Bruising first reported on a 6-week-old boy in March 2016, with further bruising and fractures documented over the next month and six days. Mother had planned a home birth but due to complications Baby Adam was born by emergency caesarean section. At first new birth visit when Adam was 12 days old, parents described how they had been traumatised by the birth; health visitor referred sibling Isaac, a 3-year-old, for assessment as he was still in nappies and not talking. Father was main carer of Isaac as mother worked; he had been in long-term unemployment due to severe chronic ill health. Adam was admitted to hospital three times for unexplained bruising; blood tests and x-rays were carried out to rule out a medical condition. Family of Asian descent. Findings: a hierarchical approach in the working environment leads to professional deference and makes challenging medical professionals and decisions difficult; child protection practice requires collaborative work and professional respect; needs of fathers must be properly assessed and engaged; change to modern service delivery models cannot guarantee continuity of care; service thresholds were applied that did not correspond to the needs described. Recommendations include: all agencies must undertake a review of internal and inter-agency information sharing systems including use of electronic recording, flagging and coding systems; community health visiting and children's social care services must incorporate a 'think family approach' as standard; the LSCB must develop and agree a protocol for responding to bruising in pre-mobile babies and disabled children who are dependent and unable to communicate.
      
 Title:  Serious case review: overview report: Baby ‘Adam’: DOB: 03.01.15. LSCB: London Borough of Tower Hamlets Safeguarding Children Board Author: Briony Ladbury Date of publication: 2019  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.                           FINAL    London Borough of Tower Hamlets Safeguarding Children Board  Serious Case Review  Overview Report   Baby ‘Adam’ DOB: 03.01.15  Independent Reviewer  and Report Author  Briony Ladbury  RN, RM, HV cert, FP certificate, BA (Hons), MSc   Published 28 February 2019          Page 2 of 72   Table of Content   1 Acknowledgements ........................................................................... 3 2 Overview Report Author .................................................................... 3 3 Introduction ..................................................................................... 3 4 Family Background and Context .................................................... 7 5 Narrative Summary and Key Episodes .......................................... 7 6 Analysis of Practice ...................................................................... 20 7 Findings, Themes and Recommendations .................................. 50 8 Conclusion ..................................................................................... 65 9 Appendix One - Summary of Recommendations ............................. 66 10 Appendix Two – Glossary ................................................................ 72          Page 3 of 72  1 Acknowledgements I would like to acknowledge the cooperation and support of Tower Hamlets Safeguarding Children Board (THSCB) Serious Case Review (SCR) Panel, who have given their time and generous access to notes and procedures.  My thanks also to Monawara Bakht for coordinating the SCR process and to a number of professionals who participated in practitioner interviews and learning events to enable key evidence to be gathered, questioned and represented in this report.  2 Overview Report Author The Independent Overview Writer for this case is Briony Ladbury RN, RM, HV cert, FP certificate, BA (Hons) Protecting Children, ENB Specialist Practitioner Award (Child Protection), MSc in Inter-Professional Practice (Society, Violence and Practice).  She has held senior roles within the NHS as a safeguarding children specialist in both strategic and practice contexts, producing and quality assuring NHS contributions to SCRs.   3 Introduction 3.1 Reasons for conducting the Serious Case Review 3.1.1   This Serious Case Review (SCR) was commissioned under statutory guidance in ‘Working Together’ (2015)1 issued by HM Government.  Regulation 5 in LSCB Regulations (2006)2 includes the requirement for an LSCB to undertake reviews of serious cases in specified circumstances.  One of those circumstances is when children have been seriously harmed and there is cause for concern as to the way in which the authority, their Board partners or other relevant persons have worked together to safeguard the child.  3.1.2 The purpose of an SCR is to provide a sound analysis of what happened in a particular case and why, and what needs to happen in order to reduce the risk of recurrence. Working Together (2015) stipulates that it should be conducted in a way which:   Recognises the complex circumstances in which professionals work together to safeguard children  Seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did  Seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight  Is transparent about the way that data is collected and analysed  Makes use of relevant research and case evidence to inform practice   3.1.3 This SCR has been undertaken with these principles in mind. It aims to give an understanding of who did what, the reasons why and the factors that influenced the service delivery to Baby Adam and his family within a specified timescale.                                                               1 Working Together’ to Safeguard Children:A guide to inter-agency working to safeguard and promote the welfare of children (2015) 2 Regulation 5 of the Local Safeguarding Children Boards Regulations 2006 sets out the functions of the LSCB under section 14 of the Children Act 2004     Page 4 of 72  3.2 Rationale for commissioning a Serious Case Review for Baby Adam 3.2.1  Baby Adam was approximately 6 weeks old when bruising was first reported to a health professional by his mother at a baby clinic.  He was subsequently referred for an urgent review at the hospital Emergency Department (ED) following a GP consultation for yet more unexplained bruising when he was nine weeks old. Deliberate harm was first raised as a possibility at this time.  Further bruising and fractures came to light over a period of one month and six days, which were duly documented, and medically investigated.  A range of health, social care and police professionals became aware of the family during this time.  3.2.2    Bruising in a pre-mobile baby, where there is no convincing explanation as to how the bruising might have happened and no evidence of any medical condition, should be treated with the utmost concern.  Pre-mobile infants are physically and emotionally immature and are entirely dependent on their principle carers (usually the parent or parents) to keep them safe and well. They are, therefore, highly vulnerable individuals and the consequences of being exposed to abuse can potentially be very grave indeed.    3.2.3   NHS and social care professionals assessing and working with families with complex histories, that include unexplained bruising and fractures inconsistent with the age or development of a child, are expected to collaborate and act in the best interest of the child by considering deliberate harm as a distinct possibility until it is ruled out.  Despite non-accidental injury (NAI) being included in the differential diagnosis3, prompt measures were not taken to protect Baby Adam, who was sent home from hospital and primary health care settings to a risky home situation on more than one occasion.  This was due to the belief that a medical cause would emerge.    3.2.4    The management of the case inevitably threw up questions as to how such a small and vulnerable baby could be discharged into a potentially abusive home situation when so many professionals were actively involved in his care. Tower Hamlets Case Review Group (CRG) considered the case at three CRG meetings to decide what multi-agency learning process would be appropriate, particularly as the case had already been subject to NHS Serious Incident investigations.  On 7th June 2016, the CRG decided that the case met the criteria for a full multi-agency SCR.  An SCR was duly commissioned under the independent Chairmanship of Keith Ibbetson.   3.3 The scope and focus of the Serious Case Review 3.3.1 The scope for this SCR covers a period of three months and twenty days, extending from January 2015, when Baby Adam was born, until after a strategy meeting4 had taken place and a formal investigation under Section 47 of the Children Act 1989 had commenced. Any relevant information prior to those dates is contained in the section entitled ‘Family Background and Context’.   3.3.2  Whilst the timeline for this SCR appears to be short, there was considerable complex activity across and within agencies within the period reviewed.  To enable a sharp focus on the most significant events, the review has been split into four important episodes of care which form the key lines of enquiry for the analysis.  They are as follows:                                                              3 Differential diagnosis: A systematic process whereby medical practitioners weigh the probability of one disease/cause versus that of other diseases/causes that might possibly account for a patient's symptoms, by using a process of elimination to establish the actual cause or disease., 4 Where information gathered during an assessment (which may be very brief) results in the social worker suspecting that the child is suffering or likely to suffer significant harm, the local authority should hold a strategy discussion to enable it to decide, with other agencies, whether to initiate enquiries under section 47 of the Children Act 1989.   Working Together’ (2015) HM Gov.     Page 5 of 72   Episode 1: Baby Adam’s birth in January 2015, until he was nine weeks old.  Episode 2: The GP consultation for unexplained bruising on 11th March 2015 until 19th March 2015, including the 1st hospital admission, discharge and care at home until Baby A’s outpatient appointment on 20th March 2015.  Episode 3: The outpatient’s consultation on 20th March 2015 until 16th April 2015, incorporating the 1st re-call and 2nd admission and discharge from hospital.  Episode 4: From 17th April 2015 until 23rd April 2015, covering the 2nd recall and 3rd admission to hospital in relation to increased clinical concern that bruising and fractures may have been deliberately inflicted.  3.4 Agencies invited to participate in this Serious Case Review Organisation Description of Involvement London Borough of Tower Hamlets (LBTH)  Children’s social care  Hospital Social Work Team  Barts Health NHS Trust  Royal London Hospital Site  Obstetrics and Maternity Services  Emergency Department  Paediatric Services (in-patient and outpatient)  Radiology Department  Community Health Services  Community Health Visiting  Primary Healthcare Services* GP Services Metropolitan Police Service Specialist Crime Review Group  Child Abuse and Investigation Team   * N.B.Barts Health NHS Trust ceased to be the provider organisation for community health services in March 2016, when the contract was awarded to GP Care Group.  Dissemination of the learning and implementation of any actions resulting from this SCR will therefore be the responsibility of GP Care Group.              3.5 How the review was undertaken  3.5.1 The LSCB Board manager was responsible for notifying the DfE and Executive leads of local agencies that a SCR was underway. An Independent Chair was contracted to lead the multi-agency SCR panel for this case and an independent overview author to write the report.  3.5.2 The SCR panel comprises senior managers from agencies who had delivered care to the family. Their responsibilities included preparing and informing front line practitioners of progress, arranging and assisting with practitioner interviews or focus groups and supplying the panel with supplementary documentation and other evidence relevant to the period under review.     Page 6 of 72   3.5.3  Information was entered into a multi-agency integrated chronology, which outlined the service interventions occurring within the selected time-scale.  Front line practitioners who had most contact with the family were identified and invited to participate in a SCR interview or focus group. Many agreed, and their contribution was invaluable.  Some, however had left Tower Hamlets by the time the SCR was commissioned.    3.6 Parallel Investigations 3.6.1 Single agency reports were not requested for this SCR.  However, two NHS Serious Incident (SI) Reports had already been completed by the time this SCR was commissioned: one combining Baby Adam’s experience of community health services and the paediatric in the Royal London Hospital (provided by Barts Health NHS Trust at the time of the incident), and the other specifically looking at the Royal London Hospital’s radiological services.   3.6.2   NHS SIs are undertaken when the consequences of an adverse event (or events) to a patient, families and carers, staff or organisations are so significant and the potential for learning so great, that a heightened level of response is justified5.  For this case, NHS SI reports were commissioned to examine to determine whether clinical and/or safeguarding systems needed to improve in the hospital and community health setting.    3.6.3  The purpose and methodology for an NHS SI, whilst similar, is not the same as for a multi-agency SCR investigation.  Both of the SI reports have been taken into account and considered as part of the evidence for this SCR.  However, the analysis in the NHS SI reports has not pre-determined the findings for this SCR, and the SI recommendations already subject to NHS improvement have not been reproduced in this review.  Changes to hospital systems arising from the NHS SI investigations, have been summarised at the end of this report.  3.6.4 Patient safety has always been a quality issue for the NHS. Following reforms in 2013 a robust accountability and assurance framework was implemented, which specifically included safeguarding children.  All NHS organisations are held to account and are required to be explicit about safeguarding children arrangements in their service specifications and assurance processes.  These are regularly reviewed by the relevant commissioning body.  Action plans for NHS safeguarding Serious Incidents (SIs) are also an area of interest for the Care Quality Commission (CQC), the current regulator of NHS provided care.  In addition progress on the NHS SI safeguarding improvement plan, should be reported to the Local Safeguarding Children Board, along with any new actions generated by this SCR.   3.6.5 Readers are reminded that there was a change of NHS provider for community health services provision in April 2016 and that the current service provider will be the responsible agency for implementing and providing assurance to the LSCB about any of the SCR or SI recommendations attributed to the community health service.   3.6.6 There was no parallel police investigation underway during the time-line for this SCR, primarily because the early management of the case, described in full in this report, meant that opportunities for a criminal investigation were missed.                                                             5 Serious Incident Framework: Supporting learning to prevent recurrence.  NHS England (2015)     Page 7 of 72  4 Family Background and Context  4.1  Mr and Mrs C, Baby Adam’s biological parents, are of Asian descent. They were both born and brought up in the Tower Hamlets area. They are competent English speakers.  They married in 2006 after a two year relationship and lived in a housing association property in the London Borough of Tower Hamlets for the entire period of this review.  4.2 Mrs C worked for approximately five years, initially full-time dropping to part-time hours, as an NHS employee in a local GP surgery. Mr C had been in long-term unemployment due to severe chronic ill health, qualifying for disability allowance which contributed to the family income.  4.3  Baby Adam, the subject of this SCR was born at the beginning of 2015.  An older sibling of approximately three years (referred to as Sibling Isaac in this report) was born at the end of December 2011.  There is no concerning or significant background information relating to the antenatal period, birth and early years experiences for Sibling Isaac before the birth of Baby Adam. 4.4  Neither of the parents nor the children were known to Tower Hamlets Children’s Services before the events that led to this SCR, and neither were the family known to the police.  5 Narrative Summary and Key Episodes 5.1 The following narrative describes the engagement with services and the care that Baby Adam and his family experienced from his birth to until he became the subject of an Interim Care Order (ICO). The story has been split into four key episodes of care to assist the reader to focus on the most significant events.   Episode 1:  Antenatal care and Baby Adam’s birth in January 2015, until nine weeks old  5.2   Mrs C attended an antenatal booking appointment at the Royal London Hospital (RLH) maternity unit when she was 12 weeks pregnant.  A birth plan for a home delivery was agreed. She attended all of the pre-booked ante-natal appointments.    5.3  After an uneventful pregnancy Mrs C went into labour at term. However, due to an unforeseen obstetric emergency, she was transferred from home to RLH for delivery by an emergency caesarean section.  Both mother and baby were deemed fit to go home from hospital at seven days post-delivery.  Safeguarding concerns were not identified during the hospital stay.    5.4  There is no record of the post-natal care delivered to Mrs C and Baby Adam at home by the community midwifery service, as the maternity notes have been irretrievably lost.  During the post-natal period, notes usually remain within the home (and indeed can be lost within the home).  On discharge, they are collected by the community midwife and appropriately filed in the clinical record.  What happened to the notes in this particular case is unknown. However, the SCR panel has been assured that this is not a common occurrence and the system usually works well.      Page 8 of 72  5.5  The health visitor, who had not met the family before, arrived to complete the new birth visit within twelve days of Baby Adam’s delivery.  Both parents and both children were seen. The family were open and engaging and described in detail how traumatised they had been by the delivery of Baby Adam.    5.6  The visit was thorough and included a dialogue with the parents about their own family background and childhood attachment experiences.  Mrs C readily answered a question about domestic abuse, responding that her husband was supportive.  The health visitor clearly made an effort to engage with Mr C, who, despite suffering from chronic ill health, was the main carer for Sibling Isaac whilst his wife went to work. The plan was for him to take care of both children when Mrs C returned to work.  5.7  The health visitor’s observations of the family did not raise any safeguarding concerns. Apart from a minor feeding problem, the parents appeared to have adjusted well to their new family circumstances.   The health visitor was, however startled by the three year old sibling.  He displayed unbounded and excitable behaviour throughout the visit, was still in nappies and made no effort to speak.  The health visitor decided that the family should receive a universal service6. A plan was also made to liaise with Sibling Isaac’s nursery about his behaviour.  On contacting the nursery, it was apparent that nursery staff had similar concerns.  The health visitor and nursery agreed he would benefit from a referral to the neuro-developmental clinic for an assessment.  5.8  A repeat home visit was undertaken by the health visitor nine days later. By this stage Baby Adam was just over three weeks old.  Mrs C was still experiencing difficulties feeding her baby and complained of feeling tired.  This was partly due to the fact that Baby Adam had a congenital tongue tie which affected his ability to feed and partly due to a stream of visiting well-wishers. Mr C continued to support his wife.  5.9  A Common Assessment Framework (CAF) assessment was completed for Sibling Isaac, with full permission from his parents.  The health visitor and the Nursery Manager took joint responsibility for the assessment. The assessment was used to refer Sibling Isaac for a specialist speech and developmental assessment.  The Health Visitor has since confirmed that Sibling Isaac’s behaviour settled spontaneously within a year of starting nursery sessions probably due to being more stimulated in the nursery environment than when he was at home in the care of his father.   5.10 As no safeguarding concerns were ever identified for Sibling Isaac, and the action of the nursery and the health visitor working together improved his identified health and development needs, his experience has not formed a major part of this SCR. The SCR acknowledges that this is a good example of interagency working.   5.11 Baby Adam’s growth and development in the first five weeks of life were normal, although he did experience feeding problems.  He was placed on a health visiting Universal Service pathway, meaning that a full health and development assessment would be offered at six weeks of age.  5.12  The six week developmental check required Baby Adam to be seen by a health visitor and a GP in a clinic setting. The health visitor had some prior knowledge of, but not an established relationship with, the family because she was employed in the same team as the health visitor who had allocated casework responsibility.                                                              6 Universal Service: Healthy Child Programme: Pregnancy and the first five years of life (2009) Department of Health.     Page 9 of 72  5.13  During the clinic contact Mrs C mentioned that bruises were appearing on Baby Adam’s face. The health visitor remembers looking over the infant really carefully, and noticing a bruise near to his right eye.  A worrying account was given of bruises ‘coming and going’ in the same area of the face. Mrs C was told by the health visitor to discuss the bruising with the doctor when she went in to the examination room for the routine six week assessment.  She then entered a note about the bruising into the electronic health visiting record.   5.14  The clinic health visitor, reassured that Baby Adam would be seen and examined by the clinic GP, took no other action.  She did however mention the bruising to Baby Adam’s allocated family health visitor when she went back to the health visiting office after the baby clinic had finished.  5.15  The baby clinic GP saw Baby Adam as arranged for his routine six week developmental medical examination.  Apart from a small cyst on the baby’s lower eye-lid, nothing abnormal was noted. Mrs C was advised to have the cyst reviewed after six weeks.  There is no record of Mrs C discussing the bruise or any previous bruising, and the doctor did not notice a bruise when she undertook the assessment.   5.16  Mrs C visited the family GP surgery after two weeks, rather than six, for the cyst on Baby Adam’s eye-lid to be checked. The consultation was undertaken by a locum GP. During the consultation, Baby Adam’s mother brought the issue of bruising to the attention of the GP, saying that Baby Adam was developing bruises on his arms and legs after being handled. She also gave a history of noticing bruises several weeks earlier, associated with intravenous antibiotics being given in his first week of life. The locum GP noted a small area of bruising on Baby Adam’s right arm.  A range of blood tests were requested and undertaken, but the possibility of deliberate harm was not mentioned and no other professional was alerted to this history.  Baby Adam and his mother returned home following the consultation.  5.17  The day after the GP consultation, the blood test results were forwarded to Baby Adam’s named GP for review. The haematology report indicated that a possible abnormality was present in one of the blood tests and also pointed out that one test needed to be repeated due to the blood sample being insufficient in volume.  The results however, were filed without any other action being taken.    Episode 2: From the GP consultation for unexplained bruising on 11th March 2015 until 19th March 2015   5.18 This episode includes the GP’s referral to the Emergency Department, 1st hospital admission, discharge and care at home until Baby Adam’s planned outpatient appointment on 20th March 2015.  5.19 Baby Adam was taken back to the surgery on Wednesday 11th March 2015 for another GP consultation about recurring bruising. The appointment was made following a telephone call from Mrs C who was clearly worried about the bruises appearing on Baby Adam’s body. This appointment was three days after the blood results, from tests taken earlier in the week had been received and filed.  Baby Adam was just over two months old at the time and not yet mobile. The consultation was undertaken by a GP who had not seen the infant before.        Page 10 of 72  5.20 The consultation centred on mother’s observation of further bruising on the right side of Baby Adam’s head and under his left eye. An examination recorded bruising and swelling over the temple region of his head, and under his eye. Red marks to his left leg were also seen. The medical notes also stated that Baby Adam had not been involved in an accident or accidentally injured in any way.    5.21 The GP telephoned the Royal London Hospital (RLH) immediately to arrange for an urgent paediatric assessment, and during the call suggested that non-accidental injury needed to be considered. A letter was prepared for Adam’s mother to take to the hospital, although no reference to NAI was made.  5.22 Baby Adam arrived for the planned paediatric assessment in the RLH Emergency Department (ED) at 18.44 on the same day as the GP consultation. He was accompanied by his parents. The GP’s referral letter noted unexplained facial and limb bruising. The letter also updated the paediatrician with regards to the blood tests taken the week before and which had not all been completed.     5.23 The paediatric registrar thoroughly examined the child in the ED, taking a full history and making full and contemporaneous notes, including a body map of the bruises. Photographs of other bruises which had appeared during the previous week, and stored on mother’s mobile phone were also shown to the registrar during the assessment. No previous admissions were indicated on the electronic recording system, confirming that this was Baby Adam’s first presentation to the hospital.  The Local Authority Children’s social care out of hours Emergency Duty Team (EDT) that provides care when children’s social care offices are closed was contacted to check if he was known. EDT responded to the call by advising the nurse that the family was not known to children’s social care.  5.24  Baby Adam’s parents could not explain how the bruises might have occurred although his father thought he may have caused the redness on the legs, after holding him down in a salt-water bath following a non-therapeutic circumcision.  Questions relating to who cared for Baby Adam confirmed that he was cared for only by his parents, mainly by his mother, and he was never left unsupervised in the company of his three year old brother.  A plan was subsequently drawn up to admit Baby Adam to the paediatric ward for further investigations, under the care of a paediatric consultant, to rule out potential NAI or other organic causes.   5.25 The paediatric registrar on night duty took over the case once Baby Adam and his mother reached the ward.  Further advice was sought from the on-call consultant paediatrician (who also happened to be the consultant paediatrician employed to provide advice and professional oversight on safeguarding matters). The advice was to request additional blood tests to the blood tests and opthalmology review that had already been ordered.  Additional tests included a chest x-ray, a computerised tomography (CT) scan of the head, abdominal ultrasound and an extended clotting screen.   Possible NAI was clearly being considered at this time, and was explicit on the X-ray request forms. At this juncture, action was taken to inform children’s social care about Baby Adam’s unexplained bruising, initially by telephone and afterwards by means of a completed interagency child protection referral form.     5.26 The consultant paediatrician who would assume lead case responsibility for Baby Adam’s care saw him for the first time the following morning on 12th March 2015.  The clinical findings were summarised as ‘unexplained easy bruising’ and the differential diagnosis included non-accidental injury, clotting disorder or a possible abdominal tumour. This was the first time a differential diagnosis had been set out in the notes. A comprehensive paediatric plan was already in place although further investigations were added to the plan, including an ultrasound scan of the abdomen to exclude neuroblastoma, a bone profile and a range of blood tests for other organic causes.     Page 11 of 72    5.27 An arrangement was also made for a member of the NHS hospital safeguarding team to gather information from community health colleagues, to help throw light on how the family functioned at home.  The family health visitor confirmed that bruising had been identified at the six-week check in clinic, although safeguarding concerns had not been identified for either parent.    5.28 The hospital children’s social work department was also contacted by the paediatricians on the morning of 12th March 2015.  By this time the standard interagency referral form sent the night before had been received and a social care contact referral had already been entered onto the Framework I electronic recording system.  The standard RLH ‘Interagency Referral Form’ had been e-mailed to the shared NHS and CSC safeguarding inbox situated in the hospital safeguarding team office.  The hospital safeguarding team consisted of both health professionals and social workers, however, whilst co-located in the same building, they were not operationally integrated.     5.29 The paediatricians confirmed that Mr and Mrs C were aware that the referral had been made.  Children’s social care were updated about the paediatric plan which was for further medical investigations to take place. The discussion was noted on the social work file.    5.30 Later on 12th March 2015 a second ward round occurred. The consultant paediatrician employed to provide advice and professional oversight on safeguarding matters, reviewed the case.  Her opinion was that the bruising was most probably due to a bleeding disorder.  She suggested that if the consultant paediatrician with lead case responsibility agreed, Baby Adam could be discharged home for the weekend. Meanwhile, the haematologist, who had observed Sibling Isaac being particularly boisterous around Baby Adam, told the consultant paediatrician about what she saw.  This was not however, thought to have been significant.   5.31 A skeletal survey had not been undertaken or requested at this juncture. The radiographer having undertaken the head, chest and abdominal x-rays queried the absence of a skeletal survey but was advised by a consultant paediatrician that it wasn’t necessary at that time.    5.32 On the morning of 13th March 2015, when Baby Adam was still an in-patient, the allocated social worker spoke with a paediatric nurse who confirmed that medical investigations were in progress.  The social worker requested to be regularly updated. During a follow-up conversation with another nurse later in the day, the social worker learnt that Baby Adam was in the process of being discharged home.  The nurse explained that the medical staff thought the bruises were most likely to be due to a medical condition.   5.33 The social worker asked for confirmation that the bruising had not resulted from deliberate harm, stating that if medical causation had been confirmed, the team could not, and would not progress the case.   Initially assurance was given by the nurse that this was the case.  However, almost immediately after receiving that assurance, another paediatric nurse contacted the social worker to ask exactly why children’s social care could not be involved after Baby Adam had gone home. The nurse explained that the paediatric team would be nervous if social care did not maintain some form of oversight, even though Baby Adam was considered ‘a low index of concern’.        Page 12 of 72  5.34 The social worker was puzzled by this assertion and asked for the term ‘low index of concern’ to be clarified.  However, no explanation was forthcoming as to what the term actually meant or measured.  Management advice and guidance was sought from the team manager who was similarly baffled by the term and how it related to risk, and why a continuing request for social work involvement was being made.  5.35 The social worker continued to ask appropriate questions as to why the doctors were discharging a baby with unexplained bruising into an unknown situation and continued to ask why the medical team thought children’s social care were still needed, if the bruises were deemed to have a medical cause, unrelated to child maltreatment.  No clear explanation was forthcoming.  5.36 Based on this confused and conflicted position, the social work team strongly advised the paediatricians not to discharge the infant whilst investigations were ongoing.  However, no statutory child protection assessment measures were instigated by the hospital social work team, other than to decide to watch and wait and oppose any potential discharge.  EDT were briefed about Baby Adam’s admission should an issue arise at the weekend.  The social work team assumed that their advice to the paediatricians not to discharge the baby had been heeded when they left the office for the weekend break.   5.37 Baby Adam’s bruises had started to resolve after his admission and no new bruises had appeared during his stay.  Blood tests were also returning satisfactory results throughout the afternoon and the evening of Friday 13th March 2015 (although some results were still outstanding).  This was interpreted as a positive sign and during the evening of 13th March 2015, following a review of the case by the consultant paediatrician with lead case responsibility, Baby Adam was discharged into the care of his parents with an appointment to return to clinic one week later on 20th March 2015.    5.38 The medical case file recorded that children’s social care had been informed about his progress earlier in the day.  It also noted that they [csc] did not intend to follow up or assess the family until all the medical tests had been completed.  As part of the discharge plan, the paediatrician with lead case responsibility arranged for Baby Adam to be included in the weekend handover discussion, in case he should need to return.   5.39 A routine single page ED discharge summary was dispatched to Baby Adam’s GP surgery.  On receipt, the administrative clinical coder in the surgery electronically attached the discharge note to the GP record and summarised the clinical information and the social care referral in the contemporaneous clinical notes.  The clinical coder recorded the admission as a ‘bruising symptom for review’ but did not assign a safeguarding code to the information.    5.40 The same ED summary, plus additional information in the form of a full history and body maps, was also received by the health visitor, but not until several weeks later on 30th April 2015, although notes suggest the hospital liaison health visitor might have made verbal contact before that.  The documents were reviewed by the health visitor on receipt and subsequently uploaded by a health visitor administrator onto the electronic record. The administrator uploaded the information as ‘GP referral facial problems’ omitting any reference to safeguarding concerns.       Page 13 of 72  5.41 Following the request from the hospital social work team, an EDT social worker telephoned the paediatric ward on Sunday 15th March 2015 to check that all was well, being totally unaware that Baby Adam had been discharged two days earlier.  The EDT social worker was told that all the test results to date had been normal, and that the medical record stated that children’s social care would not be assessing the family.  The EDT social worker noted this information and took no further action.   5.42 The hospital social worker telephoned the ward shortly after her return to the office on the Monday morning.  Her intention was to be updated on Baby Adam’s situation over the weekend.  It was at this point that she discovered that Baby Adam had gone home, contrary to her advice.  Questions were asked as to why. The social worker was advised that as the test results being returned were all satisfactory and the paediatric team were of the opinion that as there were no safeguarding concerns, there was no reason to keep Baby Adam in hospital. The discharge summary was copied to the hospital social work team four days after Baby Adam had gone home, on 19th March 2015.  5.43 The GP routinely reviewed the cyst on Baby Adam’s eye lid on Tuesday 17th March 2015, shortly after his discharge from hospital.  The admission for bruising was discussed, and the GP was appraised by Mrs C of the paediatric plan and ongoing medical investigations to try to identify a cause. The doctor was also informed that Baby Adam was due for a hospital review in four weeks.  However, the next time Baby Adam would be seen by healthcare professionals would be at the planned outpatient appointment three days later.      Episode 3: From the outpatient’s appointment on 20th March 2015 until 16th April 2015  5.44 This episode encompasses the outpatient appointment and the 1st recall to hospital, leading to the 2nd admission and discharge from hospital.   5.45 The hospital social worker attended a meeting for management oversight and supervision for the Baby Adam case early on Friday 20th March 2015.  The social worker remained anxious about the medical management of the case, particularly as children’s social care had voiced their opposition to releasing the baby from hospital whilst tests were in progress and his situation remained unclear.   5.46 The social worker noticed on the hospital discharge summary, received the day before, that test results remained inconclusive as to the cause of the bruising. A plan to follow up the progress and assess the safety of Baby Adam was agreed.  A paediatric appointment had been scheduled for later that afternoon, so the social worker obtained consent from Baby Adam’s mother and the paediatric consultant to be present during the appointment.   5.47 Baby Adam and his mother attended the paediatric outpatients department as planned.  An examination by consultant paediatrician with lead case responsibility for Baby Adam found that the old bruises had subsided, although a more recent resolving bruise could be seen on the baby’s left arm. A sub-conjunctival haemorrhage in his left eye was also noted, a sign also suggestive of either a bleeding disorder or non-accidental trauma7.                                                                7 Subconjunctival Haemorrhages in Infants and Children: A Sign of Non accidental Trauma, DeRidder, Catherine A. MD; Berkowitz, Carol D. MD; Hicks, Ralph A. MD; Laskey, Antoinette L. MD, MPH. (2013) Paediatric Emergency Care (2013) V29, p222-6       Page 14 of 72   5.48 The consultant explained to Baby Adam’s mother that the latest blood test results had not found any abnormality, although not all of the test results had been returned.  A skeletal survey, a series of X-rays to identify fractured bones, had been ordered for later that afternoon.  The reference to the skeletal survey in the medical notes clearly indicated this was to exclude non-accidental injury. The consultant also warned Baby Adam’s mother that if the skeletal survey was abnormal he would have to be readmitted.   5.49 The social worker engaged with Mrs C during the appointment without any reported difficulty.  A full social history was taken.  There was little in the discussion to raise concern.  Baby Adam’s mother was suitably concerned about the recurring bruising, and also talked openly about her older son’s health and odd behaviour.  The social worker explained that if the skeletal survey results for Baby Adam were concerning, children’s social care would need to become involved in a child protection capacity.   5.50 On returning to the office, the social worker immediately discussed her conversation in the clinic with her line-manager.  Management advice was for the social worker to follow up Sibling Isaac with the health visitor and continue to gather information, including documentation about the current medical investigations being carried out by the paediatric team.  5.51 During the discussion, the social worker expressed an anxiety to her manager about information relating to the case being withheld from the social work team by medical colleagues.  These anxieties, born out of an awareness that only some of the medical information had been shared, were subsequently expressed to the medical team and resolved later that day.  5.52 The skeletal survey was undertaken as planned in the afternoon and the films were sent by the radiologist for radiological reporting in the normal way.  The consultant paediatrician, along with Baby Adam and his mother waited in the clinic for the report to arrive for some considerable time.  Eventually the consultant decided to go in person to the radiology department to get a verbal report.  The consultant paediatrician needed the results of the X-rays, as they would determine the next course of action.    5.53 She spoke to a paediatric consultant radiologist in the x-ray department and was reassured that the x-ray pictures looked normal. On the basis of this verbal reassurance, Baby Adam was discharged home by the consultant paediatrician with social care agreement and with an instruction that he should return to the clinic in one month for a review.       5.54 Prior to leaving to go on holiday the consultant paediatrician with lead case responsibility, had a conversation about Baby Adam with her colleague, the consultant employed to provide advice and professional oversight on safeguarding matters. They decided together that a watching brief would be maintained on Baby Adam’s case when the lead consultant was on holiday. This process of case hand-over was quite informal and was not fully documented in any clinical record. The reason for including Baby Adam in the handover discussion was driven by an underlying concern about the unexplained nature of the bruising in the light of normal blood test results and a normal skeletal survey.                                                                                                                                                                                               Page 15 of 72  5.55 Later that evening the skeletal survey was reviewed by another paediatric radiologist in line with the standard reporting system.  A written report summarised the findings. This time, the report suggested some periosteal (bone membrane) reaction in both legs. This is commonly seen in babies under six months and on a single x-ray can be hard to distinguish from traumatic injury.  In addition, the radiologist reported a possible suspicious area on the left chest wall, explaining that the image might have been masked by a skin fold, making interpretation difficult.  Neither of the findings were conclusive evidence of non-accidental injury.    5.56 A recommendation in the written report was to repeat X-rays of the chest and legs after an interval of 10 days, to enable clarification of the initial findings.  There was no suggestion of repeating the skeletal survey.  The findings in the report were not immediately or verbally conveyed to the paediatrician.  The report waited until after the weekend and was eventually read by the paediatrician on Monday 23rd March 2015, after which requests for repeat leg and chest X-rays were sent to the x-ray department.   5.57 Mrs C telephoned the GP on 25th March 2015, to report yet more bruises on Baby Adam’s body.  The GP knew that the infant was under the care of the hospital paediatric team and that a social work referral had been made. Mrs C was advised to continue to send photographs of the bruises to the consultant paediatrician as and when they occurred.  The GP did not arrange to see the baby in surgery or telephone the paediatric team to alert them to yet more bruises, on the assumption that all that could be done was being done by the paediatricians and social work team in the hospital.  5.58 Baby Adam attended the planned appointment on Tuesday 31st March 2015, eleven days after the skeletal survey, for repeat X-rays.  He went home shortly after the X-rays had been taken.  The requests for the repeated X-rays did not explicitly draw attention to the differential diagnosis or that non-accidental injury might be a factor in the history.      5.59 After taking the X-rays, the radiographer attempted to make verbal contact with a paediatric radiologist to review and interpret the films, in line with the hospital protocol, but there was no response to the call.  Having failed to make contact, the films were put into a system for routine reading and reporting, which did not afford them any immediate attention or priority status.     5.60 Baby Adam also attended the community baby clinic on 31st March 2015 to see the health visitor.  At this time he was almost three months old. The health visitor managing the clinic was the same practitioner who had undertaken his six week check.  Mrs C explained how Baby Adam was being investigated and monitored closely by the paediatric team for unexplained bruising.  New bruising to Baby Adam’s left shoulder was reported and Mrs C also described how the baby cried when he moved, as if he was in pain.  She also told the health visitor that social care had been notified of the bruising, but were waiting on the results of medical tests before making a decision on how they would respond.     5.61 The health visitor took the history from mother at face value and recorded the conversation.  The information was not shared with a GP, the hospital paediatricians or the hospital NHS safeguarding team, although an informal discussion took place with Baby Adam’s family health visitor who was based at the same office and due to visit later that week.  Neither was the hospital social worker informed that Baby Adam had been seen in the baby clinic.      Page 16 of 72  5.62 The family received a home visit from their allocated family health visitor two days later on 2nd April 2015.  All the members of the family were seen.  Both parents described being extremely tired as they adjusted to two children rather than one.  They were also anxious about the bruising to the baby which continued to appear and explained how they were sending photographs of new bruises to the consultant paediatrician by email.    5.63 They also confirmed that social care had been notified about the bruising but had not yet taken any action.  The role and function of children’s social care, should abuse be suspected, was sensitively explained to the family by the health visitor.   However, the health visitor also reassured the family that she was not concerned about their parental care of the baby, and would share this opinion with the social worker.  Views were also expressed about Sibling Isaac’s difficult behaviour, which was in the process of being assessed.   5.64 The health visitor observed first-hand how Baby Adam only settled with his mother when he cried for attention.  This triggered a conversation with Mr C, who was clearly worried about being rejected by his baby, stating that he thought the baby did not like him.  The health visitor reassured Mr C and gave him advice on how he might promote attachment between himself and his new son.  She explained that Baby Adam, would inevitably settle more readily in his mother’s presence as she was, at that stage, his primary care-giver.    5.65 The health visitor was satisfied with Baby Adam’s wellbeing and development.  The conversation and observations including the recurrent bruising and occasional loud crying were documented in full.  The care plan noted that all new bruises should continue to be transmitted to the consultant paediatrician by means of direct email communication.  In recognition of the inherent complexities of the case however, the health visitor decided to discuss the family in a reflective supervision session.  5.66 The formal report for the repeated chest and leg X-rays did not arrive until April 13th 2015, a fortnight after they had been taken, and a week over the expected reporting timescale. This delay was due to the films being placed in the routine reporting pile, and being subsumed into a general back-log of cases waiting for review over the Easter weekend, when demand was high and staffing capacity reduced.  5.67 The delayed report had noted healing fractures of the ribs, a sign indicative of non-accidental injury.  No other fractures were in evidence.  On seeing the X-ray results a decision was made by the paediatric team to recall Baby Adam to hospital and he was readmitted in the evening to the paediatric ward.  A paediatric examination on readmission identified swelling over the left rib area. A full history was taken, but an explanation or reason for the rib fractures could not be ascertained.    5.68 The social work EDT was alerted to Baby Adam’s readmission for further medical investigations associated with bruising and identified rib fractures.  The advice was for the case to be followed up by the hospital social work team in the morning. Baby Adam was settled into the ward with his mother who was to be resident with him.    5.69 The hospital social work team made contact with the paediatric lead consultant the next day.  Records of the conversation strongly suggested that a medical cause was still being pursued.  Baby Adam was being depicted as a baby ‘who bruised easily’ and his parents were being described as ‘appropriate, concerned, cooperative and compliant’.        Page 17 of 72  5.70 Great Ormond Street Hospital (GOSH) metabolic team were consulted for a specialist opinion as to whether there were any links between the bruising and the rib fractures, however a quick response from GOSH confirmed that the features of the presentation did not suggest an underlying metabolic cause.  They did, however suggest further rheumatology investigations as another line of enquiry.  5.71 The social worker advised the paediatricians that in the face of no other explanation, a child protection strategy meeting would need to be convened. The team manager supported this action, and prior to the strategy meeting taking the place, the social worker and team manager had decided in advance that, in the absence of any explanation, Baby Adam needed, at the very least, to be the subject of an assessment to ascertain what level of support would benefit both him and his family as a whole.    5.72 The plan to hold a strategy meeting was discussed with the hospital paediatric team, and whilst wanting to work towards discharging the infant, they were happy to keep Baby Adam in hospital until his circumstances and management were clearer. Contact was also made with the community health visitor who agreed to participate in the social work plan.    5.73 The police were also invited to the strategy meeting, but were of the view that the information they had seen and heard from social care had not clearly explained the rationale for convening it, and unless medical evidence supported non-accidental injury as a concern they would not be able to prioritise or justify an officer attending.  This view was reiterated the next day, despite the fact that the strategy meeting had been set. The police recorded these conversations as ‘strategy discussions’.    5.74 The police decision created difficulties for the hospital social work team.  Working Together (2015) guidance, and local child protection procedures were clear that, as a minimum, a strategy meeting must be attended by social care, health and police professionals.  The fact that the police felt unable to prioritise the meeting rendered the planned strategy meeting as inquorate8, leaving the social work team in a rather awkward predicament.   5.75 To manage the dilemma of being unable to convene the proposed strategy meeting, the hospital social work team decided to go ahead with what they called a ‘professionals meeting’ instead.  The so-called professionals meeting, would have no statutory authority or function in child protection terms.   5.76 The professionals meeting held on 15th April 2015, was attended by health and social care staff and Baby Adam’s parents. The specialist nurse employed to provide safeguarding advice and oversight and a new paediatric consultant with limited safeguarding experience, provided the health representation. The meeting was chaired by a social work manager.    5.77 The outcome of the meeting was that the threshold of actual or likely significant harm had not been met. This multi-agency decision was taken despite the history of recurrent unexplained bruising and unexplained rib fractures.  It was influenced by a consistent view from those attending, that the unexplained fractures and bruises could not be assigned to the care given by either of his parents.  Baby Adam was once again discharged home without a considered child protection plan, although the family was deemed eligible for a child in need (CIN) assessment for possible family support.                                                             8 A local authority social worker and their manager, health professionals and a police representative should, as a minimum, be involved in the strategy discussion. Other relevant professionals will depend on the nature of the individual case. Working Together (2015) HM Gov.       Page 18 of 72  5.78 The professionals tasked with the CIN assessments for both children were the social worker and the family health visitor. They met with the parents after the professionals meeting. The parents expressed their dissatisfaction with their experience of mixed messages and muddled responses resulting in an emergency recall and admission to hospital. They were advised about the complaints system and also of what the CIN assessments would entail. Part of the plan was to repeat the skeletal survey as non-accidental injury had not been entirely excluded. The social worker warned that if child protection concerns emerged, social care would respond with a child protection investigation and invoke the necessary Court orders.    Episode 4:  From 17th April 2015 until 23rd April 2015  5.79 This final episode extends from the 2nd recall to hospital which led to Baby Adam’s 3rd admission.  It includes the immediate management and a follow up strategy meeting to decide whether enquiries under section 47 of the Children Act (1989) should be undertaken.  5.80 The next day on 16th April 2015, a routine paediatric Multi-Disciplinary Team (MDT) meeting took place.  Four consultants were present, including the consultant paediatrician employed to provide advice and professional oversight on safeguarding matters and the new consultant, who had attended the professionals meeting.  Having reflected overnight, the new and relatively inexperienced consultant expressed misgivings about the decision to send the baby home.  The consultant paediatrician employed to provide advice and professional oversight on safeguarding matters was equally concerned, particularly in the light of a combined and continuing history of unexplained bruising and rib fractures. She strongly believed that Baby Adam might have been discharged to an unsafe environment, risking further harm.   5.81 Several telephone calls were placed by the consultant paediatrician employed to provide advice and professional oversight on safeguarding to the hospital social work team throughout 17th April 2015.  She insisted that Baby Adam needed to be readmitted urgently.  She urged the hospital children’s social work team to rethink the Child in Need threshold and consider a child protection response, suggesting his presentation was could be indicative of non-accidental injury. The social work team were puzzled by the rapid change of medical opinion and were initially reluctant to change the CIN threshold, as no new evidence had emerged.    5.82 Nevertheless, the police were consulted and asked by the social worker to undertake police checks on the parents, which both returned negative results.  The social care service manager was also called for advice.  He concurred that there was insufficient evidence, and no basis for either an Interim Care Order (ICO) or emergency action unless the medical staff had articulated at least a suspicion that the bruises and fractures resulted from parental care.    5.83 After several hours the social work team finally agreed with the paediatric consultant that it was appropriate for Baby Adam to be recalled for further medical and social work activity. Baby Adam was readmitted for further investigations and a repeat skeletal survey late on Friday night 17th April 2015, at approximately eleven o’clock.   EDT were informed of the admission when it took place.  It was agreed that Baby Adam would stay in hospital until all the investigations had been undertaken. Sibling Isaac remained at home.   A note of the admission was sent to the GP for information.        Page 19 of 72  5.84 A paediatric examination was undertaken on 18th April 2015.  At this time there were no visible bruises on Baby Adam’s body.  The social worker engaged with Mr and Mrs C, who were clearly upset and distressed by the readmission.  They also expressed their dissatisfaction in emails to the social worker and health visitor.     5.85 A comprehensive paediatric care plan was drafted and sent to the social work team.  The social worker noted and recollected during the SCR interview, that they were advised by a paediatrician to treat the bruising and rib fractures as separate entities, despite unexplained bruising and fractures both being indicative of significant harm9.   Even so, child protection measures were clearly assuming a much higher priority for health and social care professionals in the hospital and Baby Adam’s parents were urged by the social worker, to consider options for alternative carers for Baby Adam, whilst a child protection investigation was underway.  The conversations with the parents were both sensitive and mindful of the stressful position they were in.    5.86 The social work team sought support from the police for section 47 enquiries to start, by the convening of a strategy meeting to share information and formulate a plan.  However the police intimated again, that they might still not be able to prioritise or commit to attending the strategy meeting due to the continuing uncertainty about possible medical causation. They subsequently agreed to attend the strategy meeting on the afternoon of 20th April 2015.     5.87 The strategy meeting was held on 22nd April 2015.  Professionals from the three key agencies, health police and social care attended, including the consultant paediatrician with lead case responsibility for Baby Adam, a senior nurse employed to provide advice and professional oversight on safeguarding matters, an officer from the police CAIT team, the family health visitor, allocated social worker and a social care practice manager acting as the Chair.  The outcome was to undertake a Section 47 Child Protection investigation.    5.88 Comprehensive notes were taken at the meeting, which included the differential diagnosis, a full chronology of Baby Adam’s contacts with health and social care professionals and accounts from key practitioners who held casework responsibility for the family.  Full medical information was requested by the hospital social care team from all of the health service disciplines involved with the family, including photographs of bruises that had been emailed to the Consultant Paediatrician over a period of weeks.    5.89 A plan was formulated that included a child protection medical for Sibling Isaac and an agreement for Baby Adam to remain in hospital whilst enquiries were in progress.   Despite the refocus on child protection activity, arrangements and plans with regard to parental access and supervision whilst Baby Adam remained on the ward were not subject to formal discussion, although instructions about seeking an Emergency Protection Order were given to staff, should Baby Adam’s parents try to remove him.  Indeed, Baby Adam had frequent unsupervised contact with both of his parents whilst he was in hospital.   5.90 On the 23rd April 2015 a legal planning meeting decided to initiate care proceedings and an Interim Care Order followed on 7th May 2015.  Baby Adam was subsequently discharged from hospital into the care of his grandparents on 8th May 2015.                                                                9 Where there are child protection concerns (reasonable cause to suspect a child is suffering, or likely to suffer, significant harm) local authority social care services must make enquiries and decide if any action must be taken undersection 47 of the Children Act 1989 ‘Working Together’ (2015) HM Gov.      Page 20 of 72  6 Analysis of Practice Episode 1. How effective was the assessment and planning within universal and community services for the family prior to the onset of bruising?  6.1 In this section, universal and community services are considered to be those which are delivered as of routine to the wider population living in the London Borough of Tower Hamlets.  This includes ante-natal, midwifery and post-natal services, community health visiting and primary care GP services.   6.2 Antenatal and immediate postnatal care  6.2.1 Mrs C received standard antenatal care prior to Baby Adam’s birth. There were no indicators that suggested clinical or safeguarding concerns and a homebirth was planned. Mrs C did not receive an antenatal contact from the health visiting service despite it being mandated by the Department of Health (DH) as one of the five key universal health reviews in ‘The Healthy Child Programme (HCP).’10 At the time, Barts Health NHS Trust, along with many other providers in the country, had decided it was unable to provide the antenatal contact due to staffing shortages and a high demand on health visitors to meet other service priorities.     6.2.2 Evidence supporting the health visiting antenatal contact suggests there is a distinct advantage for the practitioner and the family to meet prior to the birth as it enables the emotional wellbeing of the family to be the primary focus without the distraction of a new-born baby.     6.2.3 The demands for health visiting services in this diverse and densely-populated area of east London continue to be a challenge.  However ‘GP Care Group’, the current provider of community health services in the borough of Tower Hamlets, have reviewed how the HCP is delivered in the area. Implementation of a new system is underway to provide health visitors with increased information about expectant mothers, so that vulnerable mothers can receive an antenatal contact.  However, a universal antenatal visit for all pregnant women is still considered unviable.     6.2.4 The emergency transfer to hospital and subsequent caesarean section was clearly perceived by Mrs C as traumatic.  Nine percent (9%) of women who describe their birth as traumatic have been found to experience some degree of post-traumatic stress disorder (PTSD) which, in turn can affect their post-natal recovery. The experience of a traumatic birth can also impact negatively on fathers. Midwives are therefore encouraged to proactively identify women who interpret their birth as difficult or traumatic and screen them for adverse effects before they leave the hospital, in order to consider their ongoing emotional needs11.    6.2.5 No evidence has been found as to how the matter of Mrs C’s traumatic delivery was addressed whilst she was an in-patient in the maternity department, and no information is available regarding the professional interactions between the community midwife and the family, as the notes are irretrievably lost.  However, the SCR panel has learnt that in 2016 the hospital maternity department opened a ‘Birth Reflections Clinic’, led by a consultant midwife, to enable families to discuss their birth experience and its impact on their emotional wellbeing.                                                              10 Healthy Child Programme: Pregnancy and the first five years of life (2009) Department of Health 11 Maternal Emotional Wellbeing and Infant Development: A good practice guide for midwives (2012) Royal College of Midwives.     Page 21 of 72   6.3 Handover from maternity to community health services  6.3.1  A midwifery discharge note was sent and received by the health visitor, but the information recorded from the birth notification onto the health visitor’s electronic record was both minimal and clinically focussed.  Wider social and emotional information including Mr C’s ill health was not included.  6.3.2  This suggests that the handover process from maternity to community health services has not embedded the public health holistic approach recommended by the Royal College of Midwives, which urges midwifery professionals to be mindful of the social and emotional, as well as physical, wellbeing of new parents12.    6.3.3 No comment can be made regarding the care that the community midwives gave the family as there are no written notes available. It is likely, and usual practice that a simple discharge note was left with Baby Adam’s mother to give to the health visitor, but there is no mention of this note in evidence sources received by the SCR panel.  Midwives have pointed out however, that the families themselves occasionally mislay the note and it is therefore not always given to the health visitor as expected.  It has been confirmed that there was no formal system in place for the community midwife to verbally hand over the case.  6.3.4 The apparent laxity in 2015 with regards to handing over care from midwife to health visitor and the filing and storage of personal and sensitive information is concerning. However the SCR has not been able to ascertain whether this was due to practitioner carelessness, a one off system failure, or a more generalised problem.    6.3.5 Conversations with professionals concerned however, have pointed to the informal handover process being generally accepted as the method of information exchange within and between organisations.  It has developed more through custom and practice than by agreed organisational protocols.  This does not however, remove the personal responsibility on a practitioner for ensuring information is shared effectively.    The failure to record and transfer clinical information can severely disadvantage users of services, and leads to the formulation of care plans on the basis of an incomplete history.    6.4 Application of Threshold for Community Health Services  6.4.1 Barts Community Health Services took over the support of the family 12 days post-delivery when a health visitor undertook a new birth visit. This was within the accepted timescale of 10 to 14 days post-delivery. The new-birth visit is a DH mandated universal health review, designed primarily to assess the health, development, safety and care of the infant. It includes some exploration of the parents’ own childhood experiences and emotional wellbeing which might influence the adjustment of the family to the new arrival.  The visit gives an opportunity to offer support, explore concerns and answer questions.  The family engaged well during this initial visit, and there is good evidence that the family valued the input from the health visiting service.    6.4.2 A comprehensive record of the family health assessment was subsequently entered into the health visitor’s electronic record. It recorded information about the infant’s health and wellbeing and included mother’s feelings about the traumatic birth and issues regarding initial feeding problems.                                                              12 High Quality Midwifery Care (2014) Royal College of Midwives.     Page 22 of 72  6.4.3 The observations arising from the family health needs assessment were analysed and a care plan formulated. Notably, the practitioner recorded concerns about the older sibling’s behaviour and development, which were mentioned by his parents. It became apparent during the visit that Mr C was Sibling Isaac’s main carer and would continue to be so.  The health visitor also noted Mr C’s chronic ill-health, which clearly affected his day to day functioning and ability to work, and she also considered how his health might impact on his ability to contain and stimulate a lively three year old. However, Mr C was not discussed with the GP, nor subject to any particular care planning or review to meet his own health and welfare needs as a significant carer.  6.4.4 The outcome of the new birth visit was to offer a Universal Service. The threshold for a Universal Service under the National Health Visiting Service Specification (2014)13 in place at the time, entitled the parents to a service that met the requirements of the national 0-5 years Healthy Child Programme (HCP).  This would comprise a further three home visits to the baby at  6-8 weeks, 9-10 months and 2-2 ½ years with a handover to the 5-19 years HCP programme prior to starting school.    6.4.5 The universal threshold is applied to families where no significant vulnerabilities have been identified. It concentrates on specific developmental milestones that are checked at set intervals. Telephone contact with a health visitor could however be initiated by the parent at any time between the set programme. Clinic attendance was encouraged for routine immunisations and ad hoc advice.    6.4.6 It could be argued that the health visitor, whilst noting significant vulnerabilities, had underestimated the potential impact they could have.  However, Baby Adam and his family received another home visit within two weeks of the new birth assessment, which was not entirely in line with the Universal HCP schedule.  This suggests that the family health visitor had indeed identified needs over and above those which qualify for the minimum Universal care programme.  This begs the question as to why the Universal threshold was applied in the first place.   6.4.7 The reasons for the repeat visit, were to seek permission from the parents to undertake a joint assessment with the manager from Sibling Isaac’s nursery, to enable Sibling Isaac’s developmental and behavioural problems to be thoroughly assessed and addressed if necessary. This was in line with the Common Assessment Framework14 (CAF) process and an entirely appropriate action. Once completed the CAF form would be sent to the neuro-developmental clinicians and therapists for follow up. This action was in line with Tower Hamlets safeguarding children guidelines which, in common with many Local Authorities, required referrals to be written in a CAF format.    6.4.8 During the visit, the health visitor recorded further difficulties that were affecting the family’s adjustment to their new circumstances.  Mrs C complained of maternal exhaustion, painful feeding problems and Sibling Isaac’s developmental delay and challenging behaviour was continuing to be a significant stressor for the family.  It could be argued therefore, that the service threshold for intervention should, at this juncture, have been reviewed and raised to offer an increased Universal Plus service.                                                              13 NHS England National Health Visiting Service Specification (March 2014/15) 14 The Common Assessment Framework for children and young people (2007) the multi-agency assessment component of the Every Child Matters:Change for Children Programme (2004) Department for Children Schools and Families (DCSF)      Page 23 of 72  6.4.9 A Universal Plus service is applied when families have known vulnerabilities and require an enhanced level of service comprised of evidence based packages of care to improve family wellbeing. The service provides more rapid expert advice and solutions for parents dealing with specific issues. It also supports children with additional health needs.  Applying this threshold would have given formal recognition that additional needs had been identified, enabling the health visiting service to provide more reflexive case management and monitoring.  6.4.10 When asked why the Universal Plus threshold had not been considered, the practitioner recalled pressures connected to staff shortages and sickness absenteeism, meaning that the capacity to deliver such a targeted service was under pressure.  However, whilst formally leaving the Universal threshold in situ, the health visitor was confident that mother would request help if needed, and there is some evidence of this happening in practice. Nevertheless consistent application of thresholds is an important systematic means of providing equity and service continuity for families on the basis of need.  6.4.11 With regards to the CAF developmental assessment for Sibling Isaac, the referral was accepted within a fortnight and an appointment was made for the end of May 2015, over two months later.  This wait from referral to appointment was not unusually long in national terms. Sibling Isaac, however, improved immensely at nursery and his behaviour and development normalised spontaneously.  This suggests that Sibling Isaac’s father, as his main carer, may not have had sufficient parenting capacity to meet his son’s health and developmental needs.    6.5 Engagement of Father  6.5.1 The focus of the family health needs assessment was typical for the service, concentrating primarily on Mrs C and the children. Less emphasis was paid to the health and welfare of Mr C, his role within the family and the impact of his own significant health needs on the safety and welfare of the children. This, despite establishing that he was the main carer to Sibling Isaac and his expressed intention to become the primary carer to Baby Adam as well, when his wife went back to work.    6.5.2 Research suggests that it is only by a holistic assessment, which incorporates each of the individuals within the family unit, that children’s lived experiences can be properly analysed.  The matter of health visitors failing to properly engage and involve fathers, however is not uncommon and has been a topic for debate for many years.    6.5.3 In 2013, the nursing research unit undertook a literature review including how health visitors engage with fathers15.  The research described a worrying lack of attention to new fathers.  Findings suggested that health visiting services in England adhered to a deeply entrenched approach which centred on mothers and their children, despite the HCP insisting on proactive engagement with fathers at every level of health visiting service specifications. However, the report also pointed out that research to support health visitors as to the best way to engage and work with fathers was both limited and relatively new.                                                               15 Why Health visiting? DH Policy Research Programme (2013)     Page 24 of 72  6.5.4 The new provider of community services in Tower Hamlets has assured the panel that a new holistic family health needs assessment, inclusive of the needs for fathers has been implemented at the point of the new-birth visit or when children have transferred into the borough from another area. This must be seen as an improvement.  However transforming traditional practice and embedding a new culture requires a great deal of practitioner support and education to support the change.  The aim should be for fathers to be included in all interactions where possible, not just at selected visits.        6.6 Recording and Exchanging Information  6.6.1 In relation to sharing information between the community health visiting service and primary care, the SCR learned that monthly formal meetings should have been taking place between GPs and health visitors to discuss vulnerable families in common.  The expectation was for the discussion to be recorded in the relevant practitioner’s notes.  When questioned, the family health visitor is certain that some conversations took place between the GP and herself with regards to Baby Adam and his family, but there is no documented evidence to confirm them in either GP or Health Visitor records. This evidence suggests a more ad-hoc system had been adopted in practice.  6.6.2 A similar ad hoc discussion was said to have occurred between the clinic health visitor and the family health visitor shortly after a routine six week developmental assessment was undertaken, but there is no documented evidence about the discussion in the notes. There is evidence that the recording and sharing of information improved as the case became more complex.   6.6.3 Professional practice guidelines for safeguarding children in primary care16, supported by the Royal College of GPs and the Care Quality Commission (CQC) suggest that GP practices should have a robust system in place that enables regular discussion with key community colleagues about vulnerable people, including children and families that are registered for primary care services. The document also advocates that those meetings should run to an agreed agenda and be properly recorded, to facilitate case continuity, audit and review.  The SCR panel has been assured that this type of meeting has now been implemented throughout the primary care system.  6.6.4 The Nursing and Midwifery Guidance17 (2009) for record keeping when Baby Adam was born, up until March 2015 when it was superseded, did allude to nursing professionals using their own professional judgement as to what they recorded in clinical notes. However for safeguarding and promoting the welfare of children, all professional interactions and outcomes are relevant. This is particularly so for babies, who are totally dependent on adults for their health and wellbeing.   6.6.5 Further evidence of ineffective communication and inattention to record keeping and information sharing manifests itself again in the GP and health visiting services after Baby Adam’s admission to hospital for bruising (this is looked at more closely in the next section).                                                               16 Safeguarding Children and Young People: The RCGP/NSPCC Safeguarding Children Toolkit for General Practice (2014)   Royal College of General Practitioners. 17 Record keeping guidance for nurses and midwives (2009) Nursing and Midwifery Council     Page 25 of 72  6.6.6 An NSPCC study18 looking at the key themes in SCRs for cases involving infants during the perinatal period concluded that information sharing between professionals involved in perinatal care is particularly problematic. This finding is mirrored in this review, and collectively the evidence points to a generalised problem with regards to information management that spans all of the services delivering universal healthcare to Baby Adam and his family. The reason for this has not been explained, but it must be addressed if children are to be adequately safeguarded in the future.     Episode 2. How effective was the practice response after the initial presentation of bruising, in various care settings and between different professionals and disciplines?    6.7 Professional Guidance and Local Procedures  6.7.1 NHS services in England are encouraged to follow the practice guidelines set out by the National Institute for Clinical and Care Excellence (NICE). The guidelines are based on research evidence and are considered the most effective and safe options for delivering healthcare.   6.7.2 The safeguarding specific NICE Guidance ‘Child maltreatment: when to suspect maltreatment‘, differentiates between when to consider maltreatment as a possible explanation for a child’s complaint and when to apply a higher threshold of concern and suspect it. The guidance states that clinicians should suspect child maltreatment in a number of circumstances, one of which is bruising, in the absence of an explanation, in a child who is not independently mobile. The NICE guidance is also clear that when child maltreatment is suspected, it should trigger a direct child protection conversation with social care.     6.7.3 The local pan-London Safeguarding Board Child Protection Procedures: Threshold Guidance Document19, designed to assist all professionals in practice, would not have provided clarity about the complex issue of unexplained bruising in a baby either. The document implied that a child protection referral should be considered when a ‘suspicious injury’ has been identified, or when two or more injuries have occurred in a non-mobile baby or child. It also references inconsistent explanations as a risk factor.  None of these categories absolutely fitted Baby Adam’s presentation.   6.7.4 Bruising in a young infant is very unusual and occurs in less than 1% of infants who are not independently mobile.  All bruising without a clear or observed explanation is highly suspicious of deliberate harm.  The younger the baby, the greater is the likelihood that bruising is non-accidental and the potential risk to that baby, who is entirely dependent on his or her primary carers, is also higher.  Any bruising in a pre-mobile baby identified in any service setting should therefore be classified as suspicious.  It should be carefully managed and assessed, and treated with the utmost caution, as soon as it has come to the attention of professionals.                                                                  18 Perinatal healthcare teams: learning from case reviews: Summary of risk factors and learning for improved practice for the health sector (2015) NSPCC 19 Threshold Document: Continuum of Help and Support: London Child protection Procedures (2015) http://www.londoncp.co.uk/files/revised_guidance_thresholds.pdf      Page 26 of 72  6.8 NHS Primary Care and Community Services    6.8.1 This section looks at the most relevant services that delivered care to Baby Adam and his family in the universal community setting.  This includes two health visitors undertaking different operational roles, one where the family was seen in their own home, and the other within a clinic environment. Other primary care professionals engaging with the family were qualified GPs.  Four GPs in total saw the family during the timeline for this review.       6.9 Response to bruising in the baby clinic setting  6.9.1 The first time that recurrent bruising was brought to the attention of a health professional was at the six week baby clinic, located in a GP surgery.  The clinic was jointly run, by a GP and health visitor, who were both on site to deliver the standard medical and mandatory health visitor assessment for babies between 6 and 8 weeks of age.  6.9.2 The health visitor appointment preceded the NHS new-born and infant physical examination20 (NIPE) screening examination. This examination has to be delivered by a suitably qualified practitioner in accordance with national guidelines - in this case a qualified GP.  6.9.3 Owing to operational practicalities, mothers and babies could not always see their allocated family health visitor or GP in the baby clinic, which inevitably impacted on continuity of service to a degree.  Nevertheless running a service in a familiar setting within a community location is a good operational model, but it relies on good inter-professional communication and team work.   6.9.4 Clinics were generally busy and frequently over-booked.  Mothers and babies were allocated clinic ‘slots’ of 10 to 15 minutes with the health visitor, during which time babies were undressed, weighed, measured, dressed and discussed.  Overrunning of clinic appointments was common and left little time for the GP and health visitor to discuss any emerging issues arising from clinic contacts. Frequently the two practitioners would not see or speak to each other for the entire clinic session, which is clearly not in a child’s best interest.  6.9.5 A visible bruise near to Baby Adam’s right eye was brought to the attention of the health visitor in the clinic. Other bruises that had previously appeared were also reported but no clear history was taken as to whereabouts on the body these lesions had occurred. The reports of the unexplained bruising were highly abnormal and the health visitor certainly suspected something was wrong, but the significance of the history in terms of child protection was not fully realised.    6.9.6 The health visitor immediately thought the causation of the bruising was organic.  When asked why the emphasis was placed on a medical cause, the SCR learnt that the practitioner’s judgement was influenced partly by the demeanour of Baby Adam’s mother, who was described as a caring, concerned, compliant parent, and partly from the health visitor’s past experience of being a paediatric nurse, which had brought her into contact with haematological conditions in children that had presented with a very similar history.                                                                  20 NIPE screens new-born babies within 72 hours of birth, and again between 6 to 8 weeks of age for conditions relating to their heart, hips, eyes and testes.  This 6-8 week screen is necessary as some conditions appear later in a child’s development.     Page 27 of 72  6.10 Holistic family assessment and information sharing  6.10.1 Health visitors as public health nurses are trained in the field of psychosocial health so they can holistically assess the impact of the community and environment on a child’s growth and development. The training adds to, and is different from, any acute nursing experience the practitioner may have.   That said, it is unsurprising that the practitioner might have drawn from previous experience.   6.10.2 A systematic comprehensive history and holistic assessment should have been undertaken when the bruising was mentioned to assess whether safeguarding might be an issue. Undertaking such an assessment would have incorporated sensitive questioning and probing into Baby Adam’s lived experience and family circumstances, which might have encouraged a face to face discussion with the GP.  However, a longer assessment would almost certainly have exceeded the time limit allocated for the appointment.    6.10.3 The outcome of the health visitor assessment was to go with her initial assumption of an organic cause.  She told Mrs C to show the bruise to the clinic doctor when the baby was examined for the six week NIPE test. A record of the bruise and history of previous bruising was entered by the health visitor into the EMIS electronic record.   6.10.4 Suggesting that the GP should review the bruise was a sensible decision by the health visitor.  However drawing the GP’s attention to the bruising should have been done by means of a conversation, to ensure that the doctor was fully appraised of the history and current presentation.   Instead, the sole responsibility for raising the bruise with the doctor was passed to Baby Adam’s mother  6.10.5 Passing the responsibility for sharing a clinical observation to a parent is professionally risky and unwise.  In this case the GP failed to notice the bruise during the six week physical examination and it was not mentioned by his mother either, during the examination.  Furthermore, the information about the bruise recorded by the health visitor on the EMIS electronic record was not reviewed by the GP prior or during the NIPE examination.  6.10.6 The SCR learned that despite being co-located, the practitioners in the baby clinic consistently operated entirely independently from one another.  The explanation as to why Baby Adam’s mother was left with the responsibility to inform the doctor about the bruise was because the health visitor assumed the GP would see it, and she also felt she had insufficient time to do the job herself.  Neither professional seemed to have the time to spare to discuss cases in the clinic environment.  6.10.7 The SCR panel learnt that health visitor notes typed into the EMIS system are seldom routinely reviewed by doctors working in baby clinics, even though the web-based system has a shared access capability.  Reading electronic health visitor notes for babies prior to, or during an examination or consultation with a clinic doctor would provide the doctor with the benefit of seeing all relevant background information, and  obtaining parental consent from parents to do so, in a clinic setting, should be relatively straight forward, as they are present during the consultation. Indeed refusing consent in itself would provoke concern.     6.10.8 The reality in practice however, is that doctors undertaking routine baby clinic assessments will simply not have time to take the necessary and complicated steps to read the notes of all of the children they are expected to see.  This would involve gaining consent, electronically opening the relevant pages, and navigating the system to find the relevant histories and notes recorded by colleagues.  In Baby Adam’s case, the GP saw no reason to suspect anything was wrong, as nothing abnormal was suspected or reported beforehand.     Page 28 of 72  6.10.9 The overbooking and time allocated for clinic appointments paid little attention to the capacity of the professionals to meet the demand. The sense of running against the clock clearly made the necessary and essential collaboration and information exchange between the practitioners more difficult, and the 6 week assessment of Baby Adam failed to identify the bruise, which in turn created the conditions whereby safeguarding actions would be far less likely to happen.  It is extremely important that clinics take into account the time it takes to share and discuss information that enables systematic health and clinical assessments which are consistent and of high quality.  Enabling quicker and easier access to electronic information systems would also be beneficial.    6.11 Responding to unexplained bruising in the GP practice  6.11.1 Multiple bruising was brought to the attention of a GP, by Baby Adam’s mother, at a routine consultation two weeks following the six week examination. Visible bruises were noted but did not trigger a safeguarding conversation or any type of inter-professional intervention.  The GP has been unable to be contacted to explain why the bruising failed to raise alarm. The single outcome of the visit was for blood tests to be taken which would be reported on the next day.  This strongly suggests that the bruising was approached in a purely clinical sense resulting in the ordering of tests to inform a medical diagnosis.       6.11.2 Clearly safeguarding issues were just not considered or suspected in relation to the bruising.  This resulted in a missed opportunity for early referral and intervention and left Baby Adam open to serious risk of what could have been a very grave injury.   6.11.3 Established GP practice guidance is clear that GPs should treat bruising in a pre-mobile baby with the utmost suspicion, and in the absence of a reasonable explanation, should take immediate action21. It would have been reasonable for the GP to seek safeguarding advice at this juncture from an NHS safeguarding children health professional.  6.11.4 GPs, who must be trained to level 3 competency, will have been exposed to best practice principles in relation to the identification of physical abuse, but for GPs to be confident and willing to apply that training in practice requires day to day professional mentorship and robust systems and processes to enable them to practice safely and effectively.  6.11.5 Five days after the consultation, Mrs C called the surgery again to report further bruising and Baby Adam was given an urgent GP appointment.  A different GP reviewed several bruises on Baby Adam’s body.  The presentation was considered unusual, raising non accidental injury concerns in the doctor’s mind that are clearly documented by the GP as an issue that needed to be excluded. The GP arranged for an emergency discussion with a paediatrician at the hospital, in line with good medical managemet.                                                               21 GP practice safeguarding children toolkit (2014) RCGP/NSPCC     Page 29 of 72  6.11.6 The GP certainly acted promptly in relation to the concerns, by taking measures to enable the bruises to be seen in the acute hospital setting.  By taking this action Baby Adam would be seen by more experienced medical colleagues. The decision and responsibility for any subsequent child protection activity however, was passed to colleagues in the hospital, rather than following best practice guidance, that expects immediate referral to social care for all cases of suspicious and unexplained bruising in a pre-mobile baby.  Practitioners must be prepared to take full responsibility for managing a suspicion of deliberate harm in the same rigorous manner as for any other potentially fatal disease.22    6.12 GP safeguarding practice: working with parents  6.12.1 There is no recorded evidence that safeguarding concerns were discussed with Baby Adam’s mother during the GP consultation and a referral to children’s social care was not made, despite the GP’s obvious concerns that the bruises might have been deliberately inflicted. A short referral letter was given to Mrs C to take to the hospital; however it did not mention safeguarding concerns, or give any social information relating to the family who were all registered at the practice.    6.12.2 Where safe to do so, it is best practice for doctors in all settings, including in primary care, to share their safeguarding concerns with the parents and refer their concerns to social care ensuring that their assessment is recorded in full23. Evidence supports that being open with parents does not necessarily damage a working relationship and can actually be of benefit to health and social care professionals, parents and children if and when they need to engage with the child protection system. GPs are no strangers to the concept of leading a courageous conversation, and this must be applied to child protection practice too.   6.12.3 The reasons why the safeguarding concerns were not shared with Adam’s parents, or why a referral to social care did not follow, remains unclear.  However past studies have consistently shown that GPs, who have a professional patient-doctor relationship with adults in the family as well as the children, report difficulties in initiating safeguarding conversations as the content is often perceived to be accusatory. In these circumstances, making a referral to children’s social care is frequently passed to colleagues in the acute sector to initiate.  It is reasonable to say that child protection work raises a lot of anxiety for GP’s delivering services to a whole registered population, particularly as they may have limited safeguarding experience.  This is why training, supervision and mentorship on site are so important.  6.12.4 As mentioned earlier, nominated practice safeguarding children clinical leads are important figures for supporting clinicians with their safeguarding practice in a primary care setting.  There is an expectation that every GP practice will have one. Baby Adam’s practice was significantly short-staffed at the time, with only one permanent GP and four locums providing a service.  The one permanent GP was undertaking all of the various primary care lead clinician roles, including the lead clinician role for safeguarding children. This would have inevitably weakened the safeguarding arrangements in the surgery.  This issue is revisited later.                                                                22 The Victoria Climbié Enquiry (2003) Lord Laming  HM Government. Recommendation 83 23 Safeguarding Children - How to Recognise Abuse or a Child at Risk: Patient: a medical resource online for supplying evidence based information on a wide range of medical and health topics. https://patient.info/doctor/safeguarding-children-how-to-recognise-abuse-or-a-child-at-risk      Page 30 of 72  6.13 Acute Hospital Services  6.13.1 Baby Adam’s case touched several departments in the hospital. Services were delivered by numerous health practitioners from a range of professional disciplines.  These included doctors, nurses, radiographers, paediatric radiologists and paediatric nurses.  Some of these qualified health professionals held distinct leadership roles for safeguarding children within the organisation. A social care team for children was also co-located within the hospital setting although it operated within office hours only.  This section looks at the inter-departmental activity and the inter-professional practice that occurred in relation to the history of unexplained bruising   6.14 The first Emergency Department contact   6.14.1 Baby Adam’s bruises were initially seen in the ED after a telephone discussion between the GP and paediatric registrar.  The baby had not been to the hospital before and there was no hospital record relating to him prior to this visit or any information highlighting a previous concern.  He was examined by a paediatric registrar in the emergency department, which is usual practice.    6.14.2 A full history, including a social history was taken, followed by a physical examination.  The recording of the consultation was clear and comprehensive and included body maps of several bruises and marks of different ages.  The notes recorded that the bruises had started to appear six days previously. Baby Adam’s mother produced photographs of the previous bruises during the examination. The photographs were mentioned in writing within the contemporaneous record. Concerns that the bruising might have been non-accidental was clearly documented.   6.14.3 The plan written by the paediatric registrar was that the child needed to be admitted for a paediatric assessment and investigations.  Baby Adam’s parents were advised that tests would be undertaken to look for a blood clotting disorder.  They were also informed that children’s social care would need to be alerted to the admission, a routine procedure for any child with unexplained bruising.  Tower Hamlets out of hours (social care emergency duty team EDT was also contacted, confirming that the family was unknown to children’s social care services.  The paediatric registrar then completed a formal child protection referral form which was dispatched to children’s social services. The NHS professionals in the hospital safeguarding team were also notified by email.   6.14.4 The response to Baby Adam’s bruising presentation in the A&E department was entirely appropriate and there is evidence of a good safeguarding assessment, management and decision making prior to his admission. This is an example of good safeguarding practice.   6.15 First admission to hospital paediatric ward  6.15.1 Baby Adam was settled with his mother into the paediatric ward for the night and his care was taken over by the night duty paediatric registrar. On reaching the ward, it appears that good communication took place between the night duty paediatric registrar and the on call-consultant with regards to any further clinical action that should take place.       Page 31 of 72  6.15.2 However, the risks and arrangements regarding parental access on the ward were not systematically assessed or considered, even though non-accidental injury had not been ruled out. Hospital staff admitted that the ward lay-out and day to day routines would almost certainly mean that the infant was out of sight for varying lengths of the time during the day and night.  The SCR learnt that the Hospital Trust did not have, and still does not have, a robust parental access and supervision risk assessment or procedure to ensure child patients admitted with safeguarding concerns are not exposed to risk from a possible perpetrator.    6.15.3 The chances for non-accidental injury to an infant being inflicted by a parent or adult carer are manifestly high and past cases have shown that children can, and have, been abused whilst in hospital by family or carers.  Any assumption that a hospital must be a safe place is flawed and increases the risk to the child.  The hospital has a legal duty to safeguard and promote the welfare of children in their care, and for suspected child abuse cases, care plans should consider the possible risks from visitors and carers whilst in the ward environment. Many hospitals have successfully implemented risk assessment and management tools to optimise safety for child patients admitted to hospital for suspected child protection reasons.    6.15.4 A full examination was undertaken by the paediatric consultant with lead case responsibility the morning after Baby Adam was admitted. The consultant also contacted the consultant paediatrician employed to provide advice and professional oversight on safeguarding matters, for her view on the safeguarding aspects. This was an appropriate and sensible decision.   6.15.5 The differential diagnosis that was made in the light of his presentation, included non-accidental injury. Standard x-rays (Chest and CT scan of head) for suspected non-accidental injury were ordered. The rationale for the x-rays was written on the request form as ‘unexplained easy bruising, rib fractures, ? NAI’. A routine referral for an ophthalmology review to check for bleeding in the eye was also performed to exclude non accidental head injury, alongside other medical investigations for bleeding and clotting defects.  6.15.6 One significant omission was for a routine skeletal survey, a test which has been recommended as best practice for all suspected NAI cases in children under two years of age since 200824.  The test is designed to spot bony injuries anywhere in the body. The radiographer contacted a consultant paediatrician once the ordered x-rays had been taken, to check that a skeletal survey was also not required, an appropriate action. The reply, was that a skeletal survey was not indicated. There is a discrepancy in the evidence gathered for this SCR, as to which consultant responded to this enquiry.    6.15.7 This decision was influenced by the medical staff witnessing a very large, unusual and palpable bruise forming when a blood test was taken.  This observation weighted the paediatrician’s opinion in favour of a blood or clotting disorder, and the fact that the initial x-rays did not show any abnormality, rather supported that view.    6.15.8 From that time onwards, evidence suggests that NAI as the cause of the unexplained bruising, whilst still part of the differential diagnosis, was not considered with the same rigour as the probability of a medical cause. The paediatric team were convinced a medical reason for the bruising would be identified.  This influenced the subsequent decision to discharge Baby Adam home without due regard to a safeguarding plan.                                                             24  Standards for Radiological Investigations of Suspected Non accidental injury: Intercollegiate report from the Royal College of Radiologists and the Royal College of paediatrics and Child Health (2008)     Page 32 of 72  6.16 Hospital inter-departmental procedure and guidance  6.16.1 The SCR has learnt that the hospital did not have an agreed child protection bruising in infancy protocol or a procedure that followed best practice guidelines. The accepted protocol for ordering a skeletal survey stipulated that skeletal survey was indicated only for children under one when signs of a fracture were present. This removed the ability to look for evidence of fractures elsewhere, increasing the chance that injuries could be missed.  Despite the paediatric assertion that a skeletal survey was not necessary, the radiologist’s report recommended that Baby Adam should have one.   6.16.2 It was right that the radiologist recommended a skeletal survey in the written radiology report, in an attempt to ensure that recommended professional practice guidance was followed.  This was all that the practitioner could do.  There was no formal mechanism in place for radiology staff to rapidly escalate professional anxieties to enable a professional challenge or managerial discussion about a paediatric decision. The culture at the time was described as one where the paediatricians had the last word.    6.16.3 The paediatricians noted that a skeletal survey had been recommended in the report, but there was no urgency for Baby Adam to return to the radiology department.  An appointment was made one week later for the procedure to be done as an outpatient.   6.16.4 A senior member of the radiological team when reflecting on the case confirmed that a skeletal survey should definitely have been ordered before the baby had left hospital.  The practitioner also confirmed that radiology staff in 2015 were directed by the paediatricians, and the relationship was not one of professional equals. Several professionals giving evidence to this SCR also hinted that the relationship between the two disciplines was somewhat irritable at times.    6.16.5 The hospital Serious Incident (SI) investigations have recommended that hospital safeguarding practice in general should improve as the standard was below that expected for some very senior staff in particular. There is also a recommendation that that national skeletal survey guidelines should be followed in all cases where NAI is being considered. It also recommends that safeguarding is included in the continuing professional development programmes for radiological staff.     6.16.6 The SI findings also outlined how radiologists and paediatricians need to work in a more collaborative way. However to consolidate a respectful partnership approach, systems and pathways need to be agreed within the radiological department to enable its staff to escalate and challenge decisions that might not be considered to be in a child’s best interest.     6.17 Multi-agency Practice Leading to Baby Adams Discharge   6.17.1 The hospital social work team picked up the child protection referral form relating to Baby Adam on the day after his admission (12th March 2015), but did not make contact with the ward until the next day.  A telephone call was made to the paediatric ward by the allocated social worker to seek information and ascertain whether children’s social care needed to take any action in accordance with Section 47 of the Children Act 198925.                                                               25 The Children Act 1989 (s47) allocates duty to local authority to make such enquiries as they consider necessary to enable them to decide whether they should take any action to safeguard or promote the child’s welfare.      Page 33 of 72  6.17.2 The social worker was surprised to hear from nursing staff that Baby Adam was already being considered for discharge because the consultant paediatrician with lead case responsibility had concluded that Baby Adam was a ‘low index of concern’. During the conversation it also became apparent that despite believing that Baby Adam was not at risk, the medical team wanted children’s social care to support the family once they had gone home.   6.17.3 Several attempts were made to clarify exactly what a ‘low index of concern’ meant, but no satisfactory explanation could be given by the nursing staff. It seemed that Baby Adam had been ‘bench-marked’ against a risk index that was totally unfamiliar to the hospital social work team and nursing professionals alike and which left them both baffled as to whether Baby Adam was at risk or not.  6.17.4 The term ‘low index of concern’ was unfamiliar and confused the social work team professionals considerably. It is not a phrase that appears in child protection policy or training. The term, coined in a patient safety framework entitled the ‘Index of Suspicion’26 was used initially in the USA to measure risk in American medical and pharmaceutical settings.  The term seems to have been applied by the consultant paediatrician as a descriptor of Baby Adam’s circumstances in a safeguarding context, which, rather than clarifying the position, left the social work team puzzled and unclear as to what to do next.  6.17.5 Using a common safeguarding language to enable effective and collaborative work between staff of different disciplines27 has been accepted as good practice for over a decade.  Medical staff will inevitably communicate with medical colleagues for medical purposes using terminology familiar to their own professional background.  However, it is important when safeguarding is an issue that doctors and other professionals consistently use only words and phrases common to child protection practice, to facilitate understanding by the rest of the multiagency partnership.  It is also important that practitioners in all disciplines take responsibility and question the meaning of unfamiliar phrases until an understanding is achieved.  6.17.6 After a discussion with her team manager, the social worker contacted the ward again. The social worker requested clarification about why the medical team thought that a social care intervention was necessary and pressed for a definitive statement that non-accidental injury had been ruled out.  When this was not forthcoming, she challenged the wisdom of discharging Baby Adam at all, and told the paediatric nurse that social care strongly advised against discharging Baby Adam particularly as his bruising remained unexplained and medical investigations were still underway.     6.17.7 A record of this discussion in the medical notes states that the nurse would ask the paediatric consultant to contact the children’s social care manager directly to explain the rationale for discharge, but there is no evidence to confirm that this message was passed on or that a conversation subsequently to took place.  However by this stage, it was clear that the professionals on the ward had come to the conclusion that social care would not support the family unless non-accidental injury was implicated. The recorded medical notes also allude to the discharge plan being effectively communicated to social care colleagues, a point which continues to be disputed by the social workers involved. Clearly, a serious miscommunication about the safeguarding risks and implications of the discharge had occurred between the two disciplines.                                                             26 An index of suspicion is defined as ‘awareness and concern for potentially serious underlying and unseen injuries or illness.’ (2012)  Institute for Safe Medication Practices, USA 27 Framework for the Assessment of Children in Need and their Families (200) DfE     Page 34 of 72  6.17.8 The social worker’s records clearly describe her discomfort about the potential discharge and in response to that concern she alerted the social work EDT office and asked them to keep in telephone contact with the ward over the weekend to check on Baby Adam’s progress.  A comprehensive follow-up e-mail was sent by the social worker to EDT including a summary of the advice not to discharge Baby Adam until the medical tests were complete.   However, despite obvious professional anxiety and failure to understand why Baby Adam might be discharged into a risky situation, the matter was not escalated by the hospital social work team manager to a more experienced senior professional for direction and legal advice. This would have required a conversation with the social work team service manager responsible for the hospital service, who was located off site in another office.    6.17.9 The social care out of hours Emergency Duty Team telephoned the ward during the weekend as requested by the hospital team social worker, only to be informed that the baby had gone home with a date to be reviewed in clinic after one week.  The medical team reiterated to the EDT social worker that there were no safeguarding concerns but investigations for the bruising were ongoing. The contradictory nature of this statement remained unchallenged by EDT. The only action taken by EDT was to make a note for the hospital social worker to follow up the issue on her return to work.       6.18 Professional perception, respect and challenge   6.18.1 There was clearly a very different perception and professional attitude about the risks of discharging Baby Adam from the hospital, and neither discipline had communicated their position effectively. The paediatricians did not consider the risk of NAI would be particularly high, but could not articulate why.  In contrast, the social worker thought the baby was at considerable risk as no cause for the bruising had been identified. Effective communication for child protection practice is much more than merely exchanging information; practitioners must ensure that it facilitates and achieves a common understanding about the reasons behind an action.   6.18.2 A SCR discussion as to why the hospital social work team did not escalate their serious concerns about the discharge concluded that the culture within the separated and bespoke hospital based social care service might have been out of tune with the operational norms practiced by other community based social care teams. For example, the hospital team had its own systems and identity, which might not have encouraged business to be discussed outside of the hospital setting. This finding surfaces again at another point in Baby Adam’s story and is discussed later in this report.    6.18.3 A major thread throughout this SCR which applies to most of the agencies involved during this episode of care, is the apparent belief that non-accidental injury needed to be confirmed by a medical diagnosis before child protection activity could be triggered. This stance shaped the multi-agency response and approach to Baby Adam’s situation which in hindsight placed him at considerable risk.  6.18.4 Any presentation of unexplained bruising in a pre-mobile infant is suspicious.  Baby Adam’s presentation should have been treated as highly indicative of significant harm until totally excluded by investigation and professional evaluation of a range of relevant medical and psycho-social factors.  Child protection activity is not dependent on a medical diagnosis, nor on the opinions of medical professionals alone.  Measures to protect Baby Adam should have been taken.        Page 35 of 72  6.18.5 It is children’s social care professionals who hold the legal responsibility for deciding when a child protection response is required, and in this case they should have exercised that leadership function more robustly by challenging the paediatric plan at the highest levels. Discharge should not have taken place until after a skeletal survey and after a multi-agency strategy meeting to discuss potential risk and likelihood of harm had taken place.    6.18.6 The hospital social worker learnt about the discharge when she returned to the office after the weekend. She was alarmed that the baby had been discharged and explained during a SCR interview how annoyed she had felt that her advice had neither been respected nor followed by the paediatric team.  She also described how the independent action taken by the paediatric team resulted in a rather negative air of mistrust between the professional disciplines. This lack of mutual professional respect is an important feature in this SCR.  6.18.7 The GMC Guidance for protecting children28 clearly sets out that doctors should understand and respect the child protection roles, responsibilities, policies and practices of other agencies and professionals, and cooperate with them.  It also urges doctors to be clear about their own role and responsibilities in protecting children and be ready to explain this to colleagues and other professionals.   Episode 3.  How effective was the practice when Baby Adam attended for the follow-up outpatient appointment and skeletal survey?  6.19 Multi-agency practice relating to outpatients appointment  6.19.1 Baby Adam was to return to the hospital for a pre-planned outpatient’s appointment, including a skeletal survey on 20th March, one week following his discharge from hospital.      6.19.2 On hearing about the outpatient’s appointment the social worker immediately discussed Baby Adam’s case in supervision for management oversight. Information sent to the social worker post discharge confirmed that test results had not indicated a medical cause and non-accidental injury was still a concern.  However, the social worker at this time had a deep suspicion that paediatricians were not sending complete and up to date information about the case, a feeling not helped by the circumstances leading to Baby Adams discharge the week before.    6.19.3 The outcome of the meeting was for the social worker to continue to work with the medical team to gain a better understanding of the family and parental account, and the approach being taken by the paediatric team with regards to ruling out non-accidental injury. A general note was placed on file suggesting that the hospital safeguarding team and the social work department needed to agree a protocol already in development to improve how NAI queries were followed through. This suggests that the effectiveness of hospital safeguarding systems had been in question for some time.                                                             28 Protecting children and young people: the responsibilities of all doctors (2012) General Medical Council.     Page 36 of 72  6.19.4 Prior to speaking to Baby Adam’s mother, the consultant paediatrician employed to provide advice and professional oversight on safeguarding matters appraised the social worker of the medical investigations, all of which were normal although two were still in progress. This is a good example of multiagency collaboration.  The paediatric consultant assured the social worker that the baby would be readmitted, if the skeletal survey due to be taken that afternoon was abnormal.  He would also be readmitted for treatment if any positive test results were received that suggested a medical condition was causing him to bruise.   6.19.5 Medical causation was still the primary concern. Mrs C reported that new bruises had emerged through the previous week and the paediatrician explained that nothing wrong had, so far, been discovered in relation to the blood investigations. These two factors taken together should have increased professional suspicion, but questions about possible deliberate harm did not assume a higher priority, from either the paediatrician or the social worker.  Instead, the social worker was content to concur with the paediatric plan to continue to look for a medical cause.  This is yet another manifestation of the medical model taking precedence over a more holistic ‘think family’29 social approach to assessing risk using a range of past and current information and child protection theory.  6.19.6 The informal verbal report of the skeletal survey given to the consultant paediatrician who had made her way to the x-ray department, was unusual and outside of best practice guidelines. The reasons why the paediatrician went in person to get the result was partly because the paediatrician was concerned about Mrs C and her baby who had been waiting for some time in the clinic, and partly because the doctor was striving to complete outstanding tasks prior to commencing an extended period of leave.  Whilst the action was outside of normal practice, it was undertaken in good faith and with good intentions.   6.19.7 The paediatric radiologist told the consultant paediatrician with lead case responsibility that the skeletal survey was ‘fine’ intimating that no abnormalities could been seen. The social worker was promptly made aware that the skeletal survey was normal, after the verbal report was given.  This conversation is recorded in the social work file but is absent from the paediatric notes.  Giving a radiological verbal opinion on a skeletal survey did not comply with the hospital radiological reporting protocol at the time, which required a more cautious and expert approach for child protection cases and which expected two senior paediatric radiologists to view the images.    6.19.8 The act of being approached and being asked for an opinion on the skeletal survey would have presented a difficult dilemma for the radiologist, who would neither have wanted to appear un-cooperative nor challenge a senior paediatric colleague.  However, protocols, including radiological protocols are designed for a purpose, often to ensure patient safety and they must be adhered to.  The matter of verbal reporting has been subject to a recommendation for improvement in the NHS SI radiological services investigation. The SCR has been assured that verbal reporting is no longer an option in the hospital.  6.19.9 After the verbal skeletal survey report had been given, the consultant paediatrician who was about to go on leave, handed over the responsibility for Baby Adam’s case to the consultant paediatrician employed to provide advice and professional oversight on safeguarding matters, recognising that the case was unusually complex and required close monitoring whilst she was on holiday.                                                               29 Think Family: Improving Support for Families at Risk. (2009) Department of Children Schools and Families     Page 37 of 72  6.19.10    A professional handover to cover absence in principle is good practice to ensure continuity and safety, but it has to be robust. In this case, there are no notes in the paediatric record of how the new bruising and subconjunctival bleed were considered, or what influenced the decision to allow Baby Adam to go home despite recurrent bruising which remained unexplained.  Handovers, should be fully recorded with the name of the consultant taking over the case responsibility explicit in the notes30.  This particular handover was informal in nature so the responsibility, accountability and planning considerations for Baby Adam whilst the lead consultant was away remained unclear during her absence.    6.19.11 A letter from the consultant paediatrician with lead case responsibility to Baby Adam’s GP, summarising the outpatients appointment, was dictated on the day of the appointment (20th March 2015), however it does not appear to have been typed until 29th April 2015, over seven weeks later.  The letter explains that medical investigations for a clotting disorder and non-accidental injury were being undertaken in parallel, but had so far returned negative results. The letter also stated that the social worker present at the appointment would meet the family to offer support.    6.19.12 To draw attention to investigations for a medical cause and non-accidental injury was useful, but the reference to the social worker offering support rather overstated their involvement and would have misled the GP into thinking that a multi-agency plan had been formulated.  When letters are written to professional colleagues alerting them to safeguarding concerns, it is important that they are accurate and unambiguous.   6.19.13 Despite the letter being dictated as a means of sharing information with the GP, in reality, it did not facilitate any timely information exchange. Evidence has shown that the letter was delayed and never reached the GP surgery until the beginning of May 2015. Letters at this time were sent off site for typing.  6.19.14 The SCR discovered that two paediatric letters, the outpatient summary dictated on 20th March and another written on April 27th following the Section 47 Enquiry were both typed and dispatched to the GP on 29th April 2015.  The time interval suggests they might have both been processed as a priority on that date.  It also suggests that an administrative back-log for typing letters, common for many hospital trusts,  might have been a factor in this case, causing consultant letters to hang around in the system.  In safeguarding terms, all information should be exchanged quickly and efficiently when safeguarding features in the history.  As a result of this delay, important medical information about Baby Adam’s outpatient appointment, did not reach the GP surgery until 6th May 2015.      6.20 Response following second radiological review of skeletal survey  6.20.1 A second consultant radiologist examined the skeletal survey images towards the end of the day on 20th March 2015, after the verbal report had been given and after Baby Adam had left the hospital.  She pointed out some possible abnormalities of the chest and leg which had simply just not been seen on the first viewing.  The recommendation was for Baby Adam to have repeat x-rays to exclude fractures after a further period of 10 days, the standard interval that would enable a more certain judgement.                                                                30 The Victoria Climbié Enquiry Report: Recommendations 76 and 80     Page 38 of 72  6.20.2 There is a difference of opinion as to whether the consultant paediatrician with lead case responsibility was informed about the anomalies on the x-rays as soon as they were discovered and before she left to go on holiday.  The radiologist vaguely remembers having a conversation with a paediatrician, but the paediatrician does not remember any such conversation, pointing yet again to the importance of recording all professional interactions.    6.20.3 The written x-ray report was prepared and subsequently read by the paediatric doctors after the weekend on the following Monday morning.  In line with the radiologist’s recommendation in the report, further x-rays were ordered. The request form stated that the images were for following up a skeletal survey, but it did not explicitly mention that NAI was being investigated.     6.20.4 The chest and leg x-rays were duly repeated on Wednesday 31st March 2015, eleven days after the skeletal survey was undertaken.  The radiographer who took the pictures, and who is not trained to spot abnormalities, made an effort to locate a paediatric radiologist to look at them.  However the attempt to locate and speak to a radiologist was abandoned when it became apparent that no one was going to respond to the telephone calls.                          6.20.5 In 2015, x-ray requests that clearly mentioned NAI on the form were automatically marked by the radiographer for high priority reporting to meet best practice guidance31.  However, as the suspicion of NAI was not indicated on the request form, the films were not prioritised and were placed into the non-urgent pile for routine reporting.  The established turnaround time for routine reporting of x-rays was one week.  6.20.6 However, the long Easter holiday weekend that commenced within 24 hours of the x-rays being taken meant that the hospital was operating a reduced out-of-hours service for four days.  This put a strain on the staffing capacity of the paediatric radiology department and a back-log of work started to grow over the holiday period.  The effect of the Easter holiday resulted in a delay of almost two weeks before Baby Adam’s x-rays could be reviewed by a radiologist.    6.21 Response by GPs following discharge from hospital   6.21.1 A one page A&E summary was dispatched and received by the GP surgery on 13th March 2015 (two days after Baby Adam’s presentation in the ED).  The information was summarised and uploaded by a practice clinical coder into the GP electronic patient record.  The event was coded as ‘bruising symptom, for review’.    6.21.2 Despite a clear reference to a child protection referral, the summary emphasised the medical investigations and also stated that social care would not be taking action whilst medical investigations were ongoing.  This might have contributed to the coder giving the event a clinical code that related only to bruising.  The code did not reflect the safeguarding concerns in the summary and it would not have provided a flag for suspected child maltreatment on subsequent visits to the GP.   In a modern GP practice, is highly unlikely that the GP would remember or have known about the past safeguarding concern without a flag to act as a reminder.                                                              31 ‘The possibility that a child has been injured non-accidentally should be clearly stated on the radiological request’: Standards for Radiological Investigations of Suspected Non-accidental Injury (2008) Royal College of Radiologists & Royal College of Paediatrics and Child Health     Page 39 of 72  6.21.3 Baby Adam had a further two contacts with a GP after he was discharged from hospital; one face to face and the other via a telephone consultation. The GPs that he saw relied on feedback from Baby Adam’s parents to inform their consultation, partly due to the fact they had not received any written paediatric summaries from the hospital on which to base their decisions.  Evidence also confirms that the GPs who saw Baby Adam failed to initiate any contact with paediatric colleagues involved in his care, in order to clarify and update the information that they were told.  Instead, Mrs C was advised to keep the consultant appraised of any new bruises by forwarding photographs to the consultant’s email address.  The GPs would not have known that the consultant was on holiday, and might not be accessing her inbox.    6.21.4 Consideration as to why the GPs thought it reasonable to take complex clinical information about a child from a parent has been discussed as part of this review.  The fact that Baby Adam’s mother was a health care assistant in a primary healthcare setting might have influenced this practice, but there is no evidence to corroborate this theory, other than comments from her primary healthcare colleagues who were confident that she always acted in a professional manner and showed a high level of concern for her child.    6.21.5 As for many city-based GP practices, Baby Adam’s GP service was under considerable organisational stress and in a state of flux at the time Baby Adam was discharged from hospital. There was only one permanent GP working in the practice, who held all of the lead clinician roles including for safeguarding. Continuity of care was impossible to organise, with the day to day GP consultations being maintained only by regularly employing locum doctors to cover for medical staffing shortages.  Ensuring that the locum doctors had sufficient safeguarding experience and safeguarding children training to the prescribed level would have been very difficult, and it was just as difficult for the lead safeguarding clinician to know just how well complex safeguarding cases were being managed.    6.21.6 As well as clinical staffing problems, the amount of information being generated for the surgery to manage was considerable. Documents were coming from a range of health and social care environments and they all needed to be processed.  Organising the paper-work and information flow was challenging both for the administrators responsible for processing it, and for the clinical staff who had very little time to read and digest the content in preparation for a patient consultation.  6.21.7 In Baby Adam’s story, there is some evidence of documents being filed rather than brought to the attention of the clinicians, and of material being processed in a purely medical context when it had safeguarding significance.   For example, not all of the documentation pertaining to Baby Adam was scanned into the electronic GP file after it was summarised, and negative investigation results were being viewed as optimistic and normal rather than an important and potential source of suspicion.  6.21.8 As a means of managing the volume of paper-work, the practice employed qualified doctors who were waiting to undertake their Professional and Linguistic Assessments Board (PLAB)32 test prior to registering with the GMC.  Their role was to specifically summarise, code and direct the flow of clinical information.  However, the effective analysing, summarising and coding of material for complex safeguarding cases, would require a good command of the English language and an understanding of the English child protection system, so the extent to which this system assisted GPs to see relevant safeguarding information is questionable.                                                             32 The PLAB test is the main route by which International Medical Graduates (IMGs) demonstrate that they have the necessary skills and knowledge to practise medicine in the UK.     Page 40 of 72  6.28.9 The research document ‘Pathways to harm, pathways to protection’33 published in 2016, looked at the initial impact of large scale health service reform on child protection practice between the years of 2011 and 2014.  The report concluded that the fragmentation of health services as a result of the reforms was having a considerable and negative effect on child protection practice generally, and this applied to primary care as well as for any other NHS service.     6.28.10 The authors of the of the research study specifically commented on the increased pressures and changed circumstances and delivery models for primary care services since the NHS reforms were implemented.  They alluded to how in the past GP services were regarded as having an important and unique function, capable of bringing together a wealth of in-depth health and social intelligence about families.  However, in a modern GP practice setting, this is less likely to be true.   6.28.11 In recognition of the change to the primary care landscape, the authors of the study recommended that LSCBs should work more closely with GPs, their commissioners and other stakeholders to ‘realistically review what can reasonably be expected of GPs as repositories and coordinators of care, and how such expectations can be supported’. For the timescale of this review, all clinicians including GPs had a statutory requirement placed upon them to safeguard and promote the welfare of any child they came into contact with. This has not changed.  However the specific difficulties of GPs to meet this requirement has clearly been recognised and the recommendations in ‘Pathways to harm, pathways to protection’ may need to be revisited in the future to enable children to be safeguarded effectively in the primary healthcare setting.   6.29 The NHS community baby clinic  6.29.1 A visit to the community baby clinic occurred two days after the repeat chest and leg x-rays, and twenty days after Baby Adam had returned home from his first admission to hospital. Details of the admission had been entered on the EMIS electronic recording system.  The clinic health visitor, who was also aware of the child protection referral, took a first-hand report about the hospital admission from Baby Adam’s mother.    6.29.2 During the clinic contact, Mrs C appraised the health visitor of the paediatric investigations.  She also reported that the baby was crying loudly at times, as if in pain, particularly on movement, and pointed out that a fresh bruise had appeared. A combination of bruising and pain on movement is highly indicative of trauma. However, the information was taken at face value and was documented, without any other probing or other action being taken.   6.29.3 The health visitor viewed the new bruise and crying as part of the medical condition already being investigated, rather than a set of new circumstances.  Her professional judgement was that she had no role to play, as all the necessary people and professionals were involved already.  She had no safeguarding concerns about Baby Adam and did not feel the baby was at risk of harm from his parents.                                                             34 Pathways to harm, pathways to protection: a triennial analysis of serious case reviews 2011 to 2014 Final Report. Sidebotham P,  Brandon M, et al ((2016) University of Warwick and University of East Anglia     Page 41 of 72  6.29.4 The reason why the information failed to instigate an action was because the clinic health visitor felt confident that all that should be done, was being done.  Whilst it is possible to explain how this assumption was formed, it was deeply flawed.  Sharing the observations and information from the contact might have been helpful to the paediatricians and social work team as well as informing her own service.   Health Visitors must report any contact with any child where child protection concerns are currently being considered, and follow up all new information, signs or symptoms of non-accidental trauma when they occur.   6.30 Home visit by the NHS community family health visitor  6.30.1 Health visitors, who are allocated home visiting responsibilities, are central to the safeguarding system.  They have case specific obligations and their primary task is to promote the health and wellbeing of children during their first five years.   Their unique role should enable them to identify need and risk and respond accordingly. They are major players in the multi-agency approach to child safeguarding and contribute to safeguarding assessment and planning processes   6.30.2 A home visit was undertaken two days after Baby Adam attended the baby clinic and three weeks after he was discharged from hospital for the first time. This might have been due to the fact that the discharge notification dispatched by the hospital was subject to a delay, and it was three weeks before it came to the attention of the health visiting service.  No explanation has been given as to why there was a gap between the hospital dispatching the note and the health visitor picking it up.  6.30.3 Following up the hospital admission was good practice, but this is best done within a week of the discharge date. A delay of three weeks is excessive when a safeguarding concern has been part of the history.  The communication system in place between the hospital and health visiting services must be robust and reliable to ensure the information flow between each service at a pace that will serve the best interests of a child.    6.30.4 At the time of the home visit, Baby Adam was almost three months old.  He had a known history of recurrent bruising, and bruises were continuing to appear.  His brother, Sibling Isaac, continued to wait for investigations of developmental delay and behavioural problems which were still evident.  Parental concerns and stressors had also been identified and were a matter of record.   6.30.5 The home visit discussion incorporated a verbal update from the parents about the medical plan and family’s progress generally.  Both parents admitted to being very tired.  They confirmed that they were taking responsibility for keeping the clinicians appraised of new bruises by emailing them directly to the consultant paediatrician.  Their verbal report was noted, although the detail of the medical plan was not clarified after the visit with either the family GP or the paediatric health visitor at the hospital, who could have liaised directly with the paediatricians to ensure a professional perspective.  6.30.6 During the visit, Baby Adam was again described as crying loudly and this was observed by the health visitor. Loud crying in and of itself is not unusual in an infant of three months.  There is no evidence in the notes that relates this comment to the ‘loud crying on movement’ that was expressed in the clinic two days earlier.  This suggests that previous electronic notes were not read prior to setting out.  Had the history of pain on movement been realised, further questions relating to the crying might have been asked.      Page 42 of 72  6.30.7 Further complexity was added to the history when Mr C revealed to the family health visitor that his baby son would only settle with his wife.  He described this inability to settle his son as ‘difficult’ and went on to disclose that he thought the baby didn’t like him. This perception, whilst not entirely uncommon for new parents, is irrational and such thoughts require careful monitoring to ensure they don’t become overly negative or intrusive, or escalate to present a potential risk to the infant.  This was new information and signalled yet another stressor for the family.  6.30.8 Reassurance and advice about bonding with his son was given to baby Adam’s father, following the disclosure, which was an appropriate response.  However, the impact on Baby Adam of the disclosure, for example, how this perception might affect his father’s psychological adjustment to fatherhood, the process of attachment34, or its possible connection to Baby Adam bruises, were not fully explored or analysed. Furthermore, the disquieting remarks uttered by Baby Adam’s father were not discussed with any of the other involved professionals immediately after the visit, being shared for the first time in a subsequent strategy meeting, several days later.  6.30.9 The known and new information that emerged during the home visit did not trigger a risk assessment. Instead, the practitioner told both parents that she had not identified any concerns regarding their care of Baby Adam, an opinion that would be relayed to the social worker at a much later date. The health visitor did however, present the case at a reflective supervision session, due to the complexities of the case.  This was an entirely appropriate action and a suitable case to discuss.  However, due to a lack of written information about the supervision session, it is difficult to see whether the supervisor provoked a deeper analysis of the family’s circumstances or if the outcome and care plan was challenged in any way.     6.30.10 Despite the growing number of stressors, the care plan remained at a universal service threshold.  Much more work could have been done to expand on the facts that were either known or coming to attention during this visit to evaluate potential risks and their effect on Baby Adam’s safety and welfare.    6.30.11 During the SCR interview the practitioner alluded to ‘knowing the family well’ which seems unlikely considering the amount of time spent with them. This notion alone might have led to the optimistic and parent centred assessment formed on the basis of limited information and knowledge, drawn from three home visits and a clinic contact. The relationship between Baby Adam’s parents and the practitioner was thought to be one of trust, however a modicum of professional scepticism and curiosity could have been kept in reserve, particularly as safeguarding concerns remained a feature in the history.   In hindsight the practitioner described how she had been utterly convinced that neither parent would harm the baby and how she would take a much more cautious approach in the future.   6.30.12 Health visitors must be clear that their primary task is the safety, health and welfare of the child and ensure that their assessments are first and foremost child centred.  Each element of their contacts and assessment should add to the overall understanding of the child’s risk and experience and the context in which they live.   Adopting a risk assessment approach and using established risk assessment techniques is a good way of promoting child centred analysis objective care planning.                                                              34 Attachment is the emotional bond formed between a child and his or her care givers through a consistent sequence of affectionate interactions.     Page 43 of 72  6.30.13 A study undertaken by the NSPCC in 201535 comments on the superficial nature of many assessments undertaken by health professionals, including health visitors, for infants where a safeguarding issue features in the history. The study notes that risk assessment techniques, essential for evaluating context and cumulative risk are not readily used by health professionals in this country generally.  The findings conclude that there is a need for safeguarding and risk assessment training for all health professionals working with complex families.    6.30.14 The analysis and learning for this particular event in Baby Adam’s story mirrors the findings in that NSPCC report.  During the timescale of this review health visitors in Tower Hamlets were neither trained nor expected to undertake formal risk assessments to inform their care plans. Skilling health visitors to calculate and manage risk more effectively, particularly where new information and safeguarding indicators like bruises are present would be a useful measure to determine their thresholds for intervention and improve the outcomes for families they are visiting.   6.30.15 Lastly, informing the family that their parenting ability was not in question in such a direct and positive manner has been a topic of discussion during this SCR.  Social workers in particular have suggested that such reassurance, based on a short period of observation rather than a robust, objective and systematic risk assessment, not only confused the parents, but was potentially unhelpful when child protection activity was still a distinct possibility.       Episode 4. How effective was the multi-agency practice following the discovery of fractured ribs?    6.31 Responses following the review of x-rays and subsequent re-admission   6.31.1 The repeated x-rays of Baby Adams chest and legs that were held up in a reporting queue, were eventually seen and evaluated by the paediatric radiologists thirteen days after they were taken, twice as long as the recommended timescale for routine reporting in national and hospital guidelines. Fractures of the 3rd to 7th ribs were seen and immediately reported to the paediatricians and to social care.  The delay in reporting had clearly exposed a risk to Baby Adam for longer than was necessary. Discovery of the rib fractures triggered his second admission to hospital.   6.31.2 Baby Adam was recalled as a matter of urgency on 13th April 2015.  This was an appropriate action. He was seen initially in the A&E department where a second social care referral form was completed. The comprehensive referral drew attention to the newly identified fractured ribs and past history of unexplained bruising.   It also recorded that a child protection medical examination and skeletal survey had been undertaken and that a previous child protection referral had been sent approximately one month before.    6.31.3 The second referral, made outside of office hours, necessitated a response from social care EDT. Generally an EDT out of hours service prioritises work according to vulnerability and risk, their core tasks being safeguarding advice and risk management. They do not normally intervene or undertake casework already allocated to a social work team for ongoing work. At the time of this admission Baby Adam was known to children’s social care, but had not been allocated for a social work assessment.                                                                35 Perinatal healthcare teams: learning from case reviews. Summary of risk factors and learning for improved practice for the health sector     Page 44 of 72  6.31.4 The EDT duty worker made contact with the paediatrician, who provided further information, including that Baby Adam was to be readmitted to the ward for further investigations whilst in a ‘place of safety’. The brief out-of-hours EDT report summarised that the baby had been recalled to hospital in view of fractured ribs which would require further investigation.  It recommended that the hospital social worker make contact with the medical staff in the morning to plan further action. The EDT activity in this case, was to take minimal details of the readmission, and pass the responsibility to the hospital social work team, when they opened for business the following day.   6.31.5 The sudden diagnosis of fractured ribs in combination with recurrent unexplained bruising to a pre-mobile infant should have rung alarm bells. They are highly indicative of non-accidental injury. There is no evidence of EDT giving any child protection advice or guidance to the ward staff to ensure Baby Adam would be safe, particularly in relation to parental access and the arrangements for his mother to stay with him overnight.  Similarly, no enquiry was made regarding the safety or potential risks to Baby Adam’s three year old brother who remained at home with his father.    6.31.6 At that point of readmission, the cause of the rib fractures remained unknown.  They were however very serious injuries and highly indicative of deliberate harm.  No consideration had been given to the question of which adult or adults in the family might pose a risk to Adam or to other children in the family network. It is important that the social care EDT operates a system that evaluates the risk of children coming to their attention, to ensure they will be protected effectively outside of office hours, regardless of any other health and social care activity.     6.31.7 Doctor Peter Sidebotham et al36 found that 78% of children subject to a SCR between 2011 and 2014 were known to children’s services at the time they were being abused. The fact that children’s social care are alerted does not in itself prevent further serious deliberate harm.  More attention should have been paid by the EDT service with regards to assessing the immediate situation for both children, so a balanced judgement could be made, explained and recorded as to whether or not any urgent safeguarding action was necessary.   6.31.8 The assumption that the hospital ward was a ‘place of safety’ gives the impression that Baby Adam would not have been exposed to risk whilst he was an in-patient.  This view, whilst common amongst health and social care practitioners, is false. In reality, the staffing levels in a hospital, particularly at night, do not guarantee the level of supervision required to ensure that the child will be safe.  Any suspected NAI case admitted to hospital, should always be subject to a risk assessment to enable the mitigation of any harm that staffing, visitors or architectural layout may pose.    6.31.9 The SCR panel have learnt that the hospital had no professional protocol in place for enabling optimal safety for paediatric admissions where child abuse is suspected.  Such a protocol, which should be agreed with social care colleagues, and which should include safety measures for parental contact or visitation, is essential for any paediatric admission when injuries are unexplained and the perpetrators unidentified.                                                              36 Pathways to Harm Pathways to Protection: Review of SCR’s 2011-14 (2016) Dr P. Sidebotham Et Al University of Warwick & University of East Anglia.     Page 45 of 72  6.31.10 The hospital social worker responded to the admission and second child protection referral by proposing that a strategy meeting should take place.  This was the right decision and was endorsed by a team manager.  Invitations were duly sent to the police and NHS colleagues, in line with national and local procedures.   6.31.11 The responsibility for convening and coordinating a strategy meeting or discussion lies entirely with the Local Authority Children’s Services Department.37 The decision whether to proceed to a section 47 Child Protection Enquiry is made on the basis of inter-professional dialogue, multi-agency information sharing and consideration of whether a child might be suffering or be likely to suffer significant harm. Once children’s social care has made the decision to initiate a section 47 Child Protection Enquiry, a multi-agency plan of how the child protection investigation will be conducted, and who will be involved, is agreed by the partnership. Strategy meetings are considered to be the most effective way of bringing professionals together to facilitate good information exchange and face to face discussion.  From a police perspective, they also provide an early opportunity for evidence gathering, should a criminal investigation be needed.   6.31.12 Statutory government guidance (2015) and the local London Safeguarding Board Child Protection Procedures (2015) were clear that a strategy meeting should always, as a minimum, include representatives from children’s social care, health and police.38 Guidance and procedures also stated that strategy meetings should be convened ‘whenever there is reasonable cause to suspect that a child is suffering, or is likely to suffer, significant harm’.  As a pre-mobile infant, Baby Adam’s history of unexplained bruising and the discovery of subsequent rib fractures, constituted a ‘reasonable cause to suspect’ and met the criteria for convening a strategy meeting in full. Furthermore, non-accidental injury, as part of the medical differential diagnosis from the start of the medical investigation, had never been excluded.  6.31.13 A senior member of the police representing the CAIT service on the SCR panel explained that the case had not met the team threshold for participating in a strategy meeting.  This was influenced by several factors, not least, that the information from children’s social care had not clearly set out the facts or the rationale for convening it.  It was also influenced by workload pressures that had resulted in strict prioritisation of all work being accepted by the CAIT team, as a measure to manage the high demand on the officers in the service.  Lastly, there was a misplaced belief that the case could not be subject to a strategy meeting until and unless the medical opinion judged the injuries to be non-accidental in nature.    6.31.14 However, the police decision to decline the invitation to the strategy meeting not only prevented any chance to secure early evidence of NAI, it ultimately altered the direction of the multi-agency response to the admission, as a statutory meeting without the police was statutorily inquorate.  Children’s social care were somewhat dismayed by the police reaction to the invitation, but the decision remained unopposed by children’s social care, despite their overarching responsibility for Baby Adam’s safety.                                                               37 Children's Services Social Care must hold a Strategy Discussion whenever there is reasonable cause to suspect that a child has suffered or is likely to suffer Significant Harm whether or not it appears that a criminal offence against a child has been committed.  38 A local authority social worker and their manager, health professionals and a police representative should, as a minimum, be involved in the strategy discussion. Other relevant professionals will depend on the nature of the individual case. Working Together (2015) HM Gov.       Page 46 of 72  6.31.15 Instead of a robust challenge and escalation for more senior advice and or intervention, to ensure that Baby Adam’s risk was addressed, the team manager, who was responsible for the child protection response under Section 47 of the Children Act 1989, deferred to the police position and advised the social worker to step down the child protection strategy meeting and proceed with a professionals meeting as part of a child in need (CIN) response39.     6.31.16 At the time of this review, the hospital had its own social care team on the hospital site. It had its own identity and culture and a distinct role of providing social work support within the hospital setting.  One key safeguarding professional described professional relationships as ‘cosy and overfamiliar’ at times.  The team perceived itself as essentially different to the other teams located in the local authority area.   The team was self-managed to a large extent, and the day to day practice, supervision and management oversight, remained within the hospital boundaries.  6.31.17 The senior and more experienced accountable service manager for the hospital team was located off site in the main local authority council building, and as such was remote and invisible to the team on a day to day basis.  Escalation of a concern for senior management guidance or legal advice might have been seen as more difficult for the hospital team under these circumstances.   6.31.18 Being absorbed into an entrenched hierarchical culture makes professional deference and lack of challenge more likely, and there are clear indicators in the actions taken or not taken by social workers, that deferring to medical (and police) opinion dictated how this case was managed.  These issues are covered later in this report as a generalised finding.   6.31.19 Since this SCR has been completed, the social work team structure in Tower Hamlets has been reviewed.  The hospital social work service has been disbanded and has been absorbed into community based teams which are expected to adhere to robust borough wide service specifications and a common approach for all children and families in the area.  This should support social workers to maintain their professional identity and core purpose.  6.31.20 The so-called professionals meeting took place in the hospital within one day of Baby Adam’s admission. It was chaired by the hospital social work team manager who decided to assign the case a child in need (CIN) response.  A newly qualified consultant with limited safeguarding experience represented the paediatric department along with the senior hospital nurse employed to provide advice and professional oversight on safeguarding matters. The family health visitor was there to exchange information and the parents were also in attendance. No formal minutes of this meeting have been submitted as evidence for the SCR suggesting that none were circulated.    6.31.21 The professionals meeting mimicked a strategy meeting to a large extent although the difference in purpose and status was not explained to participants. It has become clear during the course of this review that several professionals attending the meeting were left wondering about what type of meeting they had attended.  Many were confused about the status, authority and ownership of the decisions made as a result.                                                             39 Child in need is defined under the Children Act 1989 (section 17) as a child who is unlikely to achieve or maintain a reasonable level of health or development, or whose health and development is likely to be significantly or further impaired, without the provision of services; or a child who is disabled.     Page 47 of 72  6.31.22 Information was freely shared between the various agencies and people attending.  Key sources of information such as the observations made by the health visitor during the home visit approximately three weeks earlier, and the fact that numerous photographs of bruises had been taken and sent to the paediatrician, were brought to the attention of hospital social work team for the first time.  There is no reference to any information from the GP being sought prior to the meeting.  6.31.23 Despite the presence of bruising and fractures and the absence of an explanation, the outcome of the meeting was for the social work team manager to apply a threshold for child in need of family support under section 17 of the Children Act 198940  with the intention that the health visitor and social worker would provide input to the support programme for the family.  6.31.24 The rationale for the decision was that no evidence had been brought forward to confirm the injuries were attributable to parental care.  One senior nurse alone voiced uneasiness about the decision in the meeting, feeling that the injuries had not been treated as the primary concern, but her point was ignored and the consensus of the group was to discharge Baby Adam from hospital and follow up with social work support at home. A social worker from the hospital was allocated to undertake and coordinate the work.   6.31.25 This decision was at odds with the criteria for child protection set out in legislation. The Children Act 1989, requires the local authority to undertake a child protection investigation when there is reasonable cause to suspect that a child is suffering or likely to suffer significant harm.  All of the evidence, including Baby Adam’s age and the nature of his injuries indicated that deliberate harm was likely, even if the diagnosis could not be absolutely certain and the identity of the perpetrator could not be proven. All the factors taken together should have led professionals to be even more cautious about Baby Adam’s safety.   6.31.26 Whilst uncertainty is a constant feature in child protection case work, there were sufficient factors in Baby Adam’s case to reasonably suspect child maltreatment. This should have been taken into account and driven the decision. Authorising Baby Adam’s discharge, put him at further risk.  6.31.27 Why the decision was not robustly challenged during the meeting has been frequently raised during the SCR process, particularly as at least two practitioners, who were present at the meeting, have described their discomfort when the decision to discharge Baby Adam from the hospital was made. Neither has been able to explain their failure to challenge the decision effectively or explain why they did not immediately escalate their concerns.  On reflection both have learnt that it is vitally important to act straight away and immediately question, challenge and escalate decisions which they consider not to be in a child’s best interest, despite any perceived power imbalance or other influencing factors going on within the room.   6.31.28 ‘Groupthink’41 may well have played a part in inhibiting practitioners to speak out about the decision and some practitioners have suggested that the presence of the parents at the meeting made speaking out even more difficult, particularly as the parents were starting to openly express their complete dismay at how the case was being handled. Many of the professionals shared that point of view.                                                               40 Under Section 17(1) of the Children Act 1989, local authorities have a general duty to safeguard and promote the welfare of children within their area who are In Need; and so far as is consistent with that duty, to promote the upbringing of such children by their families, by providing a range and level of services appropriate to those children’s needs. 41 Groupthink is a psychological phenomenon that occurs within a group of people in which the desire for harmony or conformity in the group results in an irrational or dysfunctional decision-making outcome. First described in Psychologists for Social Responsibility (1982) by Irving Janis.     Page 48 of 72  6.31.29 Baby Adam was discharged home on the same day based on the outcome of the meeting, i.e. that the parents needed support and were not deliberately harming him. This suggests yet another example of parent rather than child centred practice. Enabling balanced child centred judgements and avoiding consensus collusion is extremely important in child protection work. Utilising established risk assessment models for formulating plans or by purposefully nominating a ‘devil’s advocate’42 within the meeting to introduce the necessary challenge would help to keep the focus on the child.  6.31.30 The new consultant paediatrician who was at the professionals meeting pondered the decision overnight.  By morning he was not convinced that Baby Adam should have gone home. He reported his concern at a routine medical MDT meeting that occurred the following morning.  Four paediatric professionals reviewed the case including the specialist paediatrician for safeguarding children.  The consensus was that the Child in Need response was incorrect. The paediatricians decided to ask children’s social care to reconsider and step up their response by readmitting Baby Adam and initiating a child protection response.    6.31.31 The consultant paediatrician employed to provide advice and professional oversight on safeguarding matters undertook the responsibility for speaking to social care. What followed was a series of telephone calls and discussions between the hospital social work team and the paediatrician to clarify why Baby Adam needed to be readmitted and investigated for non-accidental injury.    6.31.32 Both the social work team manager and a more senior service manager, who had been consulted about the matter, could not understand why the paediatric opinion had changed from the day before stating that there was no grounds for emergency action unless the injuries were deemed to be non-accidental. This is technically incorrect in that ‘reason to suspect’ significant harm is an acceptable threshold for intervention.   6.31.33 Exactly why the more experienced service manager failed to challenge or test the rationale for applying a no action threshold has not been confirmed.  Working assumptions include that he might have been going along with the decision in support of a junior member of staff, or that he honestly believed, from the information at hand, there were no grounds on which to readmit the baby to hospital.   The practitioner has not been able to be interviewed to tell us exactly what influenced the conversation.  6.31.34 The paediatricians continued to argue that they could not provide concrete evidence that proved the bruises and fractures had been inflicted deliberately, particularly when medical tests were still underway. However they were concerned that deliberate harm could not, and had not been ruled out and was highly likely to be responsible.                                                              42 Devil’s Advocate: A Group member who is nominated to take the role of critic, to specifically challenge all of the assumptions the group makes.     Page 49 of 72  6.31.35 After almost two days of difficult negotiation, described by the paediatrician as ‘tetchy’, an agreement was reached that Baby Adam should be re-admitted for the third time.  The significant delay in recalling Baby Adam as a child protection case, was caused purely by medical and social care professionals failing to agree that the injuries might be attributable to the parental care.  Whilst these discussions went on Baby Adam remained at risk at home.  Medical professionals do not hold the legal responsibility for making child protection decisions, that task lies with children’s social care.  The delay was clearly not in Baby Adam’s best interests.  Social care must be prepared to act on reasonable cause to suspect, rather than wait for absolutes backed by medical evidence.     6.31.36 Baby Adam was re-admitted late in the evening on Friday 17th April 2015. As for the previous admission social services EDT were informed. However no action was taken by the team, other to ring the ward to check that Baby Adam had not been discharged.  There was no risk assessment or questions asked about Baby Adam’s safety on the ward and no questions asked about the safety of Sibling Isaac who remained at home.    6.31.37 There is no evidence that either the community health visiting team or the GP were notified of the sudden admission at the earliest opportunity on the Monday morning. In fact it appears that the health visitor was informed of the admission in an email from Baby Adam’s mother, before a professional contact from children’s social care took place.    6.31.38 During the following week there was a considerable amount of work undertaken by the hospital social work team to engage the family and set arrangements in train for a strategy meeting. Medical professionals and the hospital social care department appeared to work effectively together during this time.    6.31.39 The police initially expressed that they would not attend the meeting unless there was confirmation of NAI or evidence of a crime, but agreed later in the day.  Police must be clear that if the local authority decides that it needs to convene a strategy meeting, they are expected to attend. If for any reason this is considered inappropriate, the CAIT should escalate the matter for more senior advice, to confirm whether their reason is justified.    6.31.40 Similarly, if either of the partner agencies (health or police) expresses to a social worker arranging the strategy meeting that they cannot send a representative, the position should be reported to their senior social work manager to enable the position to be challenged.   6.31.41 The strategy meeting was eventually held six days post admission. The time interval between admission and the meeting was due to an intervening weekend and the unavailability of key representatives. Delaying a strategy meeting until all relevant partners can attend is acceptable as long as interagency discussions and cooperation are not put on hold and all children associated with the case are deemed to be safe.  6.31.42 When the meeting took place, it was attended by a range of key professionals including a radiologist, in order to share and question all available information.  This was good practice. Minutes of the discussion including the outcome and plan were circulated after the meeting in line with safeguarding children practice guidelines.       Page 50 of 72  6.31.43 The outcome of the strategy meeting was for Baby Adam to remain in hospital whilst plans for his immediate safety and arrangements for the medium term were arranged.  A Section 47 investigation was initiated jointly with the police.  Legal advice was secured and care options were explored.  It was at this juncture that a child protection medical was arranged for Sibling Isaac as part of a risk assessment plan.    6.31.44 There is good evidence of consistent and efficient inter-professional practice and assessment throughout the following fortnight, during which an application for a Court order was made.  An Interim Care Order was subsequently granted on 08th May 2015 when Baby Adam was discharged from hospital into the care of his grandparents.    7 Findings, Themes and Recommendations 7.1 This section highlights learning points that emerged throughout the analysis and which link to safeguarding and child protection professional practice.  Some require the attention of a single discipline or agency in order to establish the relevant change in practice.  Other lessons learned require a wider LSCB response as they suggest a generalised improvement is required across the partnership.  7.2 Partnership changes already implemented or in train will be indicated where they apply.    7.3  Learning Point - Professional Deference, Challenge and Respect 7.3.1 The traditional medical model, with its associated institutionalised systems and hierarchies is common in many acute hospital settings.  It was the prevalent culture within the Royal London Hospital at the time Baby Adam was a patient.  Within this type of working environment, which focuses primarily on medical diagnosis and interventions, doctors are often regarded as the professionals with the most expertise. They are often afforded a status and power superior to that of other professionals.  This sets off a set of associated power differentials between and within disciplines which, in a child protection context can result in an over-reliance on medical diagnosis and/or the clinicians managing the medical investigation.  This hierarchical approach frequently leads to professional deference and makes challenging medical professionals and decisions especially hard.     7.3.2 It appears that responding to Baby Adam’s needs was hindered by generalised professional deference and lack of challenge.  Opinions, actions and instructions issued by senior consultant paediatricians remained unchallenged, even when they were deviating from good practice guidelines. There was also some evidence of tension within and between hospital departments and individuals that must have impacted on working relationships and the ability to work together effectively. This situation was further complicated by the fact that one of the paediatric consultants involved, held the senior leadership and management responsibility for the hospital paediatric medical service as a whole.        Page 51 of 72  7.3.3 From evidence given to this SCR, it appears that the hospital job plans for the professionals employed to provide the safeguarding leadership and expertise, lacked clarity and deviated from the recommended national job descriptions set out in the Intercollegiate Document43 in regard to time allocated for the role, and the competencies required to fulfil the responsibilities.  The NHS SI investigators included this finding into their report and the issue is already subject to a recommendation and improvement plan (see p9.4, page 63).    7.3.4 The status and power of the paediatric consultants also exerted pressure on the social workers attached to the hospital social work team.  Several times during a SCR focus group, social work practitioners expressed their concern about some of the paediatric actions and decisions, which clearly did not seem to reflect good practice and which they judged not to be in Baby Adam’s best interests.  However, despite the social work leadership function in respect of child protection practice, they did not challenge the paediatric professionals robustly, and neither were the concerns referred to more senior social care professionals outside of the hospital team for immediate management and intervention.    7.3.5 Similarly there were two occasions where children’s social care accepted a dubious police position without question, which led to a statutory strategy meeting being cancelled. An unconscious but long established perception of police power, built on enforcement and authority might, in this case, have also exerted an undue influence over the hospital social care professionals.    7.3.6 Importing traditional organisational hierarchies into child protection practice with the resulting power imbalances is counterproductive to collaborative work and professional respect. The complex psychosocial nature of a child protection problem cannot be solved by individual expertise alone. It requires a multi-disciplinary response drawn from a range of practice expertise.   7.3.7 Whilst safeguarding and promoting the welfare of a child remains a primary concern for all practitioners, child protection activity, in all but very dire emergencies, relies on the actions and decisions of the local authority children’s social care department, who lead and coordinate the statutory response. Other agencies have a duty in law to cooperate. Professional deference interfered in that process suggesting that roles and responsibilities were confused.  Promoting role awareness and understanding agency perspectives and the key tasks and limitations of the various disciplines involved, increases professional respect and reduces the chance of establishing professional deference as a cultural norm.   7.3.8 Since undertaking this SCR the hospital social work department has been closed and the social workers relocated to geographically based community teams.  Referrals from the hospital are routed through the Multi-Agency Safeguarding Hub (MASH)44 which serves the borough as a whole.  This should help to promote a more collaborative approach that invites discussion and challenge on a more equal basis.                                                                  43 Safeguarding children and young people: roles and competences for healthcare staff. Intercollegiate Document (2014).   A competency framework agreed by all of the medical Professional Royal Colleges.  It applies to all groups, from non-clinical staff to experts and provides information on education and training and role descriptions for health professionals with specific safeguarding responsibilities.  It enables staff to understand their responsibilities in in the recognition of child maltreatment and how to take effective action.      Page 52 of 72  Recommendation 1a  To enable a cultural change and better inter-professional relationships within the partnership, the LSCB and member agencies training and development programmes for safeguarding children should include partner roles and responsibilities, professional limitations and the concepts of professional respect and respectful challenge.  Recommendation 1b The LSCB and member agencies must implement systems for escalating professional concerns and or disputes and systems for enabling collective decision making, between and across agencies.   7.4 Learning Point – Communication and Information Sharing 7.4.1 An NSPCC national study looking at the key themes in SCRs for cases involving infants during the perinatal period concluded that information sharing between professionals involved in perinatal care is particularly problematic.  This finding is mirrored in this review. Examples of poor communication and information sharing between universal healthcare providers during the perinatal period, for example between midwives, health visitors and GPs were identified throughout Baby Adam’s story. The reason for this has not been fully explained, but it must be addressed if children are to be adequately safeguarded in the future.     7.4.2 With regard to communicating with the family, relying solely on parental verification of medical and/or social care data was deeply flawed and risky.  By its very nature, if a safeguarding concern has been raised but remains unexplained, the possibility of abuse by any parent or carer cannot be discounted.  Several SCRs in the past have demonstrated how parents might deliberately mislead to avoid suspicion.   Any verification of information that relates to safeguarding or promoting the welfare of a child, should be done by means of professional to professional communication.  Recommendation 2  Professionals working with vulnerable families, or those where safeguarding has been raised, must be reminded that information needs to be shared or verified by means of professional to professional communication.  The practice of relying on a parent to pass information to a colleague or update a progress report where safeguarding might be an issue should cease immediately.    7.4.3 The analysis showed several points in the story where inter-professional communication between key professionals in health and social care settings either didn’t happen at all, was of poor quality or was ineffective.  Much of the work undertaken appeared to be task oriented against a particular agency service specification and despite known safeguarding concerns, the outcomes of a number of professional contacts are only recorded in single agency records.  This so-called ‘silo’ working is known to adversely affect multi-agency relationships and intelligence sharing, and efforts should be made to ensure practitioners work in an inter-professional context and not in isolation.      Page 53 of 72  7.4.4 Professionals must also effectively communicate their actions and interventions with each other and communicate regularly, including whenever the child is seen.  This enables a dynamic chronology to be kept on file, keeps the child at the centre of the process and keeps the various professionals delivering care to the family up to date with accurate information.      7.4.5 All case handover processes should be formal and recorded in practitioner notes, particularly when case responsibility is being passed to a new worker for a specified period of time, or when new information indicates a change in family circumstances. Information should include a clear plan and identify any new person who is taking over case responsibility.   7.4.6 When child protection information is to be shared with another discipline, consideration should be given as to what information should be shared and by whom, for example when nurses or receptionists are asked to pass on information for a colleague.  In addition, all staff should be kept up to date with plans and actions taken by their agency so that accurate and unambiguous information can be exchanged.  Since the completion of this report the hospital have included safeguarding information in the patient safety huddles system45 to ensure staff are updated with accurate and up to date information of children admitted to the ward.   7.4.7 Lastly, practitioners should use language familiar to child protection practice and refrain from using professional jargon that may serve to confuse or mislead. The use of an unfamiliar phrase to describe risk, and a poor understanding generally of the term ‘index of concern’ served only to confuse and delay appropriate safeguarding responses.  Recommendation 3  The paediatric hospital service must implement a robust formal handover process and a system that ensures unambiguous, accurate safeguarding and child protection information is passed on by well informed and appropriately trained professionals.     7.4.8  In healthcare settings in particular, notes which indicated previous safeguarding concerns were not always accessed or read by the right clinician prior to face to face contacts with the family.  Practitioner time, capacity and the change to modern service delivery models which cannot guarantee continuity of care by one person, were all said to have contributed to this finding.  In addition, organisational and technological advances in record management and processing, and the change to electronic record keeping systems, including those for coding, flagging and shared access facilities, have all contributed to practice failures in one way or another.  Of particular note is the delegation of information processing tasks to administrators and or third party coders, and the necessary reliance on those individuals to share appropriate information effectively.    7.4.9 A combination of these factors all contributed to professionals not seeing test results or documents that pertained to this complex case.  Agencies will need to examine their internal systems and processes to ensure, where safeguarding is an issue, that relevant information reaches the right clinician or practitioner without undue delay.                                                               45 Patient safety huddles are short multidisciplinary briefings designed to give healthcare staff, clinical and non-clinical, an opportunity to understand what is going on with each patient and anticipate future risks to improve patient safety and care.      Page 54 of 72   Recommendation 4a  All agencies must undertake a review of the internal and inter-agency information sharing systems and protocols in their organisations to assess and understand the nature and extent of barriers or obstacles to the flow of information from one practitioner to another (including the use of electronic recording, flagging and coding systems where appropriate).  Recommendation 4b  Action must then be taken where necessary to improve the pace and quality of information that is shared within and between agencies for children with complex medical or safeguarding needs, to ensure that it is timely, easily understood and accurate.   7.5 Learning Point – Assessment and Risk Assessment 7.5.1 The assessments reviewed for health and social care were of variable quality. Systematic analysis of background information in terms of the impact on the child did not feature in many of the agency records.    7.5.2 Paediatric medical assessments for example concentrated on clinical evaluation and took an insufficient account of relevant background information and social context and how they might impact on Baby Adam’s safety.  This was recognised in the NHS Serious Incident investigations.  7.5.3 Health visitor assessments consisted of detailed descriptions of visits and contacts.  However, what the observations meant in terms of the family’s functioning and Baby Adam’s health and wellbeing was far less visible. It was difficult to ascertain the rationale for why an action was taken or not taken, and what the outcome or risks might be.    7.5.4 Social care records were similarly descriptive.  They clearly expressed anxieties about Baby Adam, but a standard, systematic and detailed risk analysis was not added to the entries in the contemporaneous record.  The notes failed to adequately explain the anxieties in terms of risk of harm, and did not trigger the level of senior management challenge required to keep Baby Adam safe.   7.5.5 Using the fundamental components of likelihood and impact, which underpin any analysis of risk, can lead to more reflective, child-centred care planning. This is particularly relevant for professionals who work with high levels of uncertainty and risk on a daily basis. The SCR panel learnt that Tower Hamlets social workers have recently adopted a restorative practice approach with families, including risk assessment and risk management as part of their solution focussed action planning. Health visitors might also wish to become proficient at using established risk assessment models, to enhance their own assessment and care planning processes.   Recommendation 5  The health visiting Service should consider using formal risk assessment models as standard for professional assessments of children where safeguarding concerns are being considered or have been identified.       Page 55 of 72  7.6 Learning Point – Professional Optimism and Professional Curiosity  7.6.1 Several professionals described the parents as ‘plausible’ and they honestly believed that the bruising and fractures could not possibly be attributable to the care either parent was giving.  The optimistic interpretation of the cooperation and demeanour of the mother in particular, led to insufficient professional challenge and a paucity of information about Baby Adam’s lived experience within his family context.  Had this been better explored a child protection referral might have been made.   7.6.2 The parents’ openness and candid discussions about their concerns and worries reassured health and social care professionals who concluded that all was well rather than probing more deeply into how the information might link to the unexplained injuries. Even the inevitable professional dilemma created by the persistent absence of an explanation was never effectively communicated to Baby Adam’s parents, leaving them puzzled at times as to why the baby was being admitted to hospital.  Professionals, rather than becoming more curious about the unexplained nature of bruising and subsequent fractures, closed the conversation down.   7.6.3 In addition, the verbal reports taken from the parents about medical interventions were consistently taken at face value by a range of professionals in touch with the family.  The detail was neither questioned nor verified by professionals within the multi-agency partnership working with the family in key roles.   7.6.4 Many child abuse cases have featured the plausible and compliant parent.  Lord Laming in the Victoria Climbie Enquiry (2003) suggested that ‘healthy scepticism’ and ‘respectful uncertainty’ should also be fundamental to the assessment process.  More recently, the Daniel Pelka Serious Case Review (2013) also urged practitioners to ‘think the unthinkable’ to counter the rule of optimism.  7.6.5 To enable workers to see that their optimism may not be a true representation of what is going on, it is important that safeguarding supervision challenges and tests pre-conceived ideas and assumptions made during limited contact. This will ensure the child’s perspective is always considered.  Supervision in Baby Adam’s case, both in health and social care settings was poorly recorded and failed to demonstrate the necessary critical thinking, curiosity and reflection essential for safe and effective care planning.    7.7 Learning Point - Engaging with Fathers 7.7.1 Poor engagement of fathers by safeguarding professionals is a common feature in cases of abuse and neglect nationally46 and this national concern is mirrored in this review.  7.7.2 The health visitor in particular noted potential difficulties for Baby Adam’s father, both physical and emotional, and made an effort to reassure him, but other than that there were no ongoing actions or plans specifically focussed to revisit or meet his needs and no contact with other health and social care professionals took place to discuss how he might be supported.                                                               46 Pathways to Harm Pathways to Protection: Review of SCR’s 2011-14 (2016) Dr P. Sidebotham Et Al University of Warwick & University of East Anglia.     Page 56 of 72  7.7.3 Practising in this way is however not unusual. Several national research studies have shown that poor engagement with fathers is the norm for the health visiting service in the UK, despite being outlined in the NHSE health visiting specifications since 2014. Research suggests this is due in part to a deeply embedded and long standing culture that defines health visiting as a mother and child service47. Researchers also commented that there is no specific training to prepare health visitors for working with fathers (or men in general) and few examples of policies and strategies for local health services to assess, meet and measure their needs.48    7.7.4 For health visiting specifically, the commissioning of the 0-5 Healthy Child Programme (HCP) shifted in 2015 from NHSE to the Local Authority.  The Local Authority as the current commissioners are required to improve services by building on the evidence base that had supported the engagement of fathers as a means to safeguard and promote the welfare of children. This will require specific attention in commissioning intentions and documents.  The current provider for the service should also ensure that health visitors are both comfortable and competent to deliver this requirement through systems that improve the family health needs assessment process.  7.7.5 The proactive use of a ‘think child, think parent, think family’49 approach to better understand and analyse the context in which Baby Adam was living will assist NHS practitioners to tailor care plans for each family member and the family as a whole. Taking all family members into account enables both parents to reflect on their situation, recognise their strengths and weaknesses and build on their parenting capabilities.  7.7.6 Similarly, there was very little mention of Baby Adam’s father in the Hospital children’s social work records or the notes made by the EDT duty social worker.  This leads to the general conclusion that the needs of Baby Adam’s father were not in mind, explored or completely realised by any agency.  They were certainly under-represented in assessments and care plans, in both NHS and social care contexts.  This is concerning as Baby Adam’s father’s needs were complex and would undoubtedly have influenced how the family adjusted after Baby Adam was born.    7.7.7 Clearly the system in Tower Hamlets to engage with fathers (or significant male carers) needs to improve across the partnership in Tower Hamlets to ensure that the needs of fathers are properly assessed and taken into account early to promote the detection and prevention of safeguarding issues.   Recommendation 6a  Community health visiting and children’s social care services, must incorporate a ‘think family approach’ as standard in their assessment and care planning processes to enable the needs of significant adults in families to be identified and planned for.  Recommendation 6b  The LSCB should seek regular assurance, through a process of audit and practice evidence, that assessment processes include all members of a child’s family, are outcome focussed and result in effective interventions.                                                                 47 Why Health visiting? DH Policy Research Programme (2013) 48 Why do UK health visitors not engage with fathers? (2016) Family Included, A project of The family Initiative, London 49 Think child, think parent, think family: a guide to parental mental health and child welfare (2011) SCIE     Page 57 of 72  7.8 Learning Point - Responding to Bruising in Pre-mobile Babies 7.8.1 The professional responses from health and social care professionals that Baby Adam received in relation to his bruising were inadequate and likely to have exposed him to further harm.   7.8.2 Professional guidance based on established research urges all professionals in all disciplines to consider unexplained bruising in a pre-mobile infant as highly suspicious and treat all cases as potential abuse until confirmed to be otherwise.  Insufficient attention was paid by professionals from across the partnership, to the age and development of Baby Adam when he presented with bruising and the failure to instigate a robust response resulted in Baby Adam’s discharge into a harmful situation on four occasions.    7.8.3 There was a failure to embrace and equally balance all of the probabilities in the differential diagnosis, with undue weighting and confidence being placed upon the probability of a medical cause.  When a differential diagnosis for unexplained bruising includes NAI, the probability of deliberate harm must be treated with the same equal vigour and vigilance, as for any other potential cause.   7.8.4 The minimisation of the unexplained bruising is further evidenced when suggestions were put forward to treat the fractures as separate and different from the bruising, rather than a more sinister and additional sign that abuse was happening.  This view was not challenged.  7.8.5 There was no standard ‘bruising protocol’ for managing unexplained bruising in the hospital in 2015. However, the Trust is developing one in response to the findings of their own internal SI investigation.  Local GPs are also currently in the process of being instructed to refer cases of unexplained bruising in infants to social care in addition to any referral for paediatric assessment.     7.8.6 To date, there is no agreed borough-wide multi-agency protocol in place in Tower  Hamlets to ensure a systematic response to children (including pre-mobile babies) who present with unexplained bruising, and the London Safeguarding Board web-site may not be seen as helpful in this respect either (explained below).  To enable a truly effective response to unexplained bruising for infants in Tower Hamlets, the LSCB needs to develop a multi-agency protocol for the identification and management of bruising in infancy that incorporates all agencies and services in the local partnership.     7.8.7 Whereas NICE guidance50 is clear that unexplained bruising in a pre-mobile infant is in itself a reason to suspect abuse and a reason to notify children’s social care, the London Safeguarding Board Threshold Guidance51, as it currently stands, is ambiguous about the matter.  The document currently states that ‘Any allegation of abuse or neglect or any suspicious injury in a pre- or non-mobile child’ meets the threshold for child protection enquiries under section 47 of the Children Act 1989. It also lists ‘inconsistent’ explanation’ as a risk factor.     7.8.8 However, the emphasis on spoken allegations, actual injuries, and inconsistent explanations, could be misleading in practice.  It is the bruising in and of itself, in the absence of any explanation that gives a strong indication (cause to suspect) that a pre-mobile baby is at risk. In Baby Adam’s case there were no allegations, no explanations put forward, nor any recognised injuries, suspicious or otherwise.                                                             50NICE guidance: ‘Child maltreatment: when to suspect maltreatment’ https://pathways.nice.org.uk/pathways/child-abuse-and-neglect‘   51 The London Safeguarding Board Threshold Guidance - http://www.londoncp.co.uk/files/revised_guidance_thresholds.pdf      Page 58 of 72  7.8.9 Several practitioners alluded to the lack of specific guidance with regards to unexplained bruising during their SCR interviews; many thought that an unexplained bruising in infancy procedure would have helped them in practice.  There was certainly a reluctance to act without a concrete diagnosis of non-accidental injury which ultimately left Baby Adam in a risky situation. A process to follow might have helped in this respect, and practitioners have told me that robust guidance would have been helpful.  Recommendation 7  Tower Hamlets LSCB must develop and agree a local multi-agency protocol for responding to bruising in pre-mobile babies and disabled children who are dependent and unable to communicate.    Recommendation 8 Tower Hamlets LSCB Chair to contact the Chair of the London Safeguarding Children Board, to discuss the possibility of adding ‘any unexplained bruising in pre-mobile babies under six months of age’ as a as a single category for action in the London Threshold Guidance Document for tier 4 (p35) ‘Section 47, Children Act 1989: Child Protection Enquiries’    7.9 Learning Point - Convening Child Protection Strategy Meetings 7.9.1 Decision making within the hospital social work team failed to demonstrate the level of leadership and challenge required for effecting a robust child protection response for Baby Adam.  This was particularly noticeable with regards to the time it took to convene a strategy meeting. Whilst grounds for a strategy meeting were met from the time Baby Adam was referred to social care with unexplained bruising, it appeared to be exceedingly difficult for the hospital social work team to arrange one.    7.9.2 The essential strategy meeting, backed by statute and designed to be led by social care to enable partners to share information and decide on action, was cancelled after Baby Adam’s second hospital admission.  This was partly because the social care invitation to the police CAIT team failed to articulate the risk clearly, partly because of the police officer’s mistaken belief that medical opinion needed to confirm non–accidental injury and partly because the children’s social work team did not rapidly challenge or escalate the CAITs decision to decline the invitation.   7.9.3 In 2016, the Social Care Institute for Excellence (SCIE) reviewed common practice issues from serious case reviews as part of a Learning into Practice Project (LiPP) funded by the DfE and the NSPCC52.  Key findings were published in a briefing to facilitate safeguarding improvement nationally. One conclusion was that strategy meetings had not been convened when they should have been.    7.9.4 Two underlying reasons, given for this conclusion were also evident in Baby Adam’s story.  Firstly, the spurious belief that proof of harm is needed before convening a strategy meeting and secondly, that police thresholds and staff capacity might encourage a route of ‘no action’.  The  LiPP report illustrated the latter point very well in a quote from a social care professional who spoke of how the police were unable to attend strategy meetings which resulted in the police ‘very much dictating                                                            52 www.scie.org.uk/children/safeguarding/case-reviews/learning-from-case-reviews     Page 59 of 72  when they [strategy meetings] could happen’.  Similar conclusions are found in a recent child protection inspection report for the Metropolitan Police Service, published in 201653. A recommendation from that report suggests that the Metropolitan Police ‘reviews together with children’s social care its responsibilities for attendance at, and contribution to strategy discussions’.    7.9.5 Many of the hospital social work responses were driven by poor individual decisions and actions, influenced by a lack of knowledge of child protection legislation and the failure to adhere to basic child protection principles and procedures. The hospital social work team leadership was weak and deferential at times, and there was a distinct lack of leadership, pro-active intervention, challenge and escalation to more senior social care management tiers for guidance and legal advice when front line social workers were expressing a high level of concern. All of the above, increased rather than decreased the risk to Baby Adam.   7.9.6 Since this review started, the structure for delivering children’s social care in Tower Hamlets has changed.  The hospital social work team has been disbanded in favour of a locality based child centred model, including a MASH for responding to referrals. The restructure should provide a more supported model and a less medicalised approach for cases that involve acute hospital care.        7.9.7 All other agencies and professionals in Tower Hamlets must also improve their child protection responses generally, and in particular ensure that they understand their duty to cooperate with children’s social care when they are asked to participate in or provide information for child protection discussions or meetings.  Recommendation 9a  Tower Hamlets LSCB must remind member agencies about the role and function of child protection strategy meetings, including the leadership function of children’s social care to invite relevant practitioners, and the obligation for Health and Police Child Abuse Investigation Team officers to cooperate/participate.    Recommendation 9b  An annual LSCB audit of partner attendance and quality of participation at strategy meetings should be undertaken.       7.10 Learning Point:  Application of Thresholds 7.10.1 National and local thresholds are put in place to meet a statutory duty for all agencies to provide services that safeguard and promote the welfare of children in whatever context they are delivered.  They apply across a continuum of children whose needs range from no recognised additional input being required to those who experience such acute difficulties that a robust social care intervention or child protection measure is warranted.  Practitioners in any agency should apply service offers that correspond to locally agreed thresholds, which are set out in local threshold guidance documents.                                                                53  Child Protection Inspections: The Metropolitan Police Service (2016)  HMIC     Page 60 of 72  7.10.2 Twice in Baby Adam’s story, service thresholds were applied that did not correspond to the needs being described or the evidence that was available. (Once when a health visiting Universal service was applied and another when social care opted for a CIN intervention despite suspicion of NAI).  There was also a third time, immediately before Baby Adam’s final admission, when social care professionals at team and service manager level initially disputed that the threshold for urgent safeguarding action had been reached, despite evidence to the contrary.    7.10.3 The professional act of applying a threshold defines the level of risk or need identified for an individual and determines what level of service or response the child and family will receive.  It is therefore extremely important that practitioners understand and apply the relevant service thresholds consistently, according to given and pre-determined criteria.    7.10.4 Organisationally and strategically, the application of the correct threshold can influence and assist the measuring and commissioning of services in the area by calculating the demand and level of need within the population as a whole.  It is therefore important that they are applied according to standard and agreed criteria.    7.10.5 Questions were raised about the application of a universal health visiting threshold, when the family were reporting additional needs and experiencing a visiting pattern over and above the universal model.   7.10.6 External workforce pressures on time and capacity can and do influence practitioner interpretation of thresholds causing them to be set at a higher level than they should be. A member of the SCR panel alluded to chronic staff shortages and large health visitor caseloads for the timescale of this SCR. This may have been the trigger for the decision to apply the universal service threshold.    7.10.7 Rather than re-assigning thresholds, systemic pressures that affect the ability of professionals to deliver against a standard and locally agreed threshold of need criteria, should be brought to the attention of service managers by practitioners to log as an organisational risk, which needs to be managed accordingly.   Recommendation 10  The LSCB should seek regular assurance that agency responses and service offers in Tower Hamlets are consistent with the criteria set out in the local and pan London Threshold Guidance.          7.11 Learning Point - Patient Safety  7.11.1 Acute Hospital   7.11.2 Many of the hospital safeguarding issues mentioned in this report were conclusions in the NHS SI investigations.  They have either been improved or are in the process of being improved (see section 9).  Other findings for the trust which have emerged from this SCR are included under previous learning point headings, as they apply to more than one agency.     7.11.3   One further recommendation has been made for this SCR, which applies only to the Hospital Trust, that is, to improve the hospital assessment of risk when a child is admitted to a ward with injuries or conditions associated with deliberate harm. Most importantly this protects the child, but it also protects the organisation’s reputation, as by law they have a duty to protect children and promote their welfare.       Page 61 of 72   7.11.4 The assumption that a hospital ward is a naturally safe place is not correct,   particularly where abuse is suspected and a perpetrator has not been identified. Risk and safety on the ward should be considered on a case by case basis. It should be undertaken in partnership with social care professionals and with EDT guidance when admissions take place outside of normal office hours.  Discussions and conversations, and any contingency planning about the child’s safety on the ward should be recorded.   Recommendation 11  Barts Health NHS Trust must assure the LSCB that a protocol is in place for children who are admitted for consideration of safeguarding concerns, to ensure that a risk assessment is undertaken for evaluating, mitigating and managing any potential risks on the ward.     7.11.4 Primary Care  7.11.5 Nationally, it is expected that GP surgeries have robust safeguarding governance and practice arrangements, including a nominated safeguarding lead clinician, a safeguarding children policy, regular MDT meetings to discuss vulnerable patients, and resources that promote accountability and safe practice. Evidence for this SCR shows that child protection practice within the GP surgery failed to respond to, or refer Baby Adam’s bruising in a timely manner and he was never discussed in formal multi-disciplinary team (MDT) meeting with the health visitor.    7.11.6 Evidence also shows that the safeguarding lead clinician was the only permanent GP in the practice. He was facing severe challenges in keeping the practice running, and locum GPs had to be employed to cover staff vacancies. Continuity of care and safeguarding discussions and oversight was therefore extremely difficult to organise.  The SCR has been told that many issues relating to primary care are currently subject to improvement.  Improvement plans are in train for the practice concerned in this case and for the primary care system in general.  7.11.7 A Named GP for safeguarding children is employed by the CCG in line with national guidelines. The post holder is currently providing safeguarding expertise and systems leadership to GP practices in the area. For example GPs have been formally reminded that they must refer suspicious bruising to social services as soon as it presents to them, rather than to pass that responsibility to a hospital colleague. This marginal change should ensure that social care becomes aware of the child at the earliest opportunity.     7.11.8 Further changes also need to happen, particularly implementing the primary care MDT meetings, which help all information known about the child and family in the community to be brought together in one place. This has been made the subject of a primary care recommendation.  Recommendation 12  Tower Hamlets CCG and GP’s, supported by the Safeguarding Named GP, should review the safeguarding arrangements in primary care, and in particular, ensure that  each general practice is holding and formally recording a regular MDT meeting with health visitors and school nurses to discuss vulnerable families.      Page 62 of 72  7.11.9 Community Health Service   7.11.10 Lack of capacity and resources in relation to community health services have featured on more than one occasion in Baby Adam’s journey.   It was mentioned in relation to delivering ante-natal contacts, and might have influenced the decision of the family health visitor to apply a universal service when the family had additional needs.   There is however, another community service delivery problem that requires remedial action, namely the time constraints imposed on the staff (doctor and nurse) in the baby clinic setting, due to the over–booking of appointments.    7.11.11 Where capacity issues and/or over-booking appear to be impacting negatively on patient safety, they should be escalated, assessed and incorporated into standard NHS organisational risk registers for monitoring and review. Service managers, responsible for service design and evaluation should regularly monitor booking systems and processes to ensure that clinic appointment slots are not becoming overextended to a point where staff cannot manage the demand.    Recommendation 13  The number of appointments allocated for local community baby clinic provision should be reviewed by the provider of Community health services to ensure that enough time is being allowed for professionals working in clinic settings to discuss cases and access notes   7.12 Learning Point – Social Care Out of Hours Provision 7.12.1 The out of hours provision from the social care Emergency Duty Team (EDT) at critical times when Baby Adam was either discharged or readmitted to hospital was extremely weak54. The situations for Baby Adam and Sibling Isaac were not explored and potential risks were not effectively calculated.  No advice or guidance seemed to be given from a social work perspective and the notes of EDT contacts were extremely brief and uninformative.    7.12.2 Social Care EDT services should not default to a minimal response for enquiries that involve hospital admission. To establish the nature and extent of EDT involvement requires an analysis of risk, to understand the complexity of the circumstances and any associated vulnerabilities of the child or children involved.  The assessment outcome and decisions should be justified and recorded, even when it is judged that the case can wait until mainstream services can be provided.    7.12.3 EDT social workers are a good source of advice and guidance for practitioners from other agencies who are working outside of office hours and who are possibly unfamiliar with complex safeguarding work.  EDT social workers should take responsibility for ensuring practitioners from other disciplines receive expert and clear social services advice about complicated child protection matters.                                                             54 Social Work Emergency Duty Team operate between 17.00hrs and 09.00hrs every day and 24 hours during weekends and holidays.      Page 63 of 72  7.12.4 It is important that Tower Hamlets properly implements a system that records EDT activity in full and is capable of logging, attaching and emailing documentation onto the local case recording system. An identical finding resulting in a similar recommendation can also be found in the Tower Hamlets SCR for Child F (2013).  It is reasonable to conclude therefore, that the service has not made the recommended improvements over the intervening two year period.55 The outcomes and quality of EDT practice should, therefore be regularly audited and reviewed to provide assurance to the local authority and the LSCB that the service is safe and effective.    Recommendation 14  EDT practice should be regularly (annually) audited to assure the LSCB of its effectiveness to record, manage and minimise child protection risks out of hours.      7.13 Learning Point - Information Governance 7.13.1 The SCR found that many of the health service systems for recording and managing information were inadequate. The quality of information recorded was also poor in places.  7.13.2 The timely transfer of safeguarding information generated by the hospital to professionals who needed to know, was frequently delayed or not prioritised.  For the post-natal period, notes were lost altogether and hospital trust still has no idea of where that information could be.  7.13.3 Primary care failed to review, summarise and code information correctly and key test results and written communications were not always scanned into the clinical record.  This inevitably meant that information used for informing the GP actions was inaccurate and incomplete and sometimes both.  7.13.4 Contemporaneous clinical notes in any setting should include all exchanges of information and intelligence pertaining to patient care including emailed information from the patient and it is a responsibility of all agencies to process and store information safely according to data protection law.  Photographs being emailed to a specific professional’s email box run the risk of remaining unseen at times when the person is absent or on leave and the lack of guidance with regards to how to record and store email messages makes them less likely to be added to the medical record.  As emails and other forms of digital communication become the norm, information governance policy and practice must reflect and account for this eventuality.    7.13.5 The increased use of photographs and emails, and how they are recorded, was subject to a recommendation in the NHS SI investigation for the hospital.  However, this needs to be broadened to include primary care, health visiting and children’s social care services, who may all need to store such information.                                                                55 http://www.childrenandfamiliestrust.co.uk/wp-content/uploads/2013/08/Child-F-Serious-Case-Overview-Report.pdf       Page 64 of 72  Recommendation 15  The CCG and GP practices must review the processes currently in place for managing incoming post, including test results, and the criteria for bringing these to the attention of the relevant GP in the practice.    Recommendation 16   GP Care Group and children’s social care must develop or amend their Information Governance Policies to cover the recording, prompt transfer and storage of patient/client emails and photographs.    7.14 Learning Points for the Royal London Hospital:  A summary of the findings and recommendations in the NHS Serious Incident (SI) Parallel Investigations for general paediatric and radiological services   7.14.1 In the hospital setting several, but not all, of the findings in this SCR were replicated in the internal Serious Incident (SI) Investigations undertaken at the Royal London Hospital.  A range of procedural changes have been implemented as a result of the SI which are outlined below.   7.14.2 Several improvements have been made, or are in progress in radiology department, to bring it into line with the Royal College of Radiologists professional guidelines. For example, the SCR has been informed that verbal radiological reporting of skeletal surveys has ceased altogether in favour of a formal reporting system consisting of routine MDT meetings to discuss radiological findings.     17.4.3 The system for requesting and undertaking skeletal surveys and repeat x-rays has also changed to ensure that the child protection aspects are emphasised.  In addition, children are now routinely admitted for skeletal surveys, and are not discharged from hospital without the results being known, and the discharge planning process for cases where child abuse may also be a factor has also improved.  17.4.4 The overall safeguarding governance structure has been reviewed, and the accountability, competencies and responsibilities of the safeguarding professionals employed to undertake safeguarding roles has been clarified and strengthened, to reduce confusion about the respective responsibilities of safeguarding professionals and those professionals providing paediatric care in general.  Particular attention has been paid to the amount of programmed activity (PA’s) allocated to the safeguarding Named Doctor role, to ensure that post holders have sufficient time to undertake the tasks and duties outlined in the named doctor sample job description, as specified in the Intercollegiate Document (2014).56  17.4.5 Training is being provided where necessary, including an emphasis on understanding the implications of a differential diagnosis and how concerns must be escalated.  As mentioned earlier, a standard trust-wide bruising protocol is also being developed.                                                            56 Safeguarding Children and Young People: roles and competencies for healthcare staff. Intercollegiate Document (2014)     Page 65 of 72   17.4.6 New recommendations for the acute hospital service have been made as a result of this review, but have been placed mainly under the relevant theme as most apply to other agencies as well and to all of the hospital services provided by Barts Health in the area.  8 Conclusion 8.1 Baby Adam was a highly vulnerable individual.  His age and development rendered him totally dependent on those who were caring for him. The SCR has looked at practice that occurred in his first four months of life, focusing sharply on a period of just under two months from when he repeatedly presented with unexplained bruises to when child protection activity commenced.    8.2 The family was compliant and cooperative throughout and were seen many times by a range of professionals, particularly those delivering health services. Child protection action was eventually taken after an interval of two months that effectively safeguarded Baby Adam and his older brother.  Baby Adam has made a full recovery.  8.3 Unexplained bruising was first observed when he was six weeks old. It took another three weeks to bring it to the attention of health, social care and police professionals as possibly indicative of deliberate harm.  Tests were commenced to exclude a medical cause and action seemed to depend solely on the medical opinion.  Despite good reason to suspect deliberate harm, the child protection aspects of the case did not command the attention they deserved.    8.4 Baby Adam was discharged home from hospital to a potentially risky environment on two occasions, despite having persistent unexplained bruising and a growing number of negative test results that were not able to confirm the bruising was associated with a medical condition.   8.5 He was diagnosed with further rib fractures less than two months after his initial hospital discharge and was recalled.  This confirms that he had been discharged to a harmful situation.  Following a professionals meeting about the discovery of rib fractures he was discharged again for the third time, despite having a combination of unexplained bruises and fractures, at a time when he was developmentally incapable of moving about independently and after significant family stressors had come to light.  8.6 Several systemic failures were identified that contributed to delays and poor decision making which served to increase Baby Adam’s risk rather than protect him.  There were also serious flaws in the interpretation of need and basic child protection measures that influenced individual practitioner responses; many are generalised to more than one agency.  These require internal and multi-agency cultural change, system improvement and monitoring.  8.7 Many improvement measures have already been put in place in the light of Baby Adam’s experience and recommendations from parallel investigations.  However, other learning points from this SCR will also require attention to ensure the whole safeguarding system works effectively within and across organisational boundaries to ensure babies in similar circumstances are protected.   1 month, 9 days (40 days) nth, 9      End. days (40 days)     Page 66 of 72  9 Appendix One - Summary of Recommendations No  Recommendation Rationale for Recommendation  Responsibility  1a      1b  The LSCB and member agencies safeguarding children training and development programmes should explain partner roles and responsibilities, professional limitations and the concepts of professional respect and respectful challenge.  The LSCB and member agencies must implement systems for escalating professional concerns and or disputes and systems for enabling collective decision making, between and across agencies.   This recommendation aims to improve the working culture and inter-professional relationships within the Tower Hamlets safeguarding partnership.     The responsibilities, roles and safeguarding functions of professionals from different disciplines were not fully understood, which led to weak and deferential practice.    There was also evidence of failing to escalate safeguarding issues in a timely way, which delayed appropriate safeguarding action.    Tower Hamlets Local Safeguarding Children Board   2  Professionals working with vulnerable families, or those where safeguarding has been raised, must be reminded that information needs to be shared or verified by means of professional to professional communication.  The practice of relying on a parent to pass information to a colleague or update a progress report where safeguarding might be an issue should cease immediately.   Progress reports were taken at face value from Baby Adam’s mother, despite safeguarding concerns being present.  A combination of engaging with the parent, but also following up with a professional to professional dialogue enables a more accurate and consistent multi-agency approach and reduces the risk of parents deliberately failing, or forgetting to pass on information or carry out an instruction.    Barts Health NHS Trust  Tower Hamlets GP Care Group (Health Visiting)  Tower Hamlets CCG (Primary Care)    3  The paediatric hospital service must implement robust formal handover processes and systems that ensure unambiguous, accurate safeguarding and child protection information is passed on by well informed and appropriately trained professional.    The systems for handing over Baby Adam’s case from one professional, or one service to another in the hospital were underdeveloped.  Information was frequently unrecorded, unclear, incomplete or used unfamiliar terminology.    The handover process prior to the lead consultant going on leave was particularly poor and did not provide clarity about the transfer, the covering arrangements or the ongoing care plan.    Barts Health NHS Trust       Page 67 of 72  No  Recommendation Rationale for Recommendation  Responsibility  4a         4b  All agencies must undertake a review of the internal and inter-agency information sharing systems and protocols in their organisations to assess and understand the nature and extent of barriers or obstacles to the flow of information from one practitioner to another (including the use of electronic recording, flagging and coding systems where appropriate).  Action must then be taken where necessary to improve the pace and quality of information that is shared within and between agencies for children with complex medical or safeguarding needs, to ensure that it is timely, easily understood and accurate.    Key safeguarding information about the family, both clinical and psychosocial was frequently not sought or passed on efficiently to those in the professional network who needed to know.  Relevant documentation was frequently lost, misinterpreted, and/or filed within single agency records without being shared or reviewed.    Some organisational and administrative systems in place prevented or delayed the passage of relevant safeguarding information.  For example, safeguarding codes were not utilised effectively and failed to flag safeguarding issues.  Electronic recording systems were not always accessed and internal and external postal systems created a delay as documents and letters ended up in an administrative ‘backlog’.    Barts Health NHS Trust  Tower hamlets GP Care Group (Health Visiting)  Tower Hamlets CCG (Primary Care)  Tower Hamlets Council Children’s Services  Tower Hamlets Police Child Abuse Investigation Team  5  The health visiting service should consider using formal risk assessment models as standard for professional assessments of children where safeguarding concerns are being considered or have been identified.     Practitioner assessments particularly in health and social care records contained a lot of descriptive content, but they consistently failed to systematically analyse the information to calculate the likelihood and impact of risk to Baby Adam within his family context.    Tower Hamlets Children’s Social Care has recently introduced a new model of assessment (Restorative Social Work) which incorporates risk assessment to enable child focussed assessments, managed risk and outcome focussed solutions.   Being skilled in risk assessment techniques will also benefit health visiting practice and improve the care planning for complex cases.      Tower Hamlets GP Care Group (Health Visiting)   6a      Community Health and Social Care agencies must incorporate a ‘think family approach’ as standard in their assessment and care planning processes to enable the needs of significant adults in families to be identified and planned for.  Health and social work records identified issues that indicated increased parental need.  Parental wellbeing and parental stressors and concerns were poorly assessed and were not visible in care plans.    Tower Hamlets GP Care Group (Health Visiting)  Tower Hamlets Council, Children’s Services  Tower Hamlets Council, Public Health      Page 68 of 72  No  Recommendation Rationale for Recommendation  Responsibility  6b  The LSCB should seek regular assurance, through a process of audit and practice evidence that assessment processes include all members of a child’s family, are outcome focussed and result in effective interventions.   To meet an individual child’s needs requires engagement and follow on action to support the needs identified for significant adults or other members of the family.     Tower Hamlets Local Safeguarding Children Board  7  Tower Hamlets LSCB must develop and agree a local multi-agency protocol for responding to bruising in pre-mobile babies and disabled children who are dependent and unable to communicate.  The interpretation of unexplained bruising has been a persistent feature of this SCR, and the lack of a standard position regarding unexplained bruising in a pre-mobile baby resulted in Baby Adam being sent home to a potentially abusive environment on four different occasions.    The hospital has recently introduced a bruising protocol, but there also needs to be a multi-agency response.  This will provide a robust framework for all agencies in the partnership working with children who are totally dependent and therefore highly vulnerable.    Tower Hamlets Local Safeguarding Children Board  8  Tower Hamlets LSCB Chair to contact the Chair of the London Safeguarding Children Board, to discuss adding ‘any unexplained bruising in pre-mobile babies’ as a single category for action in the London Threshold Guidance Document, for tier 4 (p35) ‘Section 47, Children Act 1989: Child Protection Enquiries’   During the course of this review, the London Safeguarding Board Child Protection Procedures and The London Safeguarding Board Threshold Document: Continuum of Help and Support, were consulted as key documents for practitioners in Tower Hamlets.  Whilst unexplained bruising in a child is mentioned throughout the document, it tends to be linked to suspicion of, or actual injury and does not reflect the different circumstances and vulnerability of very small dependent infants.  Unexplained bruising in pre-mobile babies should always be considered as suspicious, until proven otherwise.  This is not explicit in the Threshold for tier 4 (p35) ‘Section 47, Children Act 1989: Child Protection Enquiries’.     Tower Hamlets Local Safeguarding Children Board      Page 69 of 72  No  Recommendation Rationale for Recommendation  Responsibility  9a        9b  Tower Hamlets LSCB must remind member agencies about the role and function of child protection strategy meetings, including the leadership function of children’s social care and the obligation for Health and Police Child Abuse Investigation Team officers to cooperate/participate.    An annual LSCB audit of partner attendance and quality of participation at strategy meetings should be undertaken.   The leadership function of children’s social care with regards to child protection activity was not fully appreciated.  An action to convene a strategy meeting was thwarted by the police CAIT, who declined the invitation to participate, rendering the meeting inquorate.  This is not in line with local or Government guidance that requires NHS and Police attendance for all strategy meetings and it resulted in an inappropriate ‘professionals meeting’.     Tower Hamlets Local Safeguarding Children Board  10  The LSCB should seek regular assurance that agency responses and service offers in Tower Hamlets are consistent with the criteria set out in the local and pan London Threshold Guidance.         Health and social care professionals applied the wrong service thresholds to meet the identified needs of Baby Adam and his family.  Applying thresholds consistent with established threshold criteria ensures that children receive equitable services designed to safeguard and promote their welfare.    Applying common service thresholds also assists practitioners to organise their work and enables strategic planners to measure and understand the levels of need within their localities.  The Healthy Child Programme thresholds correspond to the LSCB and Pan London Thresholds Documents.    Tower Hamlets Local Safeguarding Children Board  11  Barts Health NHS Trust must assure the LSCB that a protocol is in place for children who are admitted for consideration of safeguarding concerns, to ensure that a risk assessment is undertaken for evaluating, mitigating and managing any potential risks on the ward.    When Baby Adam was admitted to the ward on three occasions, a risk assessment was not undertaken to work out the patient safety issues connected to parental contact and visiting arrangements.   A protocol for guiding practitioners on how to consider and mitigate child safeguarding risks during day and night time hours, particularly when a potential perpetrator has not been identified, is an important addition to NHS patient safety responsibilities.     Barts Health NHS Trust       Page 70 of 72  No  Recommendation Rationale for Recommendation  Responsibility  Implementing a system which prioritises child welfare by proactively assessing and mitigating risk serves two purposes. First and foremost to protect the child and second, to protect and assure the organisation’s reputation.    12  Tower Hamlets CCG and GP’s, supported by the Safeguarding Named GP, should review the safeguarding arrangements in primary care, and in particular, ensure that  each general practice is holding and formally recording a regular MDT meeting with health visitors and school nurses to discuss vulnerable families.   The primary care systems, processes and support for the GPs involved with Baby Adam were underdeveloped and ineffective, potentially exposing Baby Adam to unnecessary risk.   In addition, whilst ad hoc and unrecorded conversations between health visitors and GP’s about Baby Adam were evident, the regular formal MDT meetings, which are a local expectation, appear not to have happened.  GPs must be effective safeguarding children practitioners.  To maintain the correct level of expertise requires practice advice, training, and on-site organisational and management systems that promote safe practice.     Tower Hamlets Local Safeguarding Children Board  Tower Hamlets CCG (Primary Care)   13  The number of appointments allocated for local community baby clinic provision should be reviewed by the provider of Community health services to ensure that enough time is being allowed for professionals working in clinic settings to discuss cases and access notes    The working conditions (time and capacity) in the clinic were aggravated by over-booking clinic availability.    The pressurised nature of the clinic made face to face discussion between the health visitor and GP more difficult.  Professionals must have sufficient time to ensure they communicate directly about complex cases or concerns.   Tower Hamlets GP Care Group (Health Visiting)  14  EDT practice should be regularly (annually) audited to assure the LSCB of its effectiveness to record, manage and minimise child protection risks out of hours.      The EDT involvement at times when Baby Adam was either discharged from or admitted to hospital was minimal and based on requests for action rather than robust risk assessment.   Sibling Isaac’s needs were never considered.       Tower Hamlets Council (Out of Hours EDT services)      Page 71 of 72  No  Recommendation Rationale for Recommendation  Responsibility    Improvement to the EDT service is necessary to ensure that children’s circumstances in Tower Hamlets are properly assessed, and recorded in full, outside of normal office hours.    15  The CCG and GP practices must review the processes currently in place for managing incoming post, including test results, and the criteria for bringing these to the attention of the relevant GP in the practice.   Test results were not interpreted in a safeguarding context.  Often they were ‘processed’ rather than professionally reviewed.  Primary care practice systems must be designed that prioritise safeguarding cases and facilitate expert clinical review by practitioners who are aware of safeguarding histories.     Tower Hamlets CCG  16      GP Care Group and children’s social care must develop or amend their Information Governance Policies to cover the recording, prompt transfer and storage of patient/client emails and photographs.   Baby Adam’s mother was emailing messages and photographs of bruises to the Consultant Paediatrician’s email address (even when the Consultant was away).  All information regarding a clinical matters should be part of the child’s contemporaneous medical record to enable full information to be shared and continuity of care.  Safeguarding information obtained via email which has safeguarding significance must also be shared promptly with Children’s Social Care.    Barts Health NHS Trust  Tower Hamlets GP Care Group  Tower Hamlets CCG         Page 72 of 72  10 Appendix Two – Glossary CAF Common Assessment Framework CAIT Child Abuse Investigation Team CIN Child in Need CT Computerised Tomography CQC Care Quality Commission DFE Department for Education DH Department of Health ED Emergency Department EDT Emergency Duty Team GMC General Medical Council GP General Practitioner HCP Healthy Child Programme HV Health Visitor LSCB Local Safeguarding Children Board MASH Multi-agency Safeguarding Hub MDT Multi-disciplinary Team NAI Non-accidental injury NHS National  Health Service NHSE National Health Service England  NICE National Institute for Health and Care Excellence NSPCC National Society for the Prevention of Cruelty to Children PA Programmed Activity PLAB Professional and Linguistics Assessment Board (UK) RCGP Royal College of GPs RCM Royal College of Midwives RCPCH Royal College of Paediatrics and Child Health RCR Royal College of Radiologists RLH Royal London Hospital SCR Serious Case Review SCIE Social Care Institute for Excellence SI Serious Incident(s) SMT Senior Management Team THSCB Tower Hamlets Safeguarding Children Board  