Injury of an 11-week-old boy in September 2014 as a result of non-accidental head injury due to shaking. Baby H and twin sibling were born 10 weeks prematurely and kept in neonatal care for almost seven weeks, then discharged into parental care. Four weeks later Baby H was admitted to A&E with head injuries, following a 999 call from Baby H's Aunt. Children's Social Care had been involved with family previously over concerns about the neglect of three older siblings, who were later removed from mother's care. Mother was charged with neglect and father charged with neglect and Section 18 wounding. Criminal proceedings were still underway at the time of writing. Learning includes: improved understanding by neonatal staff about the triggers which can lead to abusive head trauma in young babies would be beneficial; help with the support and guidance that neonatal staff offer to all parents, particularly those whose babies may be considered vulnerable; lack of professional awareness of specific details of pre-birth Assessment Procedures and consequently potential risks; during organisational change local authorities need to be aware of the risks that transitions pose to safeguarding practices. Recommendations include: criteria and procedures for starting pre-discharge meetings should be robust and understood by all professionals involved; consideration should be made to co-operating with other LSCBs to explore how learning can be shared to develop policy and practice. Please note that this report was written in June 2016 but was published in 2018.
      
 Title:  Serious case review: Baby H. LSCB: Oldham Local Safeguarding Children Board Author: Linda Richardson Date of publication: 2018  This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC.  This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above.                               1          Serious Case Review   Baby H    June 2016     2 Contents   1.  Local Safeguarding Children Boards and Serious Case Reviews  2. The circumstances which led to this Serious Case Review   3. The approach used  4. Scope and Terms of Reference  5. The parent’s perspective  6. The family as known to agencies   7. Appraisal of practice     8. Concluding Comments    Appendix 1: Single agency learning  Appendix 2: List of Findings and Recommendations     Key:  MT 1982 Mother of Baby H HS1  1999 Half Sibling  HS2 2002 Half Sibling  HS3 2004 Half Sibling   FH  1979 Father of FS1, Baby H and TS FS1  2012 Full Sibling  TS   2014 Twin Sibling  Baby H 2014 SUBJECT       3 1 Local Safeguarding Children Boards (LSCBs) and Serious Case Reviews 1.1 The main responsibilities of Local Safeguarding Children Board’s (LSCBs) as set out in section 14 of the Children Act 2004 are to co-ordinate and quality assure the safeguarding children activities of member agencies. The statutory guidance which accompanies legislation and which underpins the work of LSCBs is very clear in its expectation that when things go wrong for children, through death or serious injury from maltreatment, there needs to be a rigorous, objective analysis of what happened and why, so that important lessons can be learnt and services improved in order to reduce the risk of future harm to children. There is an expectation that these processes known as Serious Case Reviews (SCRs) should be transparent with findings of reviews shared publicly. 1.2 Statutory guidance1 stipulates that when undertaking Serious Case Reviews, LSCBs should ensure that frontline practitioners are fully involved in the process and are invited to contribute their perspectives without fear of being blamed for actions, which they took in good faith. Boards should also consider ways of involving family members and sensitively and appropriately managing their expectations.  2 The circumstances which led to this Serious Case Review   2.1 Baby H and TS were twins born prematurely, in September 2014 to parents MT and FH. 2.2 Baby H was admitted to hospital age 11 weeks, following a 999 call made by the Baby’s Aunt who was concerned about Baby H’s condition.  FH was present at the time.  Following MRI and CT scans a diagnosis was made indicating that the injuries to Baby H were consistent with abusive head trauma caused by shaking.  Baby H, TS and their sibling, FS1 were placed under Police Powers of Protection,2 Baby H remained in hospital and TS and FS1 were placed with foster carers.  2.3 Children’s Social Care (CSC) had been involved with MT when concerns about the neglect of her three older children led to each of them being removed from her care as infants in 2001, 2002 and 2006.  When MT established a relationship with FH and became pregnant for a fourth time with FS1 in 2012, a pre-birth assessment was undertaken.  MT and FH agreed to work co-operatively with services so their child could remain in their care and when FS1 was born and made subject to a child in need plan, both parents responded positively. FS1 was observed by professionals to be well cared for and reaching key developmental milestones and as there were no further concerns, Children’s Social Care (CSC) ended their involvement early in 2013, following a multi-agency child in need meeting.  2.4 MT’s relationship with FH continued and in February 2014, she became pregnant with twins.  The twins were born 10 weeks premature and remained in the care of the neo-natal intensive care unit for almost 7 weeks. They were discharged to their parents’ care in                                                              1 Working Together to Safeguard Children: A guide to inter-agency working to safeguard and promote the welfare of children, March 2015, HM Government 2 The Police have powers under Section 46 of the Children Act 1989 to protect children where emergency measures are required.     4 August 2014.   Four weeks later, Baby H was admitted, as an emergency, to hospital where head injuries were diagnosed.  3 The Independent Chair of Oldham LSCB agreed that the circumstances surrounding the injuries to Baby H met the criteria for a SCR and confirmed this decision on 4th September 2014   4 The approach used 4.1 Oldham LSCB wanted to ensure that the review process looked not only at what happened to Baby H, but also identified some of the factors that may have influenced why professionals acted as they did or why they may not have acted at all.  An independent reviewer with experience of using a systems methodology was commissioned to lead the serious case review process.  4.2 A small Review Team of senior professionals representing the agencies that were or had been involved with the family was established. Their role was to provide information about their own agency and their involvement with Baby H’s family through their contributions to the SCR process and through the submission of an Agency Learning Report3.  Together with the Lead Reviewer, the Review Team gathered and analysed data, appraised practice and agreed the content of this report.  Members of the Review Team were: Linda Richardson  Lead Reviewer  LSCB Business Manager  Oldham LSCB Named Nurse Safeguarding Children Pennine Acute Hospitals NHS Trust (PAT) until November 2015 Assistant Director of Nursing (Safeguarding)  Pennine Acute Hospitals NHS Trust (PAT) from November 2015 Named Nurse Safeguarding Children    Pennine Care NHSFT (PCFT) Designated Nurse Safeguarding  Clinical Commissioning Group (CCG) Head of Service  Oldham Children’s Social Care (CSC) Social Work Manager  Oldham Children’s Social Care (CSC) Police  Detective Sergeant   4.3 Members of the Review Team also identified frontline practitioners who had worked with Baby H’s family.  These practitioners, where they were still in employment, formed the ‘Practitioner’s Group’ and they met on three occasions.  Due to rota arrangements, health professionals from the Acute Services were not always able to attend these meetings.  Practitioners offered details about the family and the work they had undertaken and helped the Review Team consider the extent to which the findings from this review were typical of practice elsewhere across the authority. Members of the practitioner’s group are listed below.                                                               3  Agency Learning Reports provide a chronology of agency involvement. Part 1 of the report provides a narrative about agency involvement and any immediate lessons identified which are, have been or are being addressed.  Part 2 of the report is completed towards the end of the review and identifies any additional learning, which has emerged from the SCR process. An action plan accompanies this report.       5 Health Visitor (HV1)  Pennine Care NHSFT  Midwives 1, 2, and 3   Pennine Acute Hospitals NHS Trust (PAT)  Hospital Doctor  (Dr1)  Pennine Acute Hospitals NHS Trust (PAT) GP    [Named] GP Practice  Manager   Multi Agency Safeguarding Hub (MASH) Oldham CSC    4.4 Data was also collected through the examination of single and multi-agency records and through individual conversations with practitioners.  5 Parallel Processes  5.1 MT was charged with neglect and FH was charged with neglect and Section 18 wounding. Criminal proceedings are still underway at the time of writing this report.  6 Scope and Terms of Reference 6.1 The Review Team decided that MT’s fifth pregnancy was a significant event given her past history, although it was acknowledged there had been no concerns about the care of FS1 in the preceding 14 months. The Review Team agreed the review would examine professional practice from March 2014 when MT’s pregnancy first became known through to September 2014 when the injuries to Baby H were diagnosed.  6.2 The review began with an open enquiry rather than a pre-determined set of questions from a terms of reference. This helped the data lead the key issues to be explored as opposed to the preconceptions of managers or a review team.  Each agency submitted a timeline of interventions at the start of the review process and this information was collated to illuminate multi-agency activity so the Review Team was clear about who knew what and when.  Key lines of enquiry began to emerge which centred on the relevance of historical information about MT’s parenting, professional involvement with the family when MT was pregnant and the extent to which health professionals understood the triggers for abusive head injuries in babies when the twins were discharged from hospital to the parent’s care.   7 The parent’s perspective   7.1 The Lead Reviewer and the LSCB Business Manager met with both parents in late October 2015. They had been advised that due to pending criminal proceedings, there should be no discussion about, or reference to, the injuries to Baby H and this was explained to MT and FH at the meeting. 7.2 MT shared information about what had happened with her three oldest children and said she felt that social workers didn’t pay enough attention to her childhood experiences and the fact that she was 17 when she had her first child. MT explained that things were very difficult when she tried to look after each of her children. She had not had any family support and described how distressing it was when they were removed from her care, one at a time and then when the two older children were adopted. When she became pregnant with her third child, the child’s father although supportive at first, became very difficult and took their child to live with him and his family. MT does not have contact with this child. FH pointed out that social workers did not seem to take into account all that had     6 happened to MT as a child and suggested that not enough had been done to support MT as a young parent.  7.3 When MT met FH and became pregnant with her fourth child, FS1, there was a pre-birth assessment and a decision taken that both parents could try to care for FS1 with professional support. FS1 developed well and there were no further concerns raised about the way in which the parents looked after their child. FH said that MT was a good mum and they were both pleased when they were eventually told that social workers did not need to visit the family any more. 7.4 MT said that when she became pregnant for the fifth time, she told the midwife that her older children did not live with her and that social workers had been involved.  MT said the midwife explained that she would have to contact children’s services and a social worker would need to visit the family.  MT said she had agreed to this as she had been told by her social worker at the time that they would have to be informed if she became pregnant again.  FH said that throughout the pregnancy they kept expecting social workers to call, especially when they learnt that they would be having twins and would need more support. When asked, both parents said they didn’t contact social workers themselves, as they did not want to give the impression they couldn’t cope, especially given MT’s previous history. They said that although they weren’t sure if there would be a pre-birth assessment like they had with FS1, they did expect that a social worker would call to see how they were managing. They assumed it would be the same social worker that visited in connection with FS1. Both parents said that the social worker was ‘lovely and really helped’.  7.5 Soon after they found out about the pregnancy, the parents said they were told they had to move out of their rented accommodation, as the landlady wanted the property for herself.  They found a new property but had to let it go as the landlady from their previous home failed to return their bond so they couldn’t pay the deposit for the new property. Consequently, they found themselves having to live in the backroom of a relative’s house. They remembered this as a very was a stressful time. The twins were then born prematurely and needed intensive care, and they had to take two bus journeys to travel to the hospital, usually with FS1, if FH was working. Sometimes they had to take taxis, which was expensive. There were also financial worries and the room in which they were living with FS1 was small and cramped.  7.6 The parents said they eventually found another property but it was dirty and needed repairs and decorating. They finished the work on the house just a short time before the twins were discharged home. The parents said they had very little support at this time, MT said she had no family to whom she could turn, and although FH’s family tried to be helpful, the couple felt they were on their own and had to somehow manage. Asked if they had thought of contacting children’s services at this stage, both parents repeated that they felt they couldn’t do that, as it would seem they couldn’t cope. MT said she felt she had to be careful where social workers were concerned ‘in case they took [FS1] and the babies’.      7 7.7 Both parents said they were surprised when told that the twins could come home, FH said they had been led to believe they would stay in hospital for a few more weeks. MT said the staff on the neonatal unit explained the night before the twins were discharged, about how to care for the twins at home and how to make sure they were feeding properly. She said that TS was the stronger twin and FH said that there had been real health concerns about Baby H, who had needed oxygen until the hospital discharge. The parents were told that a nurse from the neonatal unit would visit once the twins were at home.  7.8 The parents explained that when the twins came home, the feeding needs and times of the babies were different and this had to be carefully managed. MT said it was quite tiring and she was always worrying about getting it right and she again explained her reluctance and concern about asking for help. FH said that going out to buy food or nappies had to be carefully planned, as they didn’t have a twin buggy so one parent had to always remain at home with two children. They bought lots of food and things for the twins so when the social worker called, she would be able to see that they were coping. They said that the Health Visitor called once and was pleased with how they were managing. They already knew her as she had provided lots of information and support about looking after FS1. She arranged to call back a few weeks after her first visit to see how the twins were doing.   7.9 When asked about a visit from the Outreach Nurse from the neonatal unit, the parents explained that she had gone to the wrong address – she had visited the home of the relative when they had been staying. The parents said no one from the unit called at their ‘new’ home although MT insisted she had told the staff on the unit they had moved house and had given them the new address. They said an uncle told them a few weeks later that ‘someone’ had left a card and a phone message but he hadn’t realised it was about the twins.  7.10 When asked what support might have been helpful, MT replied that just for someone to ask how they were managing and to check if they needed anything would have helped; FH explained that he and MT only had each other.  He spoke at length about MT not having any support from her own family and described how and why there were tensions in his own family, partly he said because some family members found it difficult not to judge MT for what had happened in the past.   7.11 Both MT and FH were given an opportunity to raise any other issues and MT asked if they could highlight that they were still the parents of their children and should be kept well informed about their progress and health needs. MT said that TS had been admitted to hospital and they had not been informed at the time. The LSCB Business Manager agreed to follow this up. 8 The family as known by agencies Background Information from Children’s Services records 8.1 MT was 17 years old when she gave birth in 1999 to HS1. Concerns about neglect, emotional and physical abuse led to HS1 being placed at 2 years old, on the Child     8 Protection register.4 Professionals found it difficult to establish a working relationship with MT and when concerns about HS1 heightened, he was made subject of a Care Order5 and freed for adoption in 2001.  8.2 When MT was pregnant again in September 2001 with HS2, a pre-birth assessment6 was completed and although MT initially engaged with children’s social care services, this was not sustained and concerns about the welfare and safety of HS2 continued. The local authority subsequently obtained a Care Order in 2002 and HS2 was freed for adoption.  8.3 MT met the father of her third child in 2003 and gave birth to HS3 in 2004. Following a pre-birth assessment and an Initial Child Protection Case Conference, HS3 was placed on the Child Protection register under the category of neglect. MT complied with requirements to meet regularly with social workers and health professionals. Concerns from agencies began to abate during 2005 during which time MT received support from her partner who did not live with her and their child, but offered daily and regular help. At that time MT lived with family members but later moved into her own accommodation with HS3 in 2006, with an intensive support package from CSC.  8.4 The relationship between MT and HS3’s father began to deteriorate and MT struggled to manage her home and to maintain the level of care for HS3 previously observed by CSC.  In May 2006, HS3 was accommodated by the Local Authority and placed with interim foster carers.  Contact sessions took place regularly for both parents and in March 2007, HS3 moved to live with father following his successful application for a residence order.7 8.5 FH and MT established a relationship and MT became pregnant for a fourth time in 2011 and the local authority undertook a comprehensive pre-birth assessment in February 2012.  This noted that MT presented as more mature than in previous assessments and that her relationship with FH was stable and supportive.  MT was reported to be still struggling with the decisions taken by the Local Authority to remove her older children from her care, but both parents agreed to work with professionals, ensure that medical appointments and follow-ups were kept and use of the support of family members to help with parenting once their baby was born.  8.6 FS1 was born in May 2012 and the parents attended all but one of the planned sessions with the multi-agency intervention team.  Both parents engaged with professionals at an initial child protection conference and agreed to work in partnership with professionals as part of a child in need process. They kept to this agreement and were noted to willingly co-operate and take advice when offered.  No concerns about the care or development of FS1 emerged and both parents were observed to be confident in their parental role, their relationship was noted to be stable and in contrast to what had been observed previously,                                                              4 Children are now made subject to Child Protection Plans rather than being placed on a ‘register’ 5 A Care Order is an order, which places a child under the care of the Local Authority. This is otherwise known as a child being’ looked after’. The Order is applied for by the Children’s Social Care and gives the Local Authority Parental Responsibility for the child 6 Social workers undertake a  pre-birth assessment to determine if a baby can be safely left in the care of a parent when it is born  and what support the parents require  so they can meet the baby’s needs.  7 A ‘residence order’ is a court order 'settling the arrangement as to the person with whom a child is to live.'      9 the house was clean and tidy.  Importantly, FS1 was seen to be achieving all his developmental milestones and following a multi-agency meeting in January 2013, a decision was taken that CSC involvement was no longer necessary.  MT was advised she should let CSC know if she became pregnant again.  CSC closed the case and there were no incidents or concerns raised in relation to FS1 after this time.  Period under review: March – September 2014   8.7 MT presented to the antenatal clinic in March 2014 at 12 weeks gestation. She informed the midwife (MW1) about her past history and said that her youngest child HS2 lived with her but social workers were no longer involved. MW1 explained she would have to confirm this information with CSC and the parents accepted this was necessary and was what they expected.   8.8 MW1 contacted CSC two days later and according to records, was advised by a duty worker8 (DSW1) that although there had been previous concerns about neglect of MT’s three oldest children, her youngest child, FS1 was living at home with both parents and CSC were no longer involved. MW1 was informed that if she had any new concerns, she should make a referral.  A record of this telephone conversation could not be located on the Frameworki 9 system but midwifery records clearly refer to it taking place.   8.9 MW1 did not have any safeguarding concerns but in line with her agency procedures, completed a ‘Special Circumstances’ Form (SCF)10 to share this information with midwifery colleagues and forwarded a copy to the Safeguarding Team at PAT where it was passed to PCFT and health visiting services.  A copy of the SCF was also placed in MT’s medical records.  8.10 HV1 made a home visit to the family in May 2014.  By this time it had been confirmed that MT was expecting twins and MT shared her anxieties with HV1 that children’s services would become involved again. FS1, then two years old, was observed by HV1 to be wandering around the house with no real purpose, not engaging in conversation and having no eye contact.  MT acknowledged she found it difficult to play with FS1 as she wanted the home to be ‘clean and tidy’ all the time.  She expressed concern about her possibly having Obsessive Compulsive Disorder (OCD) and HV1 explored various options with her.  MT said that FS1 enjoyed spending time with a childminder, but no additional information is recorded about these arrangements.  FH was reported to have started work that day.  8.11 HV1 visited again in early June and recorded that FS1 was reaching key milestones.  MT said that she had a hospital appointment, as one of the twins seemed not to be growing as well as the other.  In July 2014, ten weeks before the expected date for delivery, MT gave birth to twins by caesarean section and was admitted to the postnatal ward where she                                                              8 It is not known to whom MW1 spoke so the reference to a ‘duty social worker’’ is used for ease of reference 9 Frameworki is a case management system software, which supports the recording and management of social work practice 10 The SCF is used to share information and concerns with other health professionals and where necessary to support the referral of concerns to [at that time] the Children’s Assessment Team. (CAT)      10 was discharged two days later.  A member of staff from the neonatal ward (SN1)11 having sight of the SCF appropriately contacted CSC the following day to enquire about CSC involvement.  She was advised by DSW2 that there were no current concerns about the care of FS1 and CSC were ‘happy’ with the care of the child and were no longer involved with the family.  SN1 was advised if she or her colleagues had any concerns they should refer these to CSC.  This conversation could also not be located on Frameworki.  8.12 The twins remained on the neonatal unit for almost 7 weeks.  During this time concerns emerged about parental visiting and the fact that MT did not visit as often as ‘other mums’ and always seemed to be in a hurry to leave.  Staff were worried about the impact of these short visits on bonding between MT and her babies.  A visiting chart was established sometime towards the end of July in response to these concerns.  HV1 contacted the unit at the end of July and spoke with SN6.  She asked to be informed about any discharge arrangements.  8.13 A phone call was taken by SN7 from the sister of FH in early August 2014.  This family member worked at the hospital and was known to the staff on the neonatal ward. She complained about staff on unit placing pressure on MT about her visiting and needing to bring nappies and bottles into the unit for the babies.  She explained that the couple were very stressed due to their poor living accommodation.  When the Maternal Aunt visited the twins, a few days later, she also informed staff on the neonatal unit that the parents were struggling financially as FH had been made redundant and their benefits had not yet come through.  In addition the Aunt said the family were living in the back room in a relative’s house and their newly acquired rented accommodation needed repair and decoration before they could move in.  The Aunt explained that this together with the need to visit the twins in hospital was proving very stressful for the parents.  8.14 SN8 rang to speak with HV1 on 12.8.14 but she was not available.  The information was left with HV2 with a request for a home visit to offer support to the family as MT had said they had no money or food and were struggling with accommodation.  HV2 left a message for the parents asking them to make contact, which they did not do.   8.15 HV1 contacted the neonatal unit on her return from leave on 18.8.14 and spoke with SN9. She was advised of their concerns about parents not visiting often or for long and was told that MT had visited the previous day and stayed for two hours but she had been anxious to leave even though Baby H was crying.  The family were also said to be moving soon to a different address.  It was agreed that although no referral to CSC was necessary, a discharge-planning meeting would be held before the twins were discharged home.  HV1 asked for the parent’s new address and requested she be kept informed. 8.16 SN2 contacted HV1 with the family’s new address on 20.8.14 and was advised that they were to discuss a discharge meeting on the unit and what support the family might need with parenting, but they were having difficulty in contacting the parents.  SN6 also spoke with HV1 a few hours later and said they had still been unable to reach the parents.  SN6 and a doctor on the ward (DR1) later discussed discharge arrangements and concluded                                                              11 A number of different nursing and midwifery staff had contact with AT, FH and the twins. For ease of reference these professionals have been coded SN1 – SN9     11 that there was no need to plan a discharge planning meeting at that time, as there were no safeguarding concerns and the need for a discharge meeting could be considered at a later date.  Meanwhile, HV1 left several messages for the parents over the next few days asking them to get in contact but the parents did not respond.   8.17 MT advised staff when she visited 23.8.14 that they were ready to move into their new accommodation.  She explained that FH found it too distressing to visit the twins and this was why he did not often visit.  Records indicate that MT was eager for the twins to be discharged home.  HV1 made a home visit on 28.8.14, but there was no answer when she called at the house.  On 29.8.14, HV1 called the neonatal unit to ask about the discharge meeting and was advised that MT had stayed the previous night and the twins were to be discharged later that day.  8.18 HV1 called to the home for a primary visit on 1.9.14 but the curtains were closed and there was no answer.  Two days later, HV1 visited and saw the family.  MT was described as happy and relaxed and was observed feeding Baby H.  HV1 noted that she had no concerns over bonding or attachment.  FH was present and spoke of how difficult things had been for the family at the time of the twins’ birth.  MT said they had family support.  HV1 arranged the next visit for the end of September.   8.19 The Neonatal Outreach Nurse12 could not make contact with family and after several unsuccessful attempts sent a discharge note to HV1 and the GP two weeks later advising that as she had been unable to gain access to the family, they had been discharged from the service.  MT did not take the twins for their 6-week development review with the GP.  8.20 MT and the Maternal Grandmother took Baby H and TS to their GP for their development review on 23.9.14.  MT was observed to be relaxed and agreed to a student nurse being present for examination.  Of the two babies, Baby H was described as being unable to lift his head when placed face down and was noted to be ‘more sleepy’ than his twin sister. The GP was however satisfied with the examination and did not identify any concerns.  8.21 Three days later Baby H was admitted to hospital by ambulance.  A medical diagnosis suggested Baby H’s injuries were consistent with abusive head trauma caused by shaking. Baby H remained in hospital and TS and FS1 were placed with foster carers.  9 Appraisal of professional practice   9.1 MT was 12 weeks pregnant, and accompanied by FH, when she presented to the antenatal clinic in March 2014.  The midwife had access to MT’s maternity records which contained ‘old’ SCFs attached in an ‘alert’ section and substantial information about previous pregnancies and several references to child protection processes.  There was reference to a pre-birth assessment and child in need decisions relating to FS1 and information that FS1                                                              12 Outreach nurses provide on-going care, advice and support to families whose babies are referred to them on their discharge from the Neonatal Unit, the post-natal ward, the children's ward and occasionally other hospitals occasionally other hospitals     12 could be discharged home with MT.  This was completed on an ‘old style’ SCF in handwriting.  9.2 There were no minutes from any child protection or child in need meetings.  The Review Team was told whilst it is expected practice within CSC that minutes of meetings are sent to all invited agencies, various multi-agency case file audits have highlighted that this is not always routine practice and neither are copies of pre-birth assessments, or the decisions emerging from them, always shared with midwifery services or GPs.  Whether integrated working is through specific multi-agency structures or existing services, success for all children at risk of poor outcomes depends upon effective partnership working and appropriate information sharing between services.  The Review Team was told by practitioners that the issue of CSC sharing information with health professionals especially in relation to decisions emerging from assessments has been problematic at times but is an area currently being addressed by CSC (See Single Agency Learning CSC in Appendix 1).  Guidance is also now in place so that partner agencies who feel that information is not shared appropriately can raise concerns through LSCB escalation procedures.  9.3 MT told MW1 that her older children no longer lived with her, but the youngest child was still in her care and CSC were no longer involved.  MW1 acted appropriately and contacted CSC to provide information and confirm what she had been told by MT and FH.  She was informed by DSW1 that unless there were any new concerns there was no need for CSC involvement.  The Pre-Birth procedures in Oldham at the time stated that pre-birth assessments should take place ‘Where a previous child has died or been seriously injured or been removed from parent(s) as a result of Significant Harm’.  Clearly the information shared and the subsequent dialogue with MW1 did not alert DSW1 to the fact that because previous children in the family had been subject to child protection procedures, the threshold for a pre-birth assessment was met.  This was a missed opportunity, which would have allowed key professionals, a social worker, health visitor, and midwife to share and assess information and provided a wider context to the family dynamics and any inherent risk factors.  9.4 MW1 did not challenge the response of CSC or seek the support of her safeguarding team to do so and neither did SN1, suggesting that both health professionals were also unaware of the relevant procedures.  The Review Team was curious to understand why the details of these procedures were not familiar to practitioners; it is a finding, which has emerged from some other SCRs published nationally.  9.5 Conversations with professionals and within the Review Team suggested that although health professionals knew of the pre-birth assessment procedures, there was an assumption that they were not relevant because FS1 was living with parents and there was no current involvement by CSC. In addition, it became obvious that the procedures were clearly seen as ‘belonging’ to CSC even though they are intended for use by all agencies. Whilst this could explain why MW1 and SN6 did not question the absence of a pre-birth assessment, it did not explain why the ‘duty officers’ in CSC did not accept the information from health professionals as a referral for action.  In discussions with practitioners, it also became apparent that health professionals were far more likely to     13 consult their own agency procedures rather than refer to those on the LSCB website, which the Review Team found to be rather complicated, lengthy and not easy to navigate.  9.6 Accessing procedures generally was also described by practitioners as ‘taking time’, ‘needing to be online and knowing where to look’ or in times of transition, being sure that procedures were current and up to date, practitioners said it was often easier to talk with ‘experienced’ colleagues or someone ‘in the know’ rather than refer directly to the procedures themselves.  This offers a perspective worthy of note about why procedures are not always followed and in relation to this review, helped the Review Team understand why MW1 and SN1 readily accepted advice from CSC perceived as ‘the experts’ that no further action at that time was necessary.  9.7 Snook’s (2000)13 explores what he describes as ‘practical drift’ - the ‘slow uncoupling of practice from procedure’ and suggests this is an inevitable aspect of human behaviour and is never ‘fixed’ by tightening procedures or increasing penalties for non-compliance.  Snook suggests what is required are opportunities for professionals to have access to regular conversations and dialogue with other colleagues about procedures so they can be reminded not just about the need to follow procedures but of the reasons why they were introduced in the first place.  Such opportunities are to be welcomed but the Review Team were told that increasing workloads and time pressures make it much more difficult to make the most of such opportunities, if and when they are offered. 9.8  The Review Team were mindful of the dangers of placing too much emphasis on whether procedures were followed rather than whether good decisions were made and some members were of the view that had the procedures been followed and a pre-birth assessment taken place, it may well have led to the potential risks and vulnerabilities arising from MT’s past history to be explored and better understood (See Single Agency Learning PCFT in Appendix 1). Finding: When professional judgment is required and health professionals are considering what to do next, they are more likely to either consult with colleagues perceived to have ‘knowledge and experience’ or access their own agency procedures rather than access procedures on the LSCB website.    Finding: Children’s Services practitioners and health professionals were unaware of the specific details of the Pre- Birth Assessment Procedures and consequently potential risks to Baby H and FS1 from MT’s history were left unexplored and unassessed.   Recommendation 1 a) Oldham LSCB should seek assurance from partner agencies that frontline practitioners are aware of the detail of Oldham’s Pre-Birth Assessment procedures and that where a previous child of either partner has been made subject to child protection procedures, a referral should always be made to CSC so that consideration of a pre-birth assessment can be made.                                                               13 Snook, S.A. (2000). Friendly fire. Princeton, NJ: Princeton University Press     14 b) Oldham LSCB should explore how practitioners can be kept abreast of LSCB procedures; how and why they are developed and what relevance they have to key professional roles.   9.9 The lack of knowledge about Pre-Birth Assessment procedures was compounded by the absence of any triggers in MT’s medical or social care files to indicate that if she became pregnant at some time in the future, a pre-birth assessment would be required.  This information should certainly have been flagged on GP records.  It was of interest to the Review Team to note that in CSC records, MT had previously asked the Social Worker when their involvement was ending, what would happen if she became pregnant again. She was advised that she would need to inform CSC.  There was however no ‘flag’ on the family files as part of a closure summary or on MT maternity records to alert professionals what action they should take if MT presented as pregnant at a future date.  It is not possible to conclude with any certainty that had a pre-birth assessment been considered, the outcome for Child H would have been different, it would however have ensured that the level of risk arising from MT’s history was better understood by professionals in terms of her vulnerabilities as a parent. (See Single Agency learning for CSC and PAHNT in Appendix 1). Finding: Where children have been subject to significant harm in a family, and work with the family ends, the absence of any shared recording systems to highlight or ‘flag’   what should happen if the mother becomes pregnant again or her relationship ends, leaves unborn babies vulnerable and fails to alert professionals of the need to refer to CSC.   Recommendation 2: Oldham LSCB should seek assurance from partner agencies that where there have been child protection concerns in a family and a decision is taken by CSC to close the case, agencies have in place appropriate recording systems to share and record what action should be taken if the mother presents as pregnant at a future date. This information should be clearly ‘flagged’ in all agency records, and mother’s maternity records amended accordingly.    9.10 Although midwifery records clearly refer to the conversation between MW1 and an unnamed ‘duty officer’ taking place, there are no additional details provided and no record of this conversation on Frameworki. Nor is there a record of the contact made with CSC by SN1 following the birth of the twins, 4 months later, although this conversation is also clearly recorded in the day-to-day records held on the neonatal unit.   9.11 The Review Team was concerned when they were informed that not one but two significant contacts with CSC made four months apart could not be located on the Frameworki system.  The Review Team accepted that these conversations took place and asked CSC personnel to track down where these conversations might have been recorded but they could not be found.  Further enquiries into how the system worked at the time indicated that whilst it was technically possible to access information about a family on Frameworki without leaving a footprint, this was an unlikely explanation, suggesting that both duty officers had not accessed any historical information about MT but had simply confirmed there was no current involvement by CSC. The findings indicated that both contacts from health professionals were regarded as ‘consultations’ or ‘contacts’ and were not recorded.  It seems that this may have been common practice during a period of     15 considerable organisational change and not all ‘contacts’ were recorded on the system especially where no further action was required on the part of CSC and the caller was not seeking to make a referral.  The Review Team considered this as extremely poor practice and demonstrated a significant weakness in recording systems and auditing processes, which had the potential to adversely impact on arrangements to safeguard children.  9.12 The Review Team was informed that around this period the MASH14 had recently been implemented as a new organisational arrangement for children’s referrals and was still in the process of setting up effective systems, protocols, and procedures for information sharing which may have meant that consistent standards were not achieved.  CSC confirmed that during this period of transition, practice and managerial oversight may have slipped and this could account for the failure to record and audit these conversations.  CSC acknowledged this had serious implications for safeguarding processes and multi-agency working and that managerial oversight of practice and processes should have been particularly robust during these times.  The Review Team was assured that improved quality assurance systems are now in place and further training has been provided to staff around recording of contacts and referrals from other agencies. (See Single Agency Learning for CSC in Appendix 1.) Finding: During times of organisational change, local authorities need to be especially alert to the risks that transitions pose to safeguarding practices and ensure plans include mitigation of identified risks which are monitored and challenged through relevant governance arrangements.   Recommendation 3:  a) Oldham LSCB should ensure it is provided with regular reports about the development and implementation of MASH operating systems, including how risks are managed, so the Board can effectively monitor and where necessary challenge, governance arrangements.  b)  Oldham LSCB should ensure that when any partner agency undergoes significant organisational change, the Board is provided with reports, which demonstrate how risks posed to existing safeguarding practices and processes have been assessed and are being managed by those agencies.    The use of the Special Circumstances Form   9.13 The SCF is an electronic form used when a midwife has information and/or concerns about a pregnant woman and needs to share this information with other health professionals. The form is also used to support a referral to CSC where necessary. In line with expected practice MW1 completed an SCF form after speaking with DSW1 and forwarded it to the safeguarding team in PAT who sent it out in an email to PCFT. HV1 received a copy of the form two days later.                                                               14 Multi Agency Support Hub (MASH) is the single point of contact for all professionals to report safeguarding concerns.      16 9.14 The SCF highlighted that MT had given birth to four other children, three of whom did not live with her.  It did not make any reference to the fact that there had been a previous pre-birth assessment for MT’s youngest child, FS1.  This information would have been useful to specifically alert health professionals that previous children had been subject to child protection procedures.   MW1 inserted ‘No’ to the question on the SCF asking if there had been any previous child protection concerns.  This was clearly not the case and there were several references in MT’s maternity records to indicate otherwise.  Being unable to speak with MW1, or access any case notes which reflected her thinking, the Review Team concluded that MW1 may have misunderstood the question on the form  and purposefully answered ‘No’ because there were no longer any current child protection concerns or it may have simply been human error and the box was ticked incorrectly.  The form was coded green and marked ‘for information only’.  Had the form included more information about past concerns, for example the pre-birth assessment for FS1, it is possible that the significance of the child protection history may have been better understood by other health professionals who were sent the SCF.  The narrative on the form stated that contact had been made with CSC, and that should new concerns arise, a new referral to CSC should be made.  9.15 The SCF did not include any reference to FH, MT’s partner and father of her youngest child.  Both parents informed the Lead Reviewer that FH was present at all the midwifery appointments and details of FH were included on the booking form but not on the SCF.  This information is important as it is widely recognised that insufficient attention is paid to the role of fathers and the benefits of, where possible/appropriate advising their GP of the impending birth.  9.16 The use of the electronic SCFs was introduced in March 2013 and is clearly well embedded into practice.  There may be merit in the Safeguarding Team at PAT considering whether any additional guidance or prompts would be of benefit to midwives responding to the child protection question and to ensure that details are provided about fathers where this information is available.  Communication and collaboration between professionals   9.17 Research 15  suggests it is important that professionals from all agencies work collaboratively, sharing knowledge and expertise if children are be supported and protected. Agencies have a collective responsibility to protect children and this demands effective communication and co-ordination of services particularly at operational levels.  9.18 MW1 contacted CSC in March 2014 when MT presented with her fifth pregnancy and SN1 contacted CSC in July 2014 soon after the twins were born. The purpose of both contacts was clearly to share information and check that the information held in MT’s records was correct and CSC were no longer involved with the family.  These contacts were both appropriate and timely.  9.19 Although some information was shared between midwifery services, HV1 and the staff on the neonatal unit, some members of the Review Team did not have a sense that there was                                                              15 Safeguarding in the 21st Century – Where to now Research in Practice 2010     17 any shared analysis or collaboration between the professionals, which may have enhanced professional understanding about the parent’s capabilities.  When the twins were born, staff in the neonatal unit started a visiting diary as they had concerns about the parent’s visiting patterns. They noted that MT did not stay long to visit the twins and always seemed to be in a hurry to leave.  They shared this information with HV1 and advised that family members had also said the parents were under a good deal of stress.  9.20 Both HV1 and staff on the neonatal ward often had difficulties in contacting MT and FH and there would have been benefit if they had jointly addressed this issue and been able to explore to what extent the parents behaviours were a symptom of resistance to professional involvement or a reluctance to engage with professional help, both of which carried implications for any support they might need in the future.  It would also have been helpful if health professionals had discussed the family’s housing situation and the impact this could have on the parents’ ability to care for their two-year-old child and twin babies, born 10 weeks prematurely.  It appeared to the Review Team that even if the relevance of history was not fully recognised, health professionals did not consider that the parent’s circumstances and levels of stress together with caring for not one, but two vulnerable babies could lead to increased frustration and anxiety for the parents, especially given their background.  9.21 The Review Team was told by some practitioners that collaboration between community and acute services could be better, but often workloads, different roles, and agendas get in the way.  Unlike HV1 who was an individual professional working with the family, there were a significant number of staff on the neonatal ward, all in contact with MT at various times and inevitably they observed and witnessed different episodes and incidents.  During the practitioner’s meetings, midwives acknowledged that this made liaison with community professionals more difficult.  Practitioners also pointed out that there are lots of examples of good joint working but thought this was more evident when there were shared safeguarding concerns and/or child protection or child in need plans and this was not the case for Baby H.  9.22 HV1 recalled several conversations held with staff on the neonatal unit and indicated that she almost had to ‘start again’ with each conversation as she seemed to speak with a different nurse every time she contacted the Unit.  HV1 said she discussed having a meeting several times but it never seemed to happen.  On reflection, HV1 said she should have discussed this with her manager at the time and insisted that a meeting took place but she also reflected that her anxiety was based on knowing the past history rather than any immediate concerns and trying to explain this to different staff on the unit each time was frustrating.  In the practitioner’s meeting, one of the midwives acknowledged the frustrations of HV1 and explained there is now an improved system in place to support better communication with colleagues and families are now allocated to a designated staff nurse who liaises with other professionals and monitors all records and contacts with families. HV1 acknowledged this would have been of benefit at the time. (See Single Agency Learning PCFT Appendix 1.) 9.23 The value and purpose of conversations with colleagues from other agencies lies not simply in their taking place, but in the opportunities afforded to having active, reflective     18 and robust discussions about concerns and how to best safeguard a child’s interests.  HV1 had been involved when FS1 was subject to a child protection conference and child in need plans and was party to the decision to ‘close the case’ the previous year and consequently; she had a wealth of knowledge about the parents’ vulnerabilities and strengths. This information would have been useful to share in a meeting but HV1 did not pursue this and staff on the Unit did not see a need for such a meeting. The Review Team was mindful that whilst past history of harm may be an indicator of future harm, parents can and do change their behaviour but the benefit of face to face meeting between health professionals would have ensured that the parent’s behaviour and apparent reluctance to engage with professionals was placed in the context of their past experiences.  9.24 Midwifery colleagues pointed out that despite some concerns about visiting and an awareness of some financial difficulties and family stressors, they did not consider that their concerns about MT and the twins were in themselves significant.  They also pointed out that neither was HV1 specific about any concerns she may have had and they had ensured that the Neonatal Outreach Nurse (ON1) would visit the family and be well placed to pick up any concerns.   When ON1 was unable to make contact with the family, she did not liaise with HV1 but simply sent a discharge letter to HV1 and the GP, which they received 18 days after the twins were discharged.  The reference to being unable to gain access to the family however did not generate any concern.  The GP advised that she had no reason to be concerned as there was no ‘flag’ on MT’s record to indicate her past history.  HV1 said because she had seen the family two weeks previously, she had no concerns about how the family were coping.  ON1 stated that as there were no safeguarding concerns identified she was not unduly worried when she was unable to gain access to the family and knew that HV1 would be visiting the family.  9.25 There are ranges of factors, which can affect a practitioners’ ability to assess or see clearly what is happening to children including having ‘fixed’ ideas about how a family is functioning.  This is compounded in some situations by the difficulty for professionals in determining the threshold for decisive action and this is where professional collaboration in terms of information and analysis is invaluable.  Finding:  Although some information was exchanged between health professionals, there was not enough collaboration between community and hospital provision and information, which may have heightened concerns, was not shared or analysed.   Recommendation 4:   Oldham LSCB should explore whether existing management systems adequately ensure and encourage recourse to effective multi-agency processes and/or joint working with families with young babies who require early help.     Discharging the twins from hospital  9.26 HV1 expected that a discharge meeting would take place to which she and the parents would be invited.  SN6 and DR1 concluded that planning for a discharge meeting was not necessary at that time as MT appeared to ‘understand the twins’ health needs and no safeguarding concerns had been noted’.  This decision was not however relayed to HV1.       19 9.27 Nine days later, HV1 rang the unit to enquire about discharge arrangements and was advised the babies were being discharged that day.  Despite her reservations, HV1 did not question why there had been no discharge meeting and acknowledged that she could have done so.  HV1 said that on reflection she believed her actions were significantly influenced by the progress the parents had made in caring for FS1 and that despite the comments of the staff on the unit, no specific concerns had been noted.  HV1 was also told that MT had successfully ‘roomed in’16 and staff felt the twins could safely be discharged home.  9.28 The decision to discharge the twins was supported by a consultant (CON1) following a conversation with SN6.  The Review Team were told that it is normal practice for a consultant to consider all available information before making the decision for discharge, this would have included any concerns highlighted by other professionals and any raised by the nursing team.  Both CON1 and Dr1 told the Review Team that there were no specific concerns raised about this family and none were raised by HV1. There is no documentation, which would suggest that the concerns recorded by staff on the unit led to a challenge from the nursing staff to discharge the twins to the care of their parents. The Review Team was assured by practitioners that this was more to do with not having concerns about the discharge than a reluctance to challenge a consultant.  9.29 Oldham’s procedures state that  ‘if, during the course of a child's stay in hospital, concerns about their vulnerability / compromised parenting become apparent, but significant harm is not yet identified then, at a minimum, the hospital staff should consider the need to hold a discharge planning meeting, in consultation with named professionals for safeguarding children’.  Dr1 suggested that on reflection, perhaps a more in depth assessment about the parent’s circumstances might have been useful but with little information in the records and the absence of any CSC or health visitor concerns, the view was that the twins could be safely discharged home and be supported through community health provision.  9.30 Research17 suggests that the birth of a premature infant is associated with higher levels of parental anxiety, hostility, depression, and is known to be linked to the disruption of attachment where there has been a significant period of hospitalisation for the pre-term baby.  Differences in a pre-term infant's behaviour and a mismatch with parental expectations can further contribute to the infant's vulnerability.  Where there are two pre-term babies, these risk factors increase considerably. Awareness of this and similar research plus learning from national and local SCRs should have alerted health professionals to the vulnerability of these babies and highlighted the importance of a discharge-planning meeting.  9.31 The decision of when to discharge babies from hospital after a stay in the neonatal unit is complex and is made primarily on the basis of the infant's medical status.  It is however complicated by several factors, which include the readiness of families for discharge, and the opinions of other professionals about the level of care that will be provided at home.                                                                16 This term is used to describe a mother sleeping at the hospital overnight and taking sole responsibility to care for her baby. Support is at hand should the mother require it 17 Very preterm/very low birth weight infants’ attachment: infant and maternal characteristics Wolke et al. Child. Fetal Neonatal Ed. 2014     20 The purpose of any discharge-planning meeting is to bring together the parents and hospital and community professionals so the needs of a vulnerable child/baby can be clearly identified before discharge and support for babies and their parents can be coordinated through community services.  Babies who have required specialist neonatal care specifically need to have their health and social care plans coordinated to help ensure a safe and effective transition from hospital to community care.  The absence of a discharge meeting for the twins meant that the only plan made was for a referral to the neonatal outreach service.  Although this referral was made, the Neonatal Outreach Nurse called at the wrong address and did not make contact with parents, so support which may have been helpful did not materialise. 9.32 Even disregarding MT’s history, a discharge meeting would have assisted health professionals to acknowledge and perhaps explore MT’s anxieties about asking for help, and provided an opportunity to discuss coping strategies for parents should they find themselves struggling with caring for not one but two vulnerable babies.  It would also have strengthened communication between health professionals and specifically the Neonatal Outreach Nurse and the GP who told the Review Team, she was unaware of the detail contained in the SCF or of MT’s background as there was no ‘flag’ on MT’s health records. 9.33 The Neonatal Outreach Nurse (ON1) attempted to contact the family when the babies went home, she was unsuccessful in making contact and consequently ‘discharged’ the family from the outreach services without reference to any other health professional.  This meant that the family and the twins were seen by only one health professional during the four-week period after their discharge and prior to the appointment with the GP.  Given their circumstances, this fell far short of expected practice and left a family with two vulnerable babies without neonatal support. 9.34 The Review Team learnt that ON1 did not have the correct address for the family and called at the house where they had lived with a relative.  She left a calling card but this was not passed to the parents until several weeks later.  In the meantime ON1 received an abusive message from a caller advising the family did not live at that address.  She was given the correct address and visited but received no answer.  Phone messages were apparently also left unanswered.  ON1 said she sent a letter to HV1 and the GP advising that she had no contact with the family and they were being discharged, she did not however try to contact HV1, which would have been expected practice, ON1 said had there been any safeguarding concerns identified, she would have made contact but as there had been no need for a discharge meeting she had not felt overly concerned.  She had sight of the SCF but noted that there was no social work involvement and this; she felt would have been a significant influence on her actions.  9.35 Had the stressors in this family been better understood, the importance of practitioners understanding the day to day lives of the parents and their children may well have highlighted the need for an increased number of home visits and direct observation of the care and interaction provided by the parents.  HV1 and MW3 agreed that had there been a more joined-up approach between health visiting and the neonatal unit, they might have gained a better understanding about parent’s capabilities and coping strategies.  They      21 expressed the view that they were to some extent reassured by the fact that CSC were not involved with the family even though they knew about MT’s pregnancy. (See Single Agency learning PCFT in Appendix 1.) Finding: There needs to be great clarity as to when discharge meetings should be held in order that community and hospital provision can be better coordinated for those families where past or present key risk indicators are known.  Particular care should also be taken on discharge to ensure that the hospital has accurate records about the address to which babies are being discharged.   Recommendation 5  Oldham LSCB must be confident that the criteria and procedures for instigating pre-discharge meetings are robust and well understood by all professionals and specifically, health professionals working in acute services.   Taking a wider perspective about safeguarding responsibilities  9.36 Specialist assessments of risk and parenting capacity may be required in some cases, but all practitioners who come into contact with babies, or expectant or new parents, have a duty to ensure that vulnerable infants are safeguarded.  9.37 Fish18 suggests that professionals need to take active steps to work against ‘our human tendency to seek only the information that we wish to find’, and confirms the dangers of a tendency to ‘stick to what we think we know’ and carry on with the plans without question or challenge.  She goes on to state  ‘one of the most common, problematic tendencies in human cognition ... is our failure to review judgements and plans – once we have formed a view on what is going on, we often fail to notice or to dismiss evidence that challenges that picture.’  There was evidence in this review that health professionals were influenced by a decision taken the year before that there were no concerns about this family and this impacted upon their readiness to recognise vulnerabilities in this family. 9.38 Views were expressed during the review process that having contacted CSC to advise about MT’s pregnancy and clarifying background information, health professionals had fulfilled their responsibilities.  It was suggested that if CSC had been concerned about MT’s pregnancy, health professionals would have been advised accordingly but given CSC expressed no concern, health professionals were reassured and considered no further action was required on their part.  The Review Team acknowledged these comments but considered that this view placed too much responsibility for safeguarding onto CSC and was not in keeping with current thinking that every agency has a role to play in keeping children safe.  Whilst the health professionals acknowledged this, they stressed that had there been safeguarding concerns noted, i.e. new or emerging issues, they were confident their practice would have been different. In itself, this raises issues about professionals being able to identify vulnerabilities and risk in families whose needs may sit just beneath the threshold for statutory intervention.   9.39 When questions were asked of practitioners and managers involved in the SCR process, whether they had been ‘curious’ about MT’s past, they suggested that competing                                                              18 SCIE Report 19: Learning together to safeguard children: developing a multi-agency systems approach for case reviews     22 demands for time and heavy workloads did not often allow them time to be ‘curious’, other than for families where there were significant and obvious concerns or where safeguarding was already an identified issue. They also described staffing issues during the period under review and the challenge of responding to a growing number of families with child protection concerns. These factors, they said continue to significantly impact on their workloads and influence to what extent they are able to ‘probe’ and  ‘dig deeper’ into the situations of some families.  9.40 However, even without knowing the detail of what happened in MT’s past, health professionals did not consider how the premature birth of twins would impact on a family with a two year old child, a working father, and a mother about whom they noted may have had difficulties bonding with her babies.  This suggested to the Review Team that there was a lack of awareness of the risk factors associated with babies under the age of one and specifically, little awareness of the research relating to the triggers in families, which can increase the risk of inflicted injury/abusive head trauma in young babies.    9.41 Research undertaken by Ofsted in 201119 summarised some key findings from 482 SCR’s evaluated between April 2007 and March 2011. 35% of children considered by these reviews were under the age of one year and the study found that information sharing between professionals was often inadequate, that parents’ own needs and the fragility and vulnerability of very young infants were underestimated by professionals and that pre-birth assessments were not undertaken or where they did occur, they were insufficiently detailed or analytical to identify risk and plan support for parents.  9.42 Research20 also suggests that prematurity, low birth weight and complex health problems can increase the physical vulnerability of babies and parents may experience more difficulty with bonding especially where there is a prolonged hospital admission.  Parents like MT, who could be regarded as vulnerable because of their own life experiences, may also have a limited understanding of typical childhood care needs and development, and unrealistic expectations of the child’s own emotional needs and responses, understanding and behaviour.  They may particularly struggle with and resent a child who cries frequently or is difficult to feed.  MT and FH described to the Lead Reviewer the difficulties they had experienced in balancing the needs of all three of their children especially as the twins had different feeding times.  They pointed out that even in hospital Child H had needed special attention.   9.43 There is a growing body knowledge which highlights how parental stress, anxiety and relationship problems can impact on a parent’s ability to respond calmly to their babies’ crying, leading to some parents  ‘shaking’ their babies and causing abusive head injuries. In the UK, nearly 200 babies suffer from these injuries each year.  Infants who are under six months old are at greatest risk of non-accidental head injury.  A Scottish study21 of non-                                                             19 Age of Concern. Ofsted 2011 20 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2566169 21 Barlow, K M. and Mins, R.A (2000) Annual Incidence of shaken impact syndrome in young children Lancet Abusive head trauma: recognition and the essential investigation Alison M Kemp Arch Dis Child Educ Pract Ed 2011 96: 202-208 originally published online September 26, 2011      23 accidental head injury cases found that the median age of victims was 2.2 months, coinciding with the time when many babies cry the most. Boys, babies born pre-term, and those with low birth weight are thought to be at increased risk, factors which all relate to Baby H.  9.44 There was little evidence that health professionals considered the impact of these risk indicators and there was enough information about the parent’s circumstances to warrant a cautious approach to the twins being discharged home without clearly defined support plans in place.   9.45 Staff across all disciplines, in both acute and community settings, would benefit from a raising of general awareness about these risk factors and especially the triggers for abusive head injuries and the importance of taking the time to be proactive and discussing with parents how to respond safely to crying babies.  Many parents may not expect or know how to deal with persistently crying infants and need advice about the risks of acting impulsively and knowing how to recognise if they are reaching snapping point, they also   need to be advised about alternative coping strategies and to whom they can turn to for support.  This sort of information offered to MT and FH as part of a proactive and preventative intervention may have been particularly valuable, especially given the family circumstances and stresses the family were likely to face at home.  Finding: Improved understanding by staff on the Neonatal ward about the triggers which can lead to abusive head trauma in young babies would be of immense benefit and help with the support and guidance offered to all parents and particularly to those whose babies may be considered as particularly vulnerable.   Recommendation 6  a) Oldham LSCB should seek assurance from all agencies and especially PAT and PCFT that work is underway to ensure that professionals are aware of the key risk indicators drawn from research and practice that highlight and respond to stressors and risk factors in vulnerable families and potential risk of harm to babies.  b) Oldham LSCB should ensure that all professionals who come into contact with babies, parents and prospective parents and carers are mindful of the need to reinforce the messages around the importance of keeping babies heads safe and receive training in recognition and risk indicators of abusive head trauma.  c) Oldham LSCB should consider how the materials associated with the NSPCC study, or other similar resources can be used to educate and inform new or soon- to- be parents in Oldham. d) There are a growing number of SCRs published nationally which relate to the death or injury of young babies from abusive head traumas. Oldham LSCB should consider the benefits of co-operating with other LSCBs across the North West to explore how learning can be shared so policy and practice in this area can be further developed.   Supervision and Managerial Oversight                                                                                                                                                                                               24 9.46 Whatever the state of their work environment, frontline practitioners must constantly assess situations and make judgements while working on their own or in teams and access to supervision and guidance is crucial. The safeguarding teams at PAT and PCFT provide leadership, knowledge, and expertise in the safeguarding of children and young people, to health professionals working in acute and community services.  None of the health professionals saw the need to contact their safeguarding leads for advice or support as they told the Review Team there were no significant concerns, which merited that contact.  9.47 In line with expected practice, MW1 complied with her agency’s safeguarding procedures by sending the SCF form electronically to the Safeguarding Team at PAT.  SCFs are coded using a traffic light system indicating whether the details are simply for information only (coded green), may require action (coded amber) or require immediate attention (coded red). The SCF circulated for MT was coded green, marked for ‘information only’ and indicated that CSC had been contacted and there were ‘no ongoing issues of concern’.  The box asking if there were any ‘previous child protection concerns’ was not ticked, neither were there any details relating to FH, although these were included on the booking form. It is clear that MW1 was satisfied that there were no ongoing concerns and used the system appropriately to share this information with health colleagues.  9.48 The view was expressed by practitioners and this was shared by some members of the Review Team, that had the SCF been coded amber, it would have come to the attention of the Safeguarding Team and may have triggered an alert for a pre-birth assessment or led to a member of the team contacting MW1 to clarify the information shared.  This led to a suggestion that where SCFs are generated and include information specifically related to past or present safeguarding concerns about child/children; these should always be coded amber or red.  This suggestion is worthy of further consideration.  9.49 At the time, all SCF forms were sent directly to the inbox of the Named Nurse for Safeguarding Children Team but only the red and amber forms were read on a daily basis. Some members of the Review Team queried the purpose and value of all SCFs being forwarded to the Safeguarding Team if they were not all monitored.  The Review Team was told that the number of SCFs generated by midwives had risen considerably since the electronic system was introduced in 2013.  The green rated SCFs, whilst containing information relevant to midwives, were not required to be quality monitored by the PAT Safeguarding Team in the same manner as the amber and red SCFs. As part of a scheduled review of SCFs it has recently been agreed that where information meets the ‘green’ SCF criteria, this will no longer result in the generation of an SCF and the information will be documented in the midwifery records in the normal manner.  Finding: The Review Team found that the use of SCF as a communication and information-sharing tool was well embedded into practice.  The recently introduced changes are to be welcomed and will clearly sharpen existing processes for midwives sharing information with health professionals.   10 The SCR Process      25 10.1 During the process of this review, several meetings were cancelled and had to be rearranged suggesting that attendance by key agencies was not given high enough priority. If this has occurred in other reviews then it needs to be addressed by the Board. The changing membership of both the Review Team and the Practitioner meetings compromised some of the learning for agencies and this is reflected in the learning reports and action plans submitted by some agencies.  10.2 It is disappointing to note that no learning was identified in the Agency Learning Report provided by the Pennine Acute Hospital NHS Trust (PAT).  Offers for the report to be updated, as there had been a change in representation in the Review Team, were declined.  From several discussions held with that agency to discuss specific aspects of this report, it is clear however that lessons have been identified and Oldham LSCB should ensure it is provided with an action plan so progress can be monitored through the Board’s auditing processes.  Finding:  The significant delay in the completion of this SCR does not reflect well on the commitment of agencies to participate and contribute to SCRs nor does it reflect well on the Board’s ability to support a robust and effective learning framework.   Recommendation 7 Oldham LSCB should ensure that commitment to SCR’s by partner agencies at strategic and operational levels is given the highest priority in any future reviews so minimising the need for rescheduling and planning additional meetings.   Additional Areas of Learning for Oldham LSCB  Finding: Agency actions plans from SCRs seem to vary in Oldham.  This makes it difficult for agencies and the LSCB to evidence where actions have led to better outcomes for children.   Recommendation 8 The single agency action plan template used in SCRs should be reviewed so the Board can more easily audit and monitor progress of single agencies in implementing agreed actions arising from SCRs. 11 Concluding comments 11.1 Consideration has been given as to whether the injuries sustained by Baby H were predictable.  Predicting the likelihood of such an outcome for a vulnerable baby is difficult to achieve with any meaningful degree of accuracy.  Whilst it cannot be inferred that what happened to Baby H was preventable, there are lessons to be learnt for all the agencies involved with this family about the sharing of information and the value of professionals communicating effectively.  Arguably, and the Review Team were not unanimous in this view, if a pre-birth assessment been undertaken a great deal of information would have been shared, perhaps exposing the vulnerability of the parents and ensuring that supportive plans were in place.         26 11.2 The absence of a discharge meeting when the twins were ready to go home was also a significant missed opportunity for professionals to discuss and explore the family circumstances which may have alerted them to potential risks included those related to inflicted head injury.  Professionals working with families need to be mindful and alert to existing and emerging research about the triggers which can increase the risk of abusive head injuries to young babies and look to sharing this information with parents and ensuring that well-co-ordinated support plans are in place.  11.3 This review is also a stark reminder to professionals of the importance of not only sharing information, but also of analysing what is being shared and questioning on what basis decisions and actions are undertaken.  This requires the continued acceptance that safeguarding children is a responsibility shared by all agencies.        27 Appendix 1 Single Agency Learning (Information below is copied directly from the Agency Learning Reports, which were said to be endorsed by the Chief Officers in each agency) Oldham Children’s Social Care 1. To fail to record important discussions and agreements reached between professionals will mean that any actions agreed to ensure that the case is properly progressed cannot be reviewed or monitored. FURTHER TRAINING FOR MASH AND CAT TEAM FOR INFORMATION RECORDING AND LINE OF ACCOUNTABILITY. 2. A need to ensure greater adherence to guidance in completing assessments. To ensure all staff are aware of the procedures around the arrangements for pre-birth assessments, to ensure that each pregnancy is considered afresh. THIS INFORMATION HAS ALREADY BEEN FED DOWN TO ALL SOCIAL WORKERS, SENIOR PRACTITONERS AND MANAGERS. 3. The need for pro-active questioning and challenge and review of information and reassessment to reflect new information. THIS WILL BE QUALITY ASSURED THROUGH THE SUPERVISION PROCESS. 4. Establishing clear protocols for information exchange thus improving service delivery. (AS 1.) 5. Embedding a Step-down process In CIN work. Once CSC tasks are completed, everyone in the Multi-agency network needs to know what will happen after CSC withdraw, Including a contingency plan to be clear about what would happen to constitute a re-referral to CSC, this information needs to be contained in the closing summary episode. TRAINING IN SMART PLANNING IS DUE TO BE COMMISSIONED FOR ALL SOCIAL CARE STAFF. Pennine Acute Hospital NHS Trust (PAT)  No learning was identified in the Agency Learning Report. However, the following areas emerged from the SCR process and the following was agreed with the Review Team. 1. Health professionals in Acute Services would benefit from opportunities to explore the relevance of Oldham’s Pre-Birth Assessment procedures to their roles and day to day practice. 2. Need to familiarise themselves with the circumstances under which pre-discharge planning meetings should take place.  3. Need to raise the awareness  of health professionals in acute services about the triggers for abusive head trauma in young babies  and how to  best  support and advise parents  about responding to crying babies.      28  Pennine NHS Foundation Trust   1. Communication to improve between HV and NNICU 2. Staff not aware of GM pre-birth policy and procedures 3. Lack of risk analysis of information available to make challenge to CSC that a pre-birth was required due to changes in circumstances       29 Appendix 2  Summary of Recommendations Recommendation 1:   a) Oldham LSCB should seek assurance from partner agencies that frontline practitioners are aware of the detail of Oldham’s Pre-Birth procedures and that where a previous child of either partner has been made subject to child protection procedures, a referral should always be made to CSC so that consideration of a pre-birth assessment can be made.  b) Oldham LSCB should explore how practitioners can be kept abreast of LSCB procedures; how and why they are developed and what relevance they have to key professional roles.              Page 13 Recommendation 2:  Oldham LSCB should seek assurance from partner agencies that where there have been child protection concerns in a family and a decision is taken by CSC to close the case, agencies have in place appropriate recording systems to share and record what action should be taken if the mother presents as pregnant at a future date. This information should be clearly ‘flagged’ in all agency records, and mother’s maternity records amended accordingly.     Page 14 Recommendation 3 a) Oldham LSCB should ensure it is provided with regular reports about the development and implementation of MASH operating systems, including how risks are managed, so the Board can effectively monitor and where necessary challenge, governance arrangements. b)  Oldham LSCB should ensure that when any partner agency undergoes significant organisational change, the Board is provided with reports, which demonstrate how risks posed to existing safeguarding practices and processes have been assessed and are being managed by those agencies.        Page 15  Recommendation 4:   Oldham LSCB should explore whether existing management systems adequately ensure and encourage recourse to effective multi-agency processes and/or joint working with families with young babies who may require early help.      Page 18 Recommendation 5  Oldham LSCB must be confident that the criteria and procedures for instigating pre-discharge meetings are robust and well understood by all professionals and specifically health professionals working in acute services.        Page 21 Recommendation 6  a) Oldham LSCB should seek assurance from PAT that work is underway to ensure that health professionals are aware of key risk indicators drawn from research and practice that help them highlight and respond to stressors and risk factors in families and the potential risk of harm to babies b) Oldham LSCB should ensure that all   professionals who come into contact with babies, parents and prospective parents and carers are mindful of the need to reinforce the messages     30 around the importance of keeping babies heads safe and receive training in recognition and risk indicators of abusive head trauma.  c) Oldham LSCB should consider how the materials associated with the NSPCC study, or other similar resources can be used to educate and inform new or soon- to- be parents in Oldham.  d) There are a growing number of SCRs published nationally   which relate to the death or injury of young babies from abusive head traumas. Oldham LSCB should consider the benefits of cooperating with other LSCBs across the North West to explore how policy and practice in this area can be further developed        Page 23   Recommendation 7 Oldham LSCB should ensure that commitment to SCRs by partner agencies at strategic and operational levels is given the highest priority in any future reviews so minimising the need for rescheduling and planning additional meetings.       Page 24  Recommendation 8 The single agency action plan template used in SCRs should be reviewed so the Board can more easily audit and monitor progress of single agencies in implementing agreed actions arising from SCRs.           Page 24         