Death of a 14-week-old boy from serious non-accidental injuries in July 2016. Elias lived with his mother, sibling and three half siblings at the time of his death. Mother married Father 2 under Islamic law but he had another family. The eldest child had a diagnosis of Autism and Elias was born with a hand deformity. Family known to Children's Social Care and Police for domestic abuse with Father 1 and allegations that mother was mistreating the children. Elias taken to hospital by ambulance after mother found him unconscious. Mother and Father 2 were arrested for grievous bodily harm and siblings taken into local authority care. Mother of Bangladeshi origin. Methodology: a systems based approach to meet learning and improvement requirements of statutory guidance. Findings: failure of the systems and processes designed to safeguard children with inaccurate recording; the interface between Child in Need and Team Around the Child did not work well; system around midwifery care was disjointed with lack of communication between midwifery teams and midwives and GPs; insufficient focus of emotional impact of Elias and Child A's diagnoses on their parents. Recommendations: health services should review documentation and assessment tools and include household composition and functioning of the household; to seek assurance from health and partner agencies of emotional impact of having a child born with any abnormality/disability features within consultations with recognition of any risks to the child; all GPs to be notified of the pregnancy of all women registered in their care; to seek assurance that the application of thresholds is now consistent.
      
 Title:  Serious case review: overview report: Child ‘Elias’: DOB: 31.03.16: DOD: 06.07.16. LSCB: Tower Hamlets Safeguarding Children Board Author: Nicki Walker-Hall 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      Tower Hamlets  Safeguarding Children Board  Serious Case Review  Overview Report      Child ‘Elias’ DOB: 31.03.16  DOD: 06.07.16       Independent Reviewer  and Report Author  Nicki Walker-Hall   MSc, MA, RSCN, RGN   Published:  28 February 2019       1   TABLE OF CONTENT ERROR! BOOKMARK NOT DEFINED. 1 INTRODUCTION 2 1.1 Initiation of Serious Case Review ........................................................................................................................................ 2 1.2 Methodology................................................................................................................................................................................... 2 1.3 Agencies involved......................................................................................................................................................................... 4 1.4 Structure of the report .............................................................................................................................................................. 4 2 CONTEXT 5 2.1 Family composition ..................................................................................................................................................................... 5 2.2 Symbrachydactyly ........................................................................................................................................................................ 6 2.3 Autism ................................................................................................................................................................................................. 6 2.4 Background ...................................................................................................................................................................................... 6 3 OUTLINE OF THE CIRCUMSTANCES RESULTING IN THE REVIEW 8 3.1 Key Events......................................................................................................................................................................................... 8 3.2 Evaluation of practice falling outside of the key focus points ........................................................................ 11 4 ANALYSIS OF THE KEY ISSUES, FINDINGS AND RECOMMENDATIONS 12 5 CONCLUSIONS 26 6.  APPENDIX 1 – GLOSSARY OF TERMS & ABBREVIATIONS 28   2 1 INTRODUCTION  1.1     Initiation of Serious Case Review   1.1.1 This serious case review was initiated following the death of Elias. An ambulance had attended the family home at the request of mother who reported Elias unconscious; on arrival Elias was in cardiac arrest, he was noted to have serious injuries. Elias was transported to hospital, accompanied by mother, where he was placed on life support. Ambulance staff had also noted scratches on Child D’s back (a sibling) and raised concerns. Mother and father 2 were arrested for grievous bodily harm; the four older children within the family were taken into Police Protection and later Local Authority care.   1.1.2 A decision was made by the Serious Case Review sub-group, supported by the chair of Tower Hamlets Local Safeguarding Children Board, that the known facts in relation to this case met the statutory requirement, in accordance with Working Together to Safeguard Children 20151:  Abuse or neglect of a child is known or suspected and   a child dies; or a child is seriously harmed and there are concerns about how organisations or professionals worked together to safeguard the child  1.1.3 The Department for Education and the National Serious Case Review Panel were informed.  1.2     Methodology  1.2.1 The review adopted a systems based approach, which aimed to meet the learning and improvement requirements of statutory guidance. The review sought to understand:  precisely who did what, through development of agency chronologies and review of relevant documentation  the underlying reasons that led individuals and organisations to act as they did, through conversations with practitioners involved in the case. Where practitioners were no longer in post, managers of the services provided organisational and service context  1.2.2 The review was managed by a panel consisting of senior managers of the involved agencies, working with an experienced lead reviewer Nicki Walker-Hall from a health background and the independent chair of the panel Keith Ibbetson from a social care background.   1.2.3 The review looks in depth at the period from June 2014 until the death of Elias in July 2016.                                                    1 Working Together to Safeguard Children, 2015 Chapter 4   3 1.2.4 The report is concise in nature reflecting the way such reports are currently written and concentrates on the findings and recommendations. In order to protect the surviving children within the family, information deemed not relevant to the findings and recommendations has been removed. The report takes account of changes that have been made to systems and processes as a result of internal audits and external inspections. Where issues identified in the report are being addressed through alternative local action plans, no additional recommendation has been made and it is for the LSCB to ensure that any such action has been taken and has been effective.  Key focus points 1.2.5 The Serious Case Review panel decided upon the key focus points for the review and highlighted the following lines of enquiry for consideration:  How effective was the identification of need and risk during the mother’s pregnancy with Elias? How effective are local arrangements for identifying need and risk during pregnancy more widely?  How effective was the response of social care, police and health colleagues, to the reported physical abuse of Elias’s half-sibling in February 2015? Was this reflective of normal practice? What factors shaped the response?   What was the coordinated Team Around the Child (TAC) approach designed to achieve and was it effective?  Was any additional need or risk identified at the time of Elias’s birth? Did the circumstances trigger any re-assessment of need?  How effective was the new birth visit and what factors shaped the service provided?  Overall, did decisions take account of relevant information about the full family background and history?  When do we understand that Elias was injured, bearing in mind the limitations of what can be reasonably inferred from medical evidence? Were there opportunities during this period for professionals to have observed signs of these injuries?  Did professionals take the right action to identify risk to Elias and other children in the family and act on their assessments during the period between his admission to hospital and his death?  Timeframe 1.2.6 The timeframe for this review has not met with statutory timescales. There was some delay between Elias’s death and the start of the SCR. The parallel process (please see section below) impacted initially; there was then a further substantial delay due to difficulties in the local authority procurement arrangement.  Parallel Processes 1.2.7 Elias’s parents were subject to criminal proceedings; both have been tried and convicted. Elias’s father was found guilty of murder and allowing the death of a child but not guilty of neglect.  Elias’s mother was found guilty of allowing the death of a child but not guilty of murder/manslaughter. The Local Authority took necessary steps to protect Elias’s siblings    4 Family participation 1.2.8 Mother and father were contacted via their offender managers, firstly to inform them of the review and latterly to invite them to be part of the review process; neither expressed a wish to participate.  Limitations 1.2.9 There have been a number of limitations to this review. The majority of professionals involved with the family have moved on. As a consequence, the lead reviewer has had limited opportunities to understand professional practice in context, thus limiting her ability to identify the factors that influenced the nature and quality of work with families. In order to mitigate these limitations, the lead reviewer has made use of internal audits, previous recent local SCRs and external inspections to understand whether issues likely relate to this case only, or are indicators of wider systemic issues.  1.3     Agencies involved  1.3.1 The following is a list of the agencies involved with the family and the services they offered. Where abbreviations have been identified these will be used throughout the report to denote the organisation the author is referring to:  Barts Health NHS Trust (Acute, Midwifery, Health Visiting, School Health)   Tower Hamlets (Children’s Social Care, Children’s Centre, Primary School)   Metropolitan Police Service (MPS)   Housing   Great Ormond Street Hospital for Children NHS Foundation Trust (GOSH)   London Ambulance Service (LAS)  1.4  Structure of the report  1.4.1 The report is structured as follows:  Chapter 2 provides context: o details of the family composition and members of the household,  o a description of what was known about the children, o the dynamics in the family, o an explanation of Symbrachydactyly and Autism  Chapter 3 gives an outline of the circumstances of the review focusing on the key events and appraising practice which falls outside of the key focus points but where the author believes there is learning for agencies.  Chapter 4 contains analysis of the key focus points, findings and recommendations.   Chapter 5 provides the conclusion.   5 2 CONTEXT  2.1     Family composition  2.1.1 Elias lived with his mother, sibling and three half siblings at the time of his death.  2.1.2 It is not clear whether father 2 was living full time in the family home at this time. Father 2 was married to mother 2 who was his second wife under Islamic/Shariah law. Father 2 had another wife and family who also lived locally. It is not believed father 2’s other children were ever part of this household.   TABLE 1: Household composition  TABLE 2: Significant others referred to in the report  The children  2.1.3 There were five children within the household. The older three were children of the relationship between mother and father 1. The two younger children were from the relationship between mother and father 2. The older children had or were all attending the same primary school; the eldest child had moved to an alternate school prior to this incident. The children were generally well presented in school; they attended breakfast clubs. The family home lacked toys for the children but it was clean and tidy and, when checked, there was food in the cupboards; they appeared happy. Child A had a diagnosis of Autism and Elias was born with a congenital abnormality to his hand (Symbrachydactyly). The lead reviewer has not had an opportunity to meet either the children, or the teachers involved with the children, to gain greater understanding.  Family Dynamics 2.1.4 Mother was of Bangladeshi origin. She reported to professionals that most of her family remained in Bangladesh, limiting her support network. Mother reported her marriage to father 1 was an arranged marriage; there had been domestic violence (father 1 to mother) in the relationship. Mother made a number of attempts to leave Term used in report Relationships Age in July 2016 Child A Half sibling 9 Child B Half sibling 7 Child C Half sibling 5 Child D Full sibling 15 months Elias Subject of the review 13 weeks Mother Mother of all the children 31 Term used in report Relationships Age in July 2016 Father 1 Father of Child A, B and C 38 Father 2 Father of Child D and  Elias 36  6 the marriage but returned after short periods. In 2014 after 9 years of marriage, they separated for the final time, divorcing in March the same year. Mother commenced a relationship with father 2, the former best friend of father 1. Father 2 remained in a relationship with his first wife at the same time as mother. Father 2 and mother were married in Islam just prior to Elias’s birth. The children from both marriages attended the same school.  2.2     Symbrachydactyly  Nature of the condition 2.2.1 Symbrachydactyly is a congenital (present at birth) hand anomaly, which affects a single upper limb. It is not inherited. It is characterised by short, stiff, webbed or missing fingers. The underlying muscles, tendons, ligaments and bones are all affected. The cause is unknown. There is no link to anything the mother did or did not do during pregnancy.  Care and treatment 2.2.2 Symbrachydactyly can be treated with surgery, with the aim of improving hand function and appearance. However, it cannot give the child a normal looking hand. As well as surgery, there is also the option of prosthetics (an artificial hand or fingers).   2.3     Autism  Nature of the condition 2.3.1 Autism spectrum disorder (ASD) is the name for a range of similar conditions, including Asperger’s syndrome, that affect a person's social interaction, communication, interests and behaviour.2  2.3.2 In children with ASD, the symptoms are present before three years of age, although a diagnosis can sometimes be made after the age of three. It is estimated that about 1 in every 100 people in the UK has ASD. More boys are diagnosed with the condition than girls.   Care and treatment 2.3.3 There is no "cure" for ASD, but speech and language therapy, occupational therapy, educational support, plus a number of other interventions are available to help children and parents.  2.4     Background  2.4.1 The following section provides relevant background information held within key agency records for the period prior to the review period. This is provided to give further context.  2.4.2 During 2009-2010 mother made three allegations of domestic abuse (DA) regarding her then husband, father 1, stating he abused her; she expressed concern for the                                                   2 https://www.nhs.uk/conditions/autism/  7 safety of the children. On one occasion father 1 was arrested, following which mother withdrew her allegation. Mother’s allegations received a varied response from Children’s Social Care (CSC), which was not in line with expectations. On the first occasion, a referral was made to CSC and a decision made that an Initial Assessment was required; this ultimately led to no further action following assessment. On the second occasion, a decision was made that an Initial Assessment was required but this was not carried out. On the third occasion mother was sent a letter on what action she could take; there was no correspondence or interaction / contact with father 1. The couple’s arrangements at that time were mother had care of their daughter and father 1 had care of their son. Health and Education staff were not aware of these incidents.  2.4.3 In December 2012 father 1 was banned from school having assaulted a teacher who was trying to break up a fight between father 1 and another parent; father 1 threatened to return with a weapon. The referral was passed to CSC for assessment. A strategy discussion was decided upon but there is no record of it. School noted father 1 had some mental health problems; there is no record that this was shared with partner agencies. The case was closed 12 days later on the grounds that no risks to the child had been identified and parents lived separately. Health staff were not aware of this incident.  2.4.4 In June 2013, mother informed School Learning Support that she had moved back in with father 1 a month earlier, but now wished to flee the marital home because of Domestic Abuse. Mother was signposted to other agencies. CSC were reassured as mother said she was going to live elsewhere with the children. It was noted that “her decision recently to move back in with Dad” called her judgment into question. The manager noted that there should be checks to establish whether mother moved out. Four days later the Police e-mailed CSC to inform that the police visited in response to a phone call from father 1, who believed he had parental responsibility. Police witnessed mother removing the children and herself and established that there were no other concerns. The CSC manager noted: “This is a private matter regarding contact. There is no order in place to stop mother from taking the older child from father. Father will be seeking legal advice. No role for CSC. Information only.”  2.4.5 In March 2014, the Police informed CSC that mother had reported an attack by father 1. Father 1 was arrested but was too ill for custody. The case was closed when mother and children moved area; the local CSC were asked to support mother.  2.4.6 Later, Housing Options contacted CSC to inform them of the date of the last DA incident. The CSC manager noted that 3, 5 and 7-yr-old children were at home, noted the case history, and recommended a London Borough of Tower Hamlets (LBTH) assessment, which cannot be found.    8 3 OUTLINE OF THE CIRCUMSTANCES RESULTING IN THE REVIEW   3.1     Key Events  3.1.1 The following table is designed to give a brief outline of the case history focusing on key events in the lives of Elias and his siblings during the period under review.   Sequence Date Event Episode 1 June 2014 Father 1 reported concerns with mother’s parenting of his children. Mother alleged a DA incident in the street, father 1 allegedly attempted to abduct Child C. CSC contacted school who had no concerns. The case was referred to the Crown Prosecution Service (CPS) and they made the decision that No Further Action (NFA) would be taken. A police Merlin3 was created for children coming to notice and this was shared with CSC on 4 days after the incident. Case closed.  Episode 2  October 2014    Maternity booking, mother 12 weeks pregnant to father 2. Midwives believed mother’s children have a social worker because of DA in previous relationship and referred mother to Gateway Midwifery, who provide enhanced midwifery care to women being identified as vulnerable, and informed CSC of the pregnancy. Mother new to the area. Case held at duty. Father 2 has 4 other children with whom he has contact.  Episode 3 January 2015 Father 1 alleged mother was mistreating the children and not feeding them properly. CSC made checks with school and health visiting; school had no concerns.  Episode 4 February 2015 Gateway midwifery took a full history from mother. Mother was in a new relationship; father 2 had left mother pregnant, returning to his wife and family. Mother had no family support. Mother needed advice and support. A referral was made to CSC, and for a Family Support Worker (FSW). The case was allocated to a FSW, however, mother did not initially engage. At 29 weeks into the pregnancy, contact was established with the FSW and a referral made to the integrated pathway support team (IPST4 (pre MASH5)). School informed re pregnancy via SW (confidential). IPST advised they would contact mother to discuss who would look after the children at the birth and emailed the FSW advising them to hold a multi-agency Team Around the Child (TAC) meeting with all involved professionals, this was arranged.                                                   3 Merlin is a database run by the Metropolitan Police that stores information on children who have become known to the police for any reason. 4 IPST – Integrated pathways and support team 5 MASH is Children’s Social Care’s front door  9 Sequence Date Event Episode 5 February 2015 Child C alleged physical abuse by mother. School referred to CSC. A strategy discussion led on to a S476 investigation. Child C had a child protection medical that deemed the injuries likely to be non-accidental. Despite verbal and written reports, the social worker believed the medical was inconclusive. Police were verbally told by the student social worker that the CP medical was inconclusive; they were not sent the report, and the Social Worker did not identify the error/ notify the Police. This belief led to closing of the case from a police perspective and a decision to manage the case as child in need from a CSC perspective. The case remained in TAC.  Episode 6 February 2015  A Professionals/TAC meeting (1) was held. Mother has had a scan that deemed the unborn child small for gestational dates. Mother has been referred to and accepted by Maternity Mates.7 No Maternity Mates worker, SW or mother present. Issues discussed:  Child protection referral  Pregnancy  Child C playing violent games unsupervised on a console  Child A no plimsolls or PE kit  Child A’s autism  Child B being shouted at by mum  Mother’s debts  Mother’s need for support especially at point of birth  Episode 7 March 2015 Second TAC/professionals meeting (2) was held. Health visitor sent apologies. The recent CP medical is acknowledged but no discussion is had re the findings. The family are isolated, previous DA by ex-partner is noted. Support is to be provided by Homestart, family support worker and Maternity Mates. A week later the HV receives a copy of the CP medical and phones the SW re a date for the suggested CP conference. Father 1 reported concerns about mother’s new partner abusing the children to CSC. No action is recorded. Information shared with partner agencies.  Third TAC/professionals meeting (3) was held. Mother and social worker were not present. Health visitor rang the social worker. The SW indicated that her manager had decided the case would be managed in CIN. Discussion held regarding plans for birth.                                                   6 S47 – Section 47 of the Children Act 1989 is initiated to decide whether and what type of action is required to safeguard and promote the welfare of a child who is suspected of, or likely to be, suffering significant harm. 7 Maternity Mates work alongside midwives and other health professionals to help the mum and baby receive the best possible care.   10 Sequence Date Event Episode 8 April 2015 Mother indicated she and father 2 are now Islamically married. Child D is born before arrival of professionals. TAC meeting (4) mother not present – 3 days post-natal. Confusion as to whether this is a TAC, professional or CIN meeting.  The health visitor conducted a new birth visit, mother was asked about domestic abuse, which she denied. Living separately from her new baby’s father but stated a good social network of friends, mother’s family live in Bangladesh and father’s family have yet to see Child D.   Episode 9 June 2015 CSC close the case – the case was to remain in TAC, however, there were no further meetings.  Episode 10 December 2015 Mother pregnant – late booking at 14/40 gestation. Mother attended scans but received no other antenatal care. Mother stated no safeguarding concerns.  Episode 11 February 2016 Child D is admitted to hospital for 3 days with an abscess, she is cared for by mother during her stay. Child D received antibiotics in hospital and then at home.  Episode 12 Mar 2016 The children’s centre closed the case. Elias is born before the midwife arrived, it is noted the distal section of all fingers on the right hand are missing. Elias is referred to plastic surgery.  Episode 13 April 2016 The health visitor completed a new birth visit – no concerns are noted other than those known. Mother indicated there is no domestic abuse between the couple and that they are living separately but father is supportive. Father 2 was not present.  Episode 14 May 2016 Elias was not taken to an appointment for immunisations, he received a further appointment, attended and was immunised.  Episode 15 June 2016 Elias was taken to his plastics appointment; mother was informed of the plan of care. Elias was to be reviewed in a year and for surgery aged 2.  Episode 16 July 2016 Mother contacted her brother-in-law, stating that Elias was unconscious; he advised her to call for an ambulance. Elias was taken to Royal London hospital (RLH) by London Ambulance Service (LAS) suffering cardiac arrest; he had visible burns to his leg. Doctors believed Elias’s injuries to be non-accidental and contacted the police. Mother attended the hospital with Elias and was subsequently arrested for Grievous Bodily Harm. Father remained at home in charge of Child D.  11 Sequence Date Event Police arrested father for Grievous Bodily Harm. All siblings were taken into Police Protection. Father’s own children were visited by police and found to be safe and well.    3.2 Evaluation of practice falling outside of the key focus points  Allegations and counter allegations 3.2.1 There was evidence of fractured relationships between mother and father 1. Contacts from father 1 provided an opportunity for CSC to carry out a fuller assessment of the circumstances in which the children were living, the level of risk and the impact of parents’ behaviours on the children, and whether mother was:  caring for the children adequately,   able to protect the children   able to protect herself.  These incidents were looked at in isolation from information already held within CSC regarding DA incidents between the couple. On the first occasion, the children’s school were contacted but no other agency. The second episode received a more proportionate response with both school and health visiting being contacted, but neither allegation led to a fuller assessment. These were missed opportunities. The family GP was not contacted on any occasion.  Referral from Gateway midwifery to IPST 3.2.2 Mother presented herself as 12 weeks pregnant with Child D to father 2. The booking midwife believed mother’s children had a social worker because of domestic abuse within her previous relationship and for that reason, and mother’s additional needs, mother was referred to Gateway Midwifery and IPST (Integrated Pathway Support Team).   3.2.3 This referral contained full and relevant information. IPST decided FSW involvement and TAC was most appropriate but referred on to CSC for support around the birth. They asked to be kept informed of progress, which is somewhat confusing as cases are not open to IPST. This suggests heightened concern from the IPST worker.  3.2.4 Mother was reportedly new to the area. CSC indicated the case had always been held at duty. Father 2 was noted to have 4 other children with whom he had contact.     12 4 ANALYSIS OF THE KEY ISSUES, FINDINGS AND RECOMMENDATIONS  4.1      Introduction  4.1.1 The following section will discuss and analyse the key issues identified by the SCR, highlighting the findings of this serious case review, with additional associated recommendations for the LSCB. The findings relate to what we have learnt about the strengths and weaknesses in multi-agency safeguarding systems and the recommendations, if taken forward, are designed to address these.  4.2      How effective was the response of social care, police and health colleagues to the reported physical abuse of Elias’s half-sibling Child C in February 2015? Was this reflective of normal practice? What factors shaped the response?  4.2.1 Child C alleged physical abuse by his mother; Child C had a large bruise on the ear said to be caused by his mother hitting him with a stick four days earlier. Child B told school staff that mother had hit Child C with a wooden spoon a day earlier, whilst at home, after he jumped on her legs.   4.2.2 The initial response by agencies to Child C’s allegations was robust:  School acted swiftly identifying risk and made a referral to IPST in line with local safeguarding procedures  Procedures were followed in determining a strategy discussion was needed to determine the next steps  The decision to conduct a S47 joint investigation was in line with policy and procedures  All the children and mother were appropriately interviewed separately  4.2.3 The CSC manager noted the previous history and decided a strategy discussion was appropriate. A S47 joint investigation was agreed by CSC and the police.   4.2.4 Mother was spoken to by the police and the duty social worker; she denied assaulting Child C indicating Child C had “banged his ear on the living room door whilst playing”. Mother also denied physically punishing the children. Of note, mother was seven months pregnant at this time; it has not been possible to establish whether this influenced any professional’s thinking or practice.  4.2.5 The social worker made an assessment of whether all the children were happy to go home and concluded they were, and indicated there appeared to be no fear; it is not fully understood what the social worker meant by this statement.  4.2.6 The subsequent assessment of risk did not meet expected standards. The assessment did not fully take account of what was previously known about the family, the recent allegations made by father 1, and was conducted without speaking to father 1, who had joint parental responsibility for the children even though he was estranged. There was no comprehensive assessment of the risks and there was not sufficient consideration of whether any actions were required to keep all the  13 children safe prior to receipt of a medical opinion on the injury, left all the children at risk of harm.   4.2.7 The assessment and decisions made gave greater credence to the explanation of mother, than the statements of the children, who were consistent with their explanations and corroborated each other. There was a lack of understanding in relation to the life of the child and too much focus on mother.   4.2.8 The findings in this case are consistent with local independent auditing of practice in the period under review. Having deemed the London Borough of Tower Hamlets “outstanding” or “good” in all areas in their 2012 inspection8 there was no further inspection until January 2017 at which time Ofsted found all areas were inadequate or required improvement. It is difficult to pin point exactly when practice changed however Ofsted 9 in the report, in relation to the 2017 inspection, comment about the findings of an audit of section 47 child protection enquiries carried out internally in May 2016 as a result of concerns identified by the newly appointed Director of Children’s Services. This audit identified significant weaknesses in safeguarding practice, including poor assessment of risk, an over-reliance on parental explanations and a lack of professional curiosity and judgement. This, coupled with significant increases in staff turnover in the assessment and intervention team from 10% in 2015 to 30% in 2016, led to establishment of the improvement and inspection board in September 2016.   4.2.9 These weaknesses continued to feature in a subsequent audit carried out in December 2016, and were common features in a number of cases seen by inspectors in January 2017.   4.2.10 The child protection medical was arranged and completed in a timely manner however, the process was not robust. The social worker accompanying Child C was a student and not the assessing social worker who interviewed Child C and the family the day previously. The information the student social worker could share with the paediatrician was limited.  4.2.11 The lead reviewer was informed that there would usually be two paediatricians present during a child protection medical however due to a changeover of trainee doctors there was no one available to accompany the consultant.   4.2.12 The paediatrician gave verbal findings to the student social worker that the injury was probably non-accidental in origin and recommended photographs be taken by the local health trust medical illustration service; this would require Child C being taken to another site. The paediatrician explained her request for a photographic record of the injuries was in preparation for any possible prosecution. There is no evidence the injuries were ever photographed by medical illustration.                                                     8 Ofsted (2012) Inspection of safeguarding and looked after children services 9 Ofsted (2017) Inspection of services for children in need of help and protection, children looked after and care leavers and Review of the effectiveness of the Local Safeguarding Children Board   14 4.2.13 The information shared between the student social worker and the assessing social worker was not documented. This verbal communication was crucial to subsequent decisions made. The assessing social worker recorded that the child protection medical was inconclusive; this was incorrect. This was a common problem. 10   4.2.14 The paediatrician put all the findings into a report. The paediatrician suggested CSC should complete the S47 and ensure Child C’s safety, provide advice on appropriate forms of discipline and support mother to access support around social isolation and pregnancy; it was noted that an older child had ASD – a child protection conference was recommended if Child C remained in mother’s care.   4.2.15 There was a 15-day delay between the CP medical being completed and the report being sent out to CSC, believed to be affected by an administrative backlog. Confusion about who the family GP was prevented the report being sent to the GP and the police were not on the routine copy list at that time.   4.2.16 CSC wrongly recorded that the child protection medical had found the “injury was inconclusive”. A written safeguarding agreement was signed by mother regarding use of physical punishment. The case was closed three and a half months later indicating there was “no role for CSC”. However, the social worker, in the LBTH assessment, in the child protection section, concluded that the hitting ‘probably’ happened. This conclusion was not considered by the team manager in the subsequent decision to close the case.  4.2.17 The police and CSC closed down the section 47 enquiry based on a belief that the child protection medical was inconclusive, before the written report from the paediatrician was received and without direct contact with the Paediatrician. There was an over reliance on medical proof of injury in this decision and a seeming dismissal of the explanations of the children.  4.2.18 Once received, the child protection medical report was uploaded on the system; there is no evidence to indicate it was seen. Subsequently, actions were taken which were at odds with the findings of the medical. It is therefore reasonable to assume it was either ignored or not seen.  4.2.19 A decision was made that the case should be managed as Child in Need, this was not followed through; not all members of the TAC were made aware of this decision, therefore the case remained in TAC with no evidence of a formal decision to step the case down to TAC. The fact that a social worker was continuing to do an LBTH assessment parallel to the TAC was an additional confusion.  4.2.20 The content of the child protection medical report, and the current situation of the family, does not appear to have been sufficiently considered at the point the case was closed by the practice manager (PM) four months later. The case closure record                                                   10 Ofsted, in its 2017 inspection found that, “Case recording by social workers and managers in many children’s case files is so poor that it is not possible to tell how decisions are reached regarding children’s lives or how intervention is reducing risk”.  15 states, “mother working well with TAC” this was factually incorrect as mother had not attended TAC meetings. The case closure record also states “child protection medical completed and pictures taken. Injury was inconclusive”, this again was factually incorrect. Case closure provides managers with an opportunity to reflect on all the information on file and ensure that children are safe. The rationale for case closure in this case was based on incorrect information  4.2.21 The CSC panel member identified concerns that a section 47 enquiry would be closed down at PM level. Ofsted’s 11 inspection found “Senior managers have not been effective in addressing poor practice by first and second-line managers. An entrenched culture of non-compliance with basic social work standards continues to be a significant weakness. This has led to delays in progressing work effectively, which have left some children in situations of escalating and actual risk of harm”.   Finding 1: in this episode, there was a failure of the systems and processes designed to safeguard children; inaccurate recording compounded the issues. This left Child C and his two older siblings (one of whom had an identified disability and was therefore more vulnerable) at risk of harm.  Recommendation 1: LSCB needs to be assured that standards in relation to safeguarding children are now satisfactory, that child protection medicals are now being conducted in line with best professional practice and that interagency working around medicals is robust.   4.3      Arrangements for early help/Team Around the Child support for the family following the reported episode of physical abuse  4.3.1 Before the reported episode of physical abuse, a TAC was thought to be the appropriate offer for the family, and related to the need to support mother in her care of the children and the imminent arrival of Child D.   4.3.2 During the section 47 enquiry, the previously arranged TAC meeting went ahead as a professionals meeting. It was well attended by professionals, however both mother and the social worker were absent, said to be attending the child protection medical. A great deal of important information was shared within this meeting. School indicated mother needed emotional and social support. Mother was pregnant with Child D. Mother was no longer involved with father 2; he had returned to his wife and family. Mother had been referred to and accepted by Maternity Mates. The safeguarding issues were discussed, preparation for the birth of Child D was also discussed. Concerns were expressed about who would look after Child A, B and C whilst mother delivered Child D; attendees were unclear regarding the plan. School raised additional concerns that Child C had been playing violent games unsupervised on a console, one of the children only had one pair of shoes and no plimsolls for PE                                                   11 Ofsted (2017) Inspection of services for children in need of help and protection, children looked after and care leavers and Review of the effectiveness of the Local Safeguarding Children Board  16 clothes. An SEN meeting for Child A, due to his Autism, indicated no concerns with progress. The children all attended breakfast and after school clubs. Mother had credit card debts and was not receiving financial support from father 1. There had been a recent incident when Child B was being shouted at by mother and did not know what to do; Child B was supported by school staff. All the professionals present expressed concern for the family as they were struggling.  4.3.3 It is not clear whether these additional concerns were ever shared with the social worker as concerns regarding the dynamics between mother, father 1 and father 2, mother shouting at Child B and mother being in debt, do not feature in the core assessment. It might have been better to postpone and reconvene the professionals meeting so the new information and the CP medical could be discussed as well.  4.3.4 At the second TAC meeting the HV sent apologies but other agencies and mother attended. Whilst the child protection medical was acknowledged, no discussions were had regarding the findings. The meeting acknowledged the family’s isolation, and previous domestic abuse by ex-partner. Support was to be provided by Homestart, family support and Maternity Mates.  4.3.5 Four weeks after the child protection medical, the report was emailed to the HV, who followed up by telephoning the SW and asking what the plans were for a child protection conference; this was good practice however the SW was on leave.  4.3.6 The third TAC became a professionals review meeting, as the SW and mother were again not present. During the meeting, the HV rang the SW, as she was concerned the SW might not be aware of the paediatrician’s request for the case to be discussed at conference, if Child C was to remain in mother’s care, and consideration for child protection medicals of the other children. The HV did not mention the medical opinion “Child C gives a clear and consistent history that mother hurt him with a stick”, and that “in view of the history and presentation, physical abuse is likely”. Social care’s understanding of thresholds and different levels of intervention was not consistent at this time and seemed to have been interpreted to suit the local authority’s lack of capacity. The SW indicated that the team manager had decided the case met the threshold for Child in Need (CIN) and a TAC would support the family.  4.3.7  It is not clear what was meant by this; a TAC meeting was arranged for the following month. There was no challenge of this decision by any professionals or discussion by the HV with the Named Nurse Child Protection within her employing Trust or the paediatrician who had carried out the medical. The SW shared that father 1 had reported concerns about mother’s care of the children to CSC.   4.3.8 Mother had agreed to TAC on the basis she was concerned about the care of her children at the time of Child D’s birth. There was much confusion over who would care for the children during delivery of Child D. The Gateway team provided information regarding a birth plan to midwifery which states ‘the children will go into foster care whilst mother is in labour as she has no family or friends to support her’ and that CSC needed to be alerted following birth. A robust plan was not established and mother expressed her frustration 37 weeks into the pregnancy.   17  4.3.9 CSC records indicate they were aware mother did not attend the first TAC following step down. This was raised with the allocated SW who discussed it with managers; management response was to continue to endorse TAC and continue with LBTH. This was another opportunity to consider convening an ICPC.  4.3.10 Over the next two weeks the FSW, emailed all members of the TAC on two occasions to update them, firstly that father’s sister will support her with the children on the day and after the birth of Child D, and that mother and father were now Islamically married. Mother was concerned how father 2’s other wife would respond but felt supported by father 2’s family. Mother indicated there was a good relationship between father 2 and her other children, suggesting greater involvement than previously known. This did not lead to further assessment.  4.3.11 Child D was born before arrival of the midwife, at home, in an unplanned home birth, in April 2015. Child D and mother were taken to hospital for checks but discharged later the same day, CSC and Gateway midwifery were informed the following day. The FSW informed all TAC members via email the following day after discovering, during a telephone call with mother, that Child D had been born.  4.3.12 The fourth TAC meeting was held a week later but as mother did not attend this was again a professionals review meeting, the SW indicated that there was a lack of toys for the children, the FSW was assisting mother with debt support agency, Homestart were supporting with a weekly visit. The chair fed back that mother was interviewed by CSC and the Police, resulting in no evidence of physical abuse with a plan to close the case the following month. It was thought likely that Child C had hurt himself on the doorframe as reported by mother; there was no challenge to this explanation. The FSW and health visitor agreed to share the lead professional role and planned to meet in 3 months.  4.3.13 In June, the case was closed to CSC; partner agencies were not informed. The SW concluded that hitting probably happened however, there was nothing recorded regarding this in the Team Managers decision to close the case. The step up/ step down process did not work in this case.   4.3.14 The case remained in TAC but there were no further meetings held.   4.3.15 Discussions and decisions were being taken by professionals in TAC meetings without knowing the intentions of CSC and without the agreement of mother. The social worker was present at one TAC meeting; CSC SW’s do not usually attend TAC meetings.   4.3.16 Whilst TAC meetings were held regularly initially, there was no clear decision to stop the meetings. It is recorded at a TAC/professionals meeting in April 2015, 7 days after the birth of Child D, that there will be a TAC meeting in three months. No date was planned and when the meeting did not take place no professional questioned why.    18 4.3.17 The Children’s Centre worker contacted CSC in August 2015 and was informed that CSC had closed the case in June. CSC advised that the FSW held another TAC meeting. It cannot be established whether the FSW was made aware of the need to reconvene a TAC but this never happened and so the TAC fizzled out.   4.3.18 In September, mother agreed to Children’s Centre case closure; mother was happy for closing summaries to be sent to the professionals involved but refused TAC. There is a record of closing summaries being sent, but no corresponding record of receipt by any agency.     Finding 2: The interface between CIN and TAC did not work well in this case. The decision that the case should be CIN but managed in TAC was flawed; the case should have remained, at the very least, in CIN. The case being managed in TAC, whilst remaining open to CSC, with continued social worker involvement caused confusion. The meetings held should have been led by CSC with the social worker as the lead professional. Because the case was managed in TAC, the safety of the children was not the primary focus, rather mother’s need for support. However, mother’s support needs were also not met, as there was a lack of robust planning. Mother expressed her dissatisfaction with CSC for the lack of support around the birth of Child D; this likely influenced her decision to refuse TAC during Elias’s pregnancy. When a date for a TAC meeting was not set, no member of the TAC followed this up with the lead professionals.  Recommendation 2a: THSCB to seek assurance from CSC that there is clear separation between CIN and TAC, and that all CIN cases are being managed within CSC with a CSC SW acting as lead professional, and no CIN cases are being managed via TAC.  Recommendation 2b: THSCB and its partners to ensure the interface between CP, CIN and TAC is understood by all professionals working with children in Tower Hamlets. Recommendation 2c: THSCB to seek assurance that the application of thresholds is now consistent.   4.4      How effective was the identification of need and risk during the mother’s pregnancy with Elias? How effective are local arrangements for identifying need and risk more widely?  4.4.1 In December 2015 mother booked in late for Elias’s pregnancy at a one-stop clinic following referral by the GP. Mother had moved GP shortly after becoming pregnant with Child D. No risk factors were identified in the GP referral; however this becomes understandable as no child protection or safeguarding issues were noted on the GP records for any of the children or mother. The GP did not receive the child protection medical report (see section 4.2). The GP had not been informed of Gateway Team’s involvement during Child D’s pregnancy so was unable to factor this into later  19 pregnancy’s. The usual flow of information is that if women are under the Gateway Team, the GP will be informed of their involvement.   4.4.2 Barts12 received the GP’s referral for Elias’s pregnancy, no concerns were noted for the ante-natal department and, as there was no disclosure of DA by mother, normal processes were followed. Normal process is reliant on mothers making appointments at the GP practice for the midwife. However, mother did not make any appointments therefore the midwife was unaware of mother’s pregnancy; thus no ante-natal care was given. As a consequence, mothers non-attendance was not picked up; of note GPs do not have a formal DNA policy for adults. No meetings are held between GPs and Midwives to share information regarding pregnant women unless there are identified issues. Copies of previous midwifery bookings should be available on CRS (hospital system).   4.4.3 Mother had an anomaly scan at 20 weeks which was normal. Due to poor imaging, a repeat scan was planned but mother did not attend, however she attended a foetal well-being scan in January 2016; no abnormalities were noted. Mother attended the GP practice for a glucose tolerance test (GTT) arranged on booking; the result was noted on the GP record indicating some care, but the lack of midwifery care was not identified. This was a missed opportunity.  4.4.4 In January 2016, an opportunity presented for communication with midwifery services. School contacted the FSW, sharing third party information that mother was pregnant. School were advised if they had any concerns they should report these to CSC or DWP.13 School reported they were not concerned about the children‘s wellbeing; the HV was documented as having given an update; she also had no concerns about the family. There is no corresponding entry in the health visiting records; no one made contact with midwifery.  4.4.5 The only other contact with professionals was an A&E attendance for Child D in February 2016. Child D was admitted with an abscess and remained an inpatient for three days on antibiotics, during which time mother was regularly present; there is no mention of mother being heavily pregnant.  4.4.6 In March 2016 the HV contacted mother following a contact from the children’s centre indicating the case was being closed. The HV believed Gateway midwifery were involved but made no contact with them; this was a missed opportunity. The HV planned to offer a universal plus service. Mother indicated she had no concerns re Child C who was now in fulltime school; there had been no contact between Child C and father 1 in a year. The HV discussed domestic abuse and mother stated she had no contact with father 1 and stated the father of Child D still lived with his first wife; she denied domestic abuse by him.  4.4.7 There is a marked contrast in the level of professional involvement during the pregnancy of Child D and that of Elias. Review of the midwifery records shows                                                   12  Barts Health NHS Trust  13  DWP – Department of Work and Pensions  20 mother was booked according to the pathway that she was referred for, with care to be shared between the GP and midwifery. The GP referral had indicated a complex family set up but had not mentioned any previous safeguarding concerns and was assessed as low risk.   4.4.8 The current system requires either the GP to inform the midwife within their referral or for the midwife, on booking, to access electronic patient records to know the previous history and previous care delivered. The midwife did not look up the previous pregnancy history available in the electronic patient records. The absence of midwifery care means no assessment of need or risk took place during this pregnancy.   Finding 3: The system around midwifery care was disjointed with a lack of communication between midwifery teams and between midwives and GPs. No professional who was made aware of the pregnancy made contact with midwifery services to establish who was leading on mother’s care. In addition, there was an over reliance on mothers to make midwifery appointments.   Recommendation 3a: Midwifery services to improve their joint working with GPs and review the current pathways to ensure a robust system is put in place so all health professionals are clear which pregnant women are in their care. Notification of attendances/non-attendance must be shared when care is being provided via multiple health disciplines.   Recommendation 3b: All women should be given their next antenatal appointment prior to leaving the booking appointment. All GPs to be notified of the pregnancy of all women registered in their care.  Difficulties in, and lack of, communication is one of the most common findings in serious case reviews nationally.  Recommendation 3c: All professionals to be reminded of the need to share all relevant information with all relevant parties and the potential negative consequences of not doing so.   4.5     Was any additional need or risk identified at the time of Elias’s birth? Did the circumstances trigger any re-assessment of need?  4.5.1 Child D was born before arrival (BBA) of the midwife, at home. The risk of having a further unplanned BBA home birth increases when mothers have had multiple births or have had a previously swift birth; both applied in this case. BBA can however result when mothers are trying to conceal births or are struggling to come to terms with a pregnancy; concealed pregnancy was not a factor in Child D’s pregnancy. However, the reasons for Child D’s BBA were not established; this would have been relevant to know for Elias’s pregnancy. The lack of information sharing and community midwifery involvement meant the opportunity to develop a  21 management plan to reduce the risk of reoccurrence or planning for a home birth in this pregnancy was missed. Mother’s lack of midwifery input during the antenatal period did not come to light and professionals were not alert to previous Maternity Mates and Gateway involvement thus nothing suggested a need to assess parent’s attitude to their situation.   4.5.2 In the post-natal period, Mother and baby had a total of 5 post-natal visits between home and post-natal clinic, mother and baby were checked and an assessment of baby wellbeing was completed. Mother was seen until day 14, which was good practice. The community midwife would have either had to have had prior knowledge of concerns, accessed previous records or contacted colleagues for previous concerns to now come to light. The lack of antenatal midwifery care is not highlighted and apart from the BBA and one failed scan attendance, there was nothing of note during this pregnancy.   4.5.3 Elias was born with missing digits. Research has shown that the birth of a baby with a visible congenital disfigurement requires parents to adjust to a baby that they may perceive as being ‘imperfect’, whilst letting go of their hopes for the perfect baby they had expected. Their responses have been described in terms of bereavement for the expected baby who has been lost, complicated by the need to adapt to the baby who has been born: 14 Whilst that may seem odd to many, the parents did lose a child—the “normal,” healthy child that they were expecting15. 4.5.4 Attitudes to disability can be affected by cultural attitudes and religious beliefs and interpreted in different ways. Research with South Asian parents with a child with autism Warner (1999)16 found that the influence of parents’ Bangladeshi background was most noticeable in their feelings about the child’s disability. Warner noted that two mothers she interviewed indicated a sense of being blamed for having a disabled child and one talked about seeking help from a religious person (pir) in Bangladesh. Jegatheesan et al. (2010)17 emphasised that Asian families’ explanations of having a child with a disability were intertwined with distinct cultural and religious beliefs.   4.5.5 The early responses of the parents can be observed as similar to grief; they often experience varying degrees of denial, anger and tearful distress. In a study18 all the parents described some sense of shock, but there was also evidence of denial. The factor which was significant in the analysis of parental adjustment was perceived family support. This mother had little family support. More thought should have been given to the emotional impact of Elias’s condition on his parents. Elias was, however, reviewed by the neonatal team due to the missing digits of the right hand and a referral made to plastic surgery.                                                     14 Solnit & Stark 1963. 15 Lemacks, J. et al (2013) Insights from parents about caring for a child with birth defects. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3774449/ 16 Warner, R. (1999). The views of Bangladeshi parents on the special school attended by their young children with severe learning difficulties. British Journal of Special Education, 26, 218-223.  17 Jegatheesan, B., Miller P.G., & Fowler, S.A. (2010b). Autism From a Religious Perpsctive: A study of Parental Beliefs in South Asian Muslim Immigrant Families. Focus on Autism and Other Developmental Disabilities, 25, 98- 109.  18 Bradbury. E.T. and  Hewison.J. (1994) Early parental adjustment to visible congenital  disfigurement.  22  4.5.6 It has not been possible to establish the impact of Elias’ condition on mother and father 2. There was nothing within health records to suggest this was considered.   Finding 4: There was insufficient focus during contacts and in assessments of the emotional impact of Elias and Child A’s diagnoses on their parents.  Recommendation 4: THSCB to seek assurance from health and partner agencies that the emotional impact on parents of having a child born with any abnormality/disability features within consultations and assessments with recognition of any risks to the child.   4.6     How effective was the new birth visit and what factors shaped the service provided?  4.6.1 The named health visitor did not do the new birth visit herself, allocating the visit to a ‘very good’ colleague. During the latter stages of the mother’s pregnancy the health visiting service had been transferred to another health provider, leading to a considerable period of anxiety and uncertainty for staff, making work on the front line difficult. The family’s named health visitor, who was the most senior member of her team, felt the need to offer support to colleagues and had a high caseload. The health visitor recalled asking her colleague to read the records before making the visit. The health visitor advised her colleague that there would also be a 13-month old child there to be reviewed. This was deemed routine work. The health visitor believed that Gateway midwives were involved in this pregnancy. It appears a lack of information sharing between health services impacted on the quality of care that could be provided.   4.6.2 The health visitor’s colleague conducted the visit, everything was documented. Whilst father was named, he was not present during the visit and no further information is documented. Elias’s fingers were checked (some were under developed). The two colleagues discussed the plan for follow up care, which should have been picked up in the antenatal period, at birth, or by the midwife. Mother had advised of a follow up hospital appointment. The health visitor established when the next contact visit would be and which other key agencies were involved. The plan was that Elias would be seen by paediatric plastics and have a 6 week check review. Discussion regarding the impact of Elias’s condition on mother and father 2 is not documented and believed not to have been discussed (see section 4.5).  4.6.3 The health visitor conducted the 6 week review for Elias, seeing Child D as well. The usual 6 week review process meant the family would go with baby to clinic, baby would be undressed so that growth monitoring could take place in a private room, then the family would see the health visitor, then see a family support worker from the children’s centre (re children’s services in the area and register), then they would see the GP, and finally the Practice Nurse for BCG immunisations. The review was  23 done this way to support the family and aid multi-agency communication/working. The inviting letter advises both parents to attend and allow an hour.  4.6.4 Father 2 was unknown to any of the professionals involved and there is no record of the role he had with the children. Absent fathers present a challenge to professionals who can become overly reliant on mothers being honest about their situations. The health visitor wondered how mother was managing as the sole carer as she believed there was no other person involved at that time. Both children were well presented. The health visitor noted mother was responsive to each child’s needs, and had the letter with the plastic surgery appointment, this demonstrated her capabilities and was noted. The health visitor communicated to the GP that the family had a plastics appointment booked for baby’s hand.  4.6.5 The new provider inherited a situation which was far from satisfactory. The HV told the SCR that she recognised how the new organisation was attempting to introduce a safer, tighter structure; child protection supervision had always been mandatory. Gradually staffing concerns were addressed and new forms of supervision and support were introduced. The service became a much better place to work, but the period that coincided with the latter stages of the mother’s pregnancy and Elias’s life, had been very tough.     Finding 5: There was insufficient focus on fathers, household composition and the functioning of the household during HV contacts and within HV assessments. Records did not assist, with no section to prompt these discussions.  Recommendation 5: Health services to review documentation and assessment tools and include household composition and functioning of the household. THSCB to seek assurance that this recommendation has been advanced and is proving effective.    4.7     What steps were taken when Elias’s parents did not subsequently bring him to appointments?  4.7.1 In the weeks following Elias’s birth, the mother made herself available for home visits. Mother was advised to attend appointments, register Elias with the GP and register the birth.   4.7.2 Mother followed the plan, taking Elias to a postnatal check, registering with the GP and attending reviews with the health visitor and the GP.   4.7.3 The only appointment mother did not take Elias for was an immunisation appointment; this was followed up as per policy and 10 days later Elias attended for immunisations.  4.7.4 In June 2016, Elias attended his appointment with the plastic surgeon; he was noted to have congenital hypoplasia of his right hand digits. A plan was made for x-rays and  24 clinical photography to be taken and for review in 1 year, with treatment to start from the age of 2, a week later a letter explaining the plan was received by the GP.   4.7.5 Mother would have been viewed as responsive.   Finding 6: Having initially thought that Elias had not been taken to appointments the review has established this was not the case and has identified an example of good practice in that policies relating to non-attendance were followed on the sole occasion mother did not take Elias to an appointment, with effect.  4.8      When do we understand that Elias was injured, bearing in mind the limitations of what can be reasonably inferred from medical evidence? Were there opportunities during this period for professionals to have observed signs of these injuries?  4.8.1 It is believed that some of the injuries were inflicted on Elias during the month prior to his death, though it cannot be stated with certainty exactly when. The only professional who saw Elias during this period was the plastic surgeon, as neither the local authority nor community health services were involved at that point. The surgeon had not been alerted to any prior safeguarding concerns and noted nothing of concern at the appointment.   4.8.2 Whilst it is normal practice to undress and weigh all babies within clinics where children are being seen by paediatricians, this was not the case in the paediatric plastics clinic, unless the surgeon had concerns. Because of the site of Elias’s Symbrachydactyly, the plastic surgeon had no need to remove any clothing and, even if this had been done, it is by no means certain that in such a small baby any signs of injury would have been seen.    Finding 7: It cannot be certain when the injuries to Elias occurred. The opportunity for professionals to observe Elias for signs of injury was limited to the one contact that was focused on the treatment that would be required for the baby’s hand. Even if Elias had been fully examined on that occasion, the nature of his injuries and the age of the baby made it unlikely that signs of abuse would have been apparent.  4.9      Did professionals take the right action to identify risk to Elias and the other children in the family and act on their assessments during the period between his admission to hospital and his death?  4.9.1 LAS immediately identified concerns on entering the family home in response to the 999 call. The couple did not appear concerned. Father was on the phone with LAS control; the controller was counting out compressions for him but he was lying on the bed and did not have Elias in sight. Elias had multiple injuries and paramedics noted scratches on Child D. Elias was in cardiac arrest and was taken to hospital  25 immediately. Emergency Department (ED) doctors believed Elias’s injuries were non-accidental and contacted the police. A strategy discussion took place. Within 15 minutes of Elias’s arrival, the police attended ED and arrested mother. Police then attended the family home and arrested father 2 who had sole care of Child D. Child A, B and C were at school; the police liaised with school, making arrangements to take all the children into Police Protection. In class discussion, Child C indicated Elias had “slept for the whole day yesterday” and was sleeping when Child C came to school. Father 2’s children were all visited and found to be safe and well.  4.9.2 LAS faxed their concerns regarding the scratches on Child D’s back to CSC at 13:29 the same day.  4.9.3 The day following admission, the hospital e-mailed CSC with detailed information about Elias’s life threatening injuries, a strategy meeting took place. Two days after admission Elias died. The following day interim care orders were granted for Child A, B, C and D.   Finding 8: Services followed the London Child Protection Procedures appropriately referring and responding to Elias and Child D’s injuries. It could be argued that Child D should not have been left in father 2’s care whilst Elias was being transferred to hospital, however the ambulance crew’s priority at this point was to preserve Elias’s life and the police were contacted soon after Elias entered hospital.  26 5 CONCLUSIONS  5.1.1 The professionals who continue to work in Tower Hamlets and agreed to be part of this process have been deeply affected by the death of Elias and the subsequent conviction and imprisonment of his parents.   5.1.2 Mother was seen as someone doing her best for her children, indeed it was felt mother was doing well on her own. Mother was observed by professionals to be attentive to the children and was, on the whole, taking the children to their appointments. Father 2 features little in any records of contact or assessments, and the level of his involvement with the children in this household was never clearly established.  5.1.3 There was mismanagement of the incident of physical abuse in 2015 within Children’s Social Care and partner agencies. The children’s voices were sought, heard and listened to, but not given appropriate weight. The children were consistent in stating mother had hit Child C with an implement; however, it was the voice of mother that was believed.   5.1.4 Systems and processes around Child Protection medicals at this time were not robust; it remains unclear as to whether Child C’s injuries were ever photographed by Medical Illustration. The child protection medical report stating the medical opinion that “in view of the history and presentation, physical abuse is likely” was at best misinterpreted, at worst never read. Children’s Social Care workers believed the medical was inconclusive. Advice given for the other children in the family to have child protection medicals, and if Child C was to return to mothers care an Initial Child Protection Conference to be held, was not followed. Clear evidence of abuse with injuries consistent with the child/ren’s explanations was lost.  5.1.5 Mother agreed to a Team Around the Child approach to support on the grounds she would need help when Child D was born with care of her other children. Team Around the Child requires parents to engage; in the months that Team Around the Child meetings were held mother attended only one, reducing Team Around the Child meetings to professionals only meetings. There was good professional attendance and evidence that professionals were working with mother, however there was no lead professional allocated until the last meeting, no challenge regarding mother’s non-attendance and no consideration that the case needed to be stepped up.   5.1.6 A robust plan to address care of the children during Child D’s birth was never developed leading to mother making her own alternate arrangements late in pregnancy. In short, it is difficult to establish any additional benefit for the children and mother from the Team Around the Child approach. Allocation of a Lead Professional at the first Team Around the Child meeting is essential. The impact of the lack of an allocated lead professional and lack of multi-agency approach cannot be under estimated. In this case, it led to a lack of co-ordination and clarity for both professionals and mother and reduced opportunities for communication between professions and teams. A lead professional would have been well placed to challenge single agency decisions.  27  5.1.7 Systems within midwifery allowed a mother to go through Elias’s whole pregnancy with no midwifery care save antenatal scans and a blood test. Mother was at risk of a born before arrival delivery, with potential risks to both mother and child. Lack of robust systems and processes and poor inter-agency communication led to a lack of midwifery care, which ultimately meant there was no plan in place to manage this potential risky situation safely.  5.1.8 The lack of recognition of the potential psychological impact of Elias’s missing digits on his parents was not fully explored; a more holistic approach to assessing and managing Elias within the context of his family was needed.        End.    28 6.  APPENDIX 1 – GLOSSARY OF TERMS & ABBREVIATIONS   A&E  Accident and Emergency ASD Autism Spectrum Disorder BBA Born Before Arrival CAF Common Assessment Framework CIN Child in Need CP Child Protection CSC Children’s Social Care DNA Did Not Attend DA ED Domestic Abuse Emergency Department FSW Family Support Worker GP General Practitioner HV Health Visitor IPST  Integrated pathways and support team LA Local Authority MASH Multi-Agency Safeguarding Hub TAC Team Around the Child    