Summary of a review into serious non-accidental injuries to a baby boy, identified by GP in March 2010. Child E was subject to a pre-birth child protection plan and subsequently became the subject of a care order; he was living in foster care during the period over which his injuries were sustained. Foster mother was arrested and charged with wilful neglect. Issues identified include: pattern of non-reporting by foster parents, concerning minor injuries to children in their care; impact of foster father's ill health on family's capacity to care for Child E; and insufficient integration between child health and social care services and adult health and fostering services. Identifies learning, including: need for the active participation of health care professionals in assessment, review and care planning for looked after children; the association between shortage of affordable fostering resources and increased risks to children. Makes recommendations for Reading Local Safeguarding Children Board.
      
 Title:  Serious case review: a baby known as “Child E”: executive summary. LSCB: Reading Local Safeguarding Children Board Author: [Reading Local Safeguarding Children Board] Date of publication: [2012]  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.                            R E A D I N G  L O C A L  S A F E G U A R D I N G  C H I L D R E N  B O A R D   SERIOUS CASE REVIEW A BABY KNOWN AS “CHILD E”     Executive Summary  February 2011    EXECUTIVE SUMMARY  1. PURPOSE & SCOPE OF THE CASE REVIEW This is a summary of a Serious Case Review (SCR) undertaken by the Local Safeguarding Children Board (LSCB) following serious non-accidental injuries in March, 2010 to a baby who was being looked after by the local authority. The baby, Child E, was the subject of a Care Order and had been living in a foster home for some months whilst arrangements for his adoption were being progressed.  The Serious Case Review follows Government guidance outlined in Working Together to Safeguard Children (2010). An Executive Summary provides an explanation of the case review process, an overview of the circumstances in which Child E lived, key lessons learned from the case review and recommendations for action by the LSCB. Findings from the review have been reported to the Office for Standards in Education (OFSTED) as is required.   2. REVIEW PROCESS Government guidance is clear that LSCBs must follow a strict timetable once it is determined that specific criteria are met and that a Serious Case Review is warranted.  On the advice of the Police, the Chair of the Reading LSCB agreed to defer commencement of this SCR until it was clear that its conduct would not interfere with an active criminal investigation.  In September, 2010 the Police advised that their investigations would no longer be impeded by the conduct of an SCR. Relevant Chief Executives were informed immediately; GOSE and Ofsted were appropriately notified on 10th September, 2010.  EXECUTIVE SUMMARY CHILD E   The Serious Case Review Panel, whose members were drawn from the constituent agencies of the LSCB, oversaw the process of the review between September, 2010 and February, 2011.   Agency Serious Case Review Panel Member Reading Borough Council Head of Children’s Social Care NHS Berkshire West (PCT) Designated Nurse Child Protection Thames Valley Police Berkshire West CI and DCI  NHS Berkshire West Community Health (PCT) Deputy Manager Community Health Reading Borough Council Service Manager, Safeguarding Adults NHS Berkshire East (PCT) Designated Doctor (Advisor to Panel))  Royal Borough Windsor and Maidenhead Service Manager, Berkshire Adoption Advisory Service (BAAS) (Advisor to Panel) Royal Berkshire NHS Foundation Trust Deputy Director, Corporate Affairs   The Panel was chaired by Stephen Barber, the Independent Chair of Reading, West Berkshire and Wokingham LSCBs. An experienced independent author was commissioned to compile an overview report. Individual agency reports were received from the Local Authority, Community Health Services, the Royal Berkshire NHS Foundation Trust and the Primary Care Trust. They provided information for the case review, as did discussion with family members.  In the course of the review, the following questions were addressed:  • Was practice by all agencies in accordance with local and national expectations for safeguarding children as set out in Working Together 2006 and other relevant guidance? • Were Child E’s needs appropriately recognised and met, including issues arising from his ethnicity? • Was the quality of medical and health examinations of a good standard? • Were there any organisational difficulties relevant to the way in which the case was managed? EXECUTIVE SUMMARY CHILD E   • What can the LSCB learn in order to better support looked after children in foster care?   3. OUTLINE OF CIRCUMSTANCES LEADING TO SERIOUS CASE REVIEW • Child E was born in difficult circumstances.  The local authority took timely action to secure Child E’s safety and a Child Protection Plan was agreed during the antenatal period. Following his birth, an Interim Care Order was granted and Child E was placed in a foster home while plans for his adoption were developed.   • At the request of the Court, a residential assessment of Child E’s mother’s capacity to care for him was undertaken along with a assessment of his father. These assessments were not successful and Child E returned to foster care while efforts to identify well matched potential adopters continued.   • The foster carers with whom Child E was placed were very experienced but there were concerns about the male carer’s poor health and the consequent stress this placed on the foster home.  • A Care Order and Placement Order were granted in respect of Child E but the judgment was reserved and delayed for some months. This delay made it difficult to seek the formal agreement of the Adoption Panel although potential adopters had been introduced to Child E. The difficulties facing the foster family continued and some arrangements were made to support their care of Child E and another foster child.  • The Court was appropriately challenged to expedite the judgment.  • There was, during this period, insufficient connection between the many health and social professionals involved in planning for Child E and as a consequence information about Child E’s progress, and the male carer’s health was not fully appreciated.  • In March, 2010 the judgment was received and a few days later Child E was found to have multiple fractures. The female carer is currently the subject of criminal proceedings.  EXECUTIVE SUMMARY CHILD E   4. INTER-AGENCY PRACTICE ISSUES ARISING FROM THE REVIEW • The need for well co-ordinated inter-agency information sharing, assessment and planning was identified as crucial when a number of professionals, across a number of organisations, including those working with adults, are working with looked after children (LAC).  • The Looked After Review provides a multi-agency forum for the comprehensive review of children’s progress and care plans. In order to be effective, its perspective needs to be widened, and participation broadened.  • Judicial timetables are one of a number of determining factors in managing complex cases and can, when delayed, jeopardise children’s best interests.  • Health professionals are key partners in supporting looked after children in foster care.   5. RECOMMENDATIONS/ACTIONS ADOPTED BY THE LSCB  5.1 The Reading LSCB (Performance Scrutiny Sub-Group)  will receive reports from the partner agencies who have contributed to this Serious Case Review and ensure that Individual Management Review Action Plans are implemented and evidenced within specified timescales.  5.2 The Reading LSCB will commission work to explore the current connection between relevant health and social care professionals working with looked after children and make recommendations.   5.3 The LSCB will ask the Family Court Business Committee to request regular monitoring reports from Family Division Liaison Judges regarding any delayed judgments in care proceedings.   5.4 Given the anticipated continued pressure on fostering resources, Health and Children’s Social Care will review, using local, regional and/or national resources, the most effective means of helping staff to recognise, assess and respond to stress arising in foster homes as a consequence of ill health or other factors.   EXECUTIVE SUMMARY CHILD E   5.5 The Reading LSCB will employ suitable processes through which the lessons learned from this Serious Case Review may be effectively disseminated and positively inform practice.  The LSCB endorsed  the SCR Overview Report  on 3rd March, 2011 along with  a detailed Action Plan   to ensure that these recommendations are implemented in a timely fashion.   EXECUTIVE SUMMARY CHILD E  