Any review, must be based on a premise of not seeking to attach blame to any individual professional or agency. On the contrary, this case review has been actioned to understand the rationale, impact and context of the agencies’ response to the family, particularly following the incident in January 2020.   3.3 The LSCP has approached this in a proportionate way, pulling together individual agency reports, including learning identified, into a consolidated review for the purposes of system learning. This has been produced under the requirements set out in Working Together 2018 and is a Child Safeguarding Practice Review.   3.4 The case presents significant challenges with two clear positions relating to this child and her dietary condition at the point of hospital admission. These are:   • That the child was reported to be a ‘picky’ eater and that the family sought to provide her with food that she would eat namely bread and milk without understanding the impact this might have on her health. It is not clear who first identified this, whether a GP or hospital, however, this was not actioned by an earlier referral to the HV Team. The child had suffered severe reflux for a long period of time, treated by hospitals. The consequence was that mother was reluctant to try new foods for fear of making her child vomit.  • That the family took insufficient action to support her improving her diet and to get her physical development back on track. However it is known that her mother sought help from her GP and the ED approximately fifteen times over 2.5 years, mostly for gastric related issues and one febrile convulsion: mother was seeking help, but the services she chose to access did not resolve her concerns by referring to the health visiting services to support mother with feeding.   This review considers both of those perspectives but recognises the significant concern regarding C’s health at the point of admission and the serious risk to her life.   3.5 In scoping this work it has been important to consider the following objectives:  • To gain an understanding of the multi-agency response to the family of this child; to extract any learning from this specific case; and to strengthen safeguarding in Ealing.  • To ascertain whether this case can highlight any wider learning given the number of agencies outside Ealing involved.   3.6 This report is intended to reflect on the circumstances of Child C leading up to her admission to hospital, however, given her age, there is very little by way of historical context that involves her specifically. The main focus therefore relates to the handling of her case then, immediately prior to admission and post discharge.    5  3.7 The history of her mother and the circumstances of her arrival into the UK are considered in this case, in so far as the impact those factors may have had in relation to C and her care.   4. Family Structure   4.1 The relevant family considered as members in this review are:    Subject: C – Aged 2 years, 6 months at time of key incident  Mother: CM – Aged 22 years  Putative Father: CF – Aged 29 years  At the time of the incident it is believed that CF was residing with another female partner. It is also unclear if he is the father of the subject child in this case. In part, the difficulties in ascertaining clearly who is the father relates to the difficult past of CM, however it is clear that this is being addressed in further work.    4.2 The ethnic origin of mother and father is reported to be Albanian; the child was born in the UK. The understanding and details relating to the circumstances by which the family came to be living here are highlighted in the section below.   4.3 There are no other family members known to be residing in the UK, although at varying points mother has highlighted members of the community who have provided support to her and her child.   5. Background prior to the Incident   5.1 This family had lived in Ealing for only a few weeks prior to this incident occurring. It is clear from piecing together the history that they had been resident in the Greater London area for some time, the mobility of the family being a challenge to professionals in gaining a clear understanding of life for them.   5.2 In July 2017, Barnet Multi Agency Safeguarding Hub received a referral from a midwife who reported that she had become aware of a young woman living in the area who was pregnant and about whom she was concerned. The referral highlighted a number of issues pertinent to this review. At the time of the referral CM was living with an Albanian family in the area but it was reported that she knew little about this family, having arrived with them in very difficult circumstances. It was also reported that the living arrangement was extremely unstable and that it had the potential to break down quickly.    5.3 The referring midwife had been able to ascertain that CM had arrived in the country illegally suspecting that she had arrived on a lorry with a group of other migrants. The circumstances of her leaving Albania were understood to relate to honour-based threats of violence from her family should she refuse to go ahead with a marriage to a much older man. Hence, she had taken the opportunity to escape and to make the journey to the UK. It is understood that this journey was via the near continent where she reported that she was forced to work as a prostitute for two weeks.  However, she escaped, seeking an opportunity to travel to the UK, where she took refuge with the family who took her in. As a consequence of the route of her arrival in the UK, CM had no recourse to public funds and no status and at the time of the situation being picked up by the midwife was heavily pregnant.   5.5 Gathering exact details of the history was reported as challenging as CM spoke little English and much of the translation was provided via the family.      6  5.6 It is understood that C was born by emergency caesarean section as she was a breach presentation at 38 weeks’ gestation.  The health visiting service in Barnet were alerted to the birth when C was six days old and attempted a new birth visit five days later, on 7th August 2017. They were unable to gain access at this point and tried repeatedly to contact mother via a mobile number that had been supplied to the midwife. Contact was eventually established, and a new birth visit conducted on 19th August 2017. The child was nineteen days old at this point and had already had one attendance at A &E with digestion issues.   5.7 Details from records at this time suggest that mother used her friend as a translator, declining the use of Language Line. CM explained that she was moving to a new house and that she was between properties. There were no concerns noted regarding the baby or mother although the full history as above is known to have been shared. A plan was agreed that included:  • Attendance at baby clinic  • The offer of a level 4 service due to the maternal and social history • To use the GP service for routine health appointments  • To continue to liaise with social services   5.8 There was a further attempt to contact mother on 22nd August 2017 using the mobile number, this was unsuccessful.   5.9 The health records indicate that C was seen on three occasions at A&E  • 11th August: referred by a midwife as C’s stomach was distended – no treatment is recorded  • 6th September: again, with concerns re digestion – CM on this occasion was described as worried, but it was recorded that the child was well  • 11th October: with reflux for which Infacol was prescribed.  5.10 On 7th September, alerted by the visit to A&E, the health visiting service was tasked to visit at home. No visit is recorded as having taken place. In May 2018 the Central London Community Healthcare Trust identified that C was living in Dagenham with her mother and the health visiting service in Dagenham were notified; this was done by both email and by sending a ‘task’ on SystmOne. However, during the course of the record gathering for this review it would appear that Dagenham were unaware that the family were living in this area.  It wasn’t until 23rd December 2019 that the GP records suggest that a routine notification was sent to the Ealing health visiting service that C and her mother had moved into the area, although records suggest she was seen twelve and fourteen days earlier by a GP who could have flagged the transfer sooner to the health visiting service. There is no record of this notification on the health visiting records. Subsequent enquiries suggest that the family had moved from Barnet to Dagenham, to Newham and then onto Ealing.   5.11 The family were living in Ealing when the incident of concern described at 2.1 occurred. On 13th January 2020 a request for an urgent visit by the health visiting service in Ealing was received from the Named Nurse for Safeguarding Children at West Middlesex University Hospital. The request related to an urgent request for a health visitor to conduct an assessment to consider child neglect: Child C had been discharged from hospital on the preceding day without a discharge meeting taking place.   5.12 Social workers and a CLCH health visitor saw mother and child on the same day – 13th January. A strategy meeting was convened on the same day; the health visitor was unable to participate but requested an update from the hospital named nurse. A number of issues were discussed, including the fact that mother indicated she had been concerned regarding C’s eating prior to her admission; she confirmed that visits to the GP on 9th and 11th December were to discuss those concerns.   7  On the social work visit, mother was living in a house of multiple occupancy in her own room. It was clean and tidy, with separate sleeping for C. The fridge was full and included fruit and vegetables. The social worker reported helping mum to cook a meal and witnessed attempts to feed C. At a further visit on 14th January 2020, CM indicated that she welcomed support and that C was gradually eating more. Health support was coordinated through CLCH with a dietician’s advice and the further support of a nursery nurse. Access was made for CM to a local food bank.   5.13 Alongside this, a package of support was coordinated for CM to support her mental health needs and to help her with her adverse experiences.   5.14 Some time in early March 2020, SC moved again to Newham, re-establishing her relationship with CF. The case was formally transferred.     6. Analysis by Key episode and identification of learning   6.1 Key episodes are periods of intervention that are judged to be significant to understanding the work undertaken with C and her family. The episodes are key from a practice perspective rather than to the history of the child, so they do not form a complete history, but will summarise the significant professional involvements that informed the review. The identification of such episodes has drawn heavily on the serious incident and root cause analysis reports of health agencies.   6.2 This report has been produced in a proportionate way appropriate to the learning and with cognisance of the impact on capacity of the Covid pandemic. It has not been possible to engage mother or other family members: in early July the family were given permission to travel to Albania and international travel restrictions have delayed their return. It is understood they do intend to travel back once restrictions are eased and there has been some planning between Ealing and Newham as part of the transfer of case responsibility.   6.3 The following key practice episodes have been identified   Practice Episode  Ensuring the correct health visiting pathway is identified and recorded for families  The processing and recording of information are critical  Robust plans must be in place when a child is discharged following an incident of concern  Understanding social factors and the contribution to risk planning   Ensuring the correct health visiting pathway is identified and recorded for families   6.4 In gathering the information for this review and in seeing the Root Cause Analysis completed by CLCH a number of issues have emerged regarding the health visiting response and the service to this family. A new birth visit which took place on 14th August 2017, after some delay in being able to contact the family, documented that the family, as a result of the social history, should be at level 4, or Universal Partnership Plus Offer.   6.5 This offer sets out an expectation of work being undertaken with agencies and with the parents in the provision of multi-agency intensive and targeted packages of support. The aim being to support families where there are complex health or safeguarding needs. Clearly this approach recognised the complexities of CM’s experience in being trafficked to the UK, the perilous nature of her housing and the added difficulties of stable support for her in caring for C.   6.6 However, from the RCA report completed it is clear the while the health visitor identified the correct pathway in Level 4 care, this was not logged correctly on the health visiting system. The family were  8  placed on a universal caseload following the new birth visit. The difference in service level as a consequence of this human error is that the LCN Level 1 offer – universal - is primarily focused on delivery of the Healthy Child programme from ante natal care to school entry by working in partnership with parents.     6.7 A number of other issues emerged in the RCA exercise including the quality of recording relating to risk. When identifying a Level 4 service was the most appropriate way to address concerns, it was important to document the identified risk factors and the mitigation actions that are required to reduce that risk.  If this had been done effectively, health visitors subsequently picking up the case notes may have spotted the error.    Learning:  1. Health visitors must ensure that the correct level of need is recorded on case management systems  2. Work needs to be undertaken to ensure that all heath visiting staff understand the levels of need set out in procedures and understand how to apply in practice   The processing and recording of information are critical   6.9 The analysis of this case has highlighted a number of issues relating to the recording and the processing of information. One of those issues is referred to above at 6.7. There were, though, other issues that emerged in the course of this review.  6.10 In May 2018 the Central London Community Healthcare Trust identified that C was living in Dagenham. Documentation suggests that this was relayed to Dagenham Health Visiting service in an email and by tasking sent on the case management system. It would appear that they were unaware of her arrival and so no service was offered.   6.11. The family made other moves, from Barnet to Dagenham and Newham before arriving in Ealing, registering with a GP on each occasion, but their arrival was not shared with health visiting services, resulting in coordinated services not being made available to C and her family.    6.12 On 23rd December 2020, the GP records suggest that C had moved into Ealing and that a routine notification was sent to the Ealing Health Visiting service. Receipt of this notification is not recorded. If this referral had been documented in the community record this would have identified the family for a moving into area visit, although not immediately requiring a enhanced service. Such a visit would have identified the circumstances that mother and C were living in and would have enabled some discussion regarding C’s health needs and development. From events post the incident of concern mother has disclosed her ongoing concern regarding C’s diet and eating pattern, which may have been picked up earlier if the information and exchange of data had been clearer, although this isn’t recorded on any GP visits or ED attendances which were also chances for health services to pick this up and signpost to support.  6.13 In reality, this family did not receive the identified level of service at Universal Plus and missed health input at critical points.   Learning:  3. There is a need to remind Central London Community Healthcare Trust administration team of the vital role they play in safeguarding children and why it is imperative that administration protocols are followed in a timely way.      9  4. There is a need to remind GP staff to contact HVs directly regarding concerning children; GPs are able to weigh children and spot a malnourished child and to recognise the need for urgent referrals.  5. All professionals need to be reminded of the need to effectively coordinate and manage case transfers.   Robust plans must be in place when a child is discharged from hospital following an incident of concern   6.14 The serious incident report completed by Chelsea and Westminster Hospital highlights the concerns relating to the discharge from hospital of C. The circumstances of her admission are set out earlier in the report, the medical assessment of her condition on admission was serious. The factors of collapse, anaemia, failure to thrive coupled with her age and the range of social issues made this the case.   6.15 Following transfusion and the treatment with oral iron she was, however, discharged later that weekend, with poor onward planning, no strategy discussion and no referral to social care. The referral to social care only occurred following the involvement of the Safeguarding Children nurse on the day after discharge, with a strategy discussion arranged for 15th January 2020.   6.16 The report highlights a lack of communication regarding the severity of the safeguarding and nutritional aspects of the child’s presentation. The senior medical and nursing team did not work together to consider the risk factors and to engage social care in any discussion about next steps prior to discharge. Indeed, there was no development of a multidisciplinary plan for C to manage the longer-term health issues. Instead the case was passed between staff and shifts without effective communication.   6.17 The lack of professional curiosity regarding the lived experience of C and the unknown aspects of her medical and social situation at the point of discharge had the potential to put her and her mother at greater risk.     Learning   6. Hospital staff need to be trained to understand the significance of safeguarding, the processes for referral and the respective roles of agencies  7. The processes for case handover within the hospital need to ensure that safeguarding is considered at each handover point.  8. Procedures for escalation of issues by nursing staff who are concerned regarding safe decision making must be clear and disseminated    Understanding social factors and the contribution to risk planning   6.18 The challenges of family mobility in this case meant that while the concerns relating to CM’s history and her arrival in the UK were known they were not consolidated into a clear appraisal of risk because information sharing was weak. When a strategy discussion was held following C’s admission to hospital and subsequent discharge, key professionals did not attend.   6.19 The health visitor was invited to the strategy discussion, but was unable join the discussion, arranging instead to contact the hospital named nurse to request an update post-meeting. Much of the health visiting history wasn’t therefore fully available to the meeting. The health visitor also took no   10  action to discuss the specific concerns or to liaise with the social worker. This in effect meant that not all the information was available, and professionals were not collaborating in partnership.   6.20 The Root Cause Analysis from Central London Community Healthcare Trust highlights the passivity of the health visitor after the strategy discussion, assuming no responsibility for contacting partners in order to discharge the health visiting role in the protection plan. There were in fact 19 days between the incident taking place and the health visitor and social worker communicating with each other.  Learning   9. Staff in all organisations to be reminded of their responsibility for playing an active part in safeguarding planning  10. All professionals to be reminded that they have an active responsibility to seek information from strategy and other planning discussions to which they have been invited but didn’t attend. Including the specific role they are expected to play in delivering outcomes    7. Conclusion and next steps   7.1 Child C had a history of gastric issues and potential seizures and she was seen by GPs, EDs and paediatricians before she suffered a serious and potentially life-threatening collapse, as a result of malnourishment and poor diet. Later medical investigations show increased faecal calprotectin level which could indicate underlying difficulties such as inflammatory disorders  The medical background, coupled with a social history and significant mobility, meant that she was at risk.   7.2 The information exchange in this case was poor from a number of organisations, resulting in no consistent health visiting service being offered to the family. The number of moves was undoubtedly a factor in this, however, the systems within health organisations are designed to mitigate against children going under the radar. The incorrect use of these systems, poor recording practice and failure to follow up meant that for large periods of C’s life, her mother was not provided with the expert advice, support and interventions to support her development.     7.3 The Serious Incident report and Root Cause Analysis completed as part of this review identify actions to address the concerns. Lessons have been identified about how agencies worked together and they have been recognised in agency reports as well as this overview report. Ealing Safeguarding Children Partnership will continue to work with agencies to embed this learning and to ensure that practitioners have the skills and awareness to drive forward practice.    