Executive summary of a review into the death of a 1-year-9-month-old child in February 2012 as the result of severe brain damage. Police were unable to establish how the subject child sustained the fatal head injuries however medical evidence indicated that they were inflicted non-accidentally. Issues identified include: maternal history of depression; and concerns raised by father and paternal grandparents relating to an unexplained burn to subject child's hand and a bruise. Identifies analysis and learning, including: a focus on parental behaviour sometimes diverting professional attention away from the child; GPs treating episodes of maternal depression in isolation with insufficient attention to broader issues of family life, parenting capacity and child wellbeing; and need for professionals to remain alert to safeguarding issues and to think critically and reflectively whilst performing routine professional activities. Makes various recommendations.
      
 Title:  Serious case review relating to a child who died at the age of one year and nine months. LSCB: Kirklees Safeguarding Children Board Author: Carole Smith Date of publication: [2015]  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       KIRKLEES SAFEGUARDING CHILDREN BOARD     SERIOUS CASE REVIEW RELATING TO A CHILD WHO DIED AT THE AGE OF ONE YEAR AND NINE MONTHS   Executive Summary by Dr Carole Smith – Independent Author   Approved by KSCB November 2013  This report has been redacted to comply with a Reporting Restriction Order   January 20142  SECTION ONE: INTRODUCTION  1.0  When the Chair of Kirklees Safeguarding Children Board (KSCB) made the decision to initiate this Serious Case Review (SCR) the relevant statutory guidance was contained in the 2010 version of Working Together to Safeguard Children: a Guide to Inter-agency Working to Safeguard and Promote the Welfare of Children (HM Government 2010). The Serious Case Review was thus guided by Working Together 2010, rather than by the Government’s more recent version of Working Together (HM Government 2013) which was effective from 15/4/13. However, as will evident from the overview report the Review based its work on the principles for learning and improvement which are identified in the 2013 Guidance.  1.1  The requirement for Kirklees Safeguarding Children Board to conduct a SCR was, at the time, detailed in Chapter 8 of Working Together (HM Government 2010) and in the Local Safeguarding Children Board Regulations 2006. The purpose of a SCR as identified in Working Together is to:   Establish what lessons are to be learned from the case about the way in which local professionals and organisations work individually and together to safeguard and promote the welfare of children.  Identify clearly what those lessons are, how they will be acted on and what is expected to change as a result.  Improve intra and inter-agency working and better safeguard and promote the welfare of children.  1.2  In her review of child protection arrangements Professor Eileen Munro recommends that Serious Case Reviews should adopt a systems theory approach to understanding why professionals and agencies respond to child protection concerns in particular ways. A systems perspective directs attention to the context of professional practice such that factors which impede effective professional judgement and decision making can be identified and changed. In summary, it has been realised that human error can be more effectively reduced by looking at the wider organisational factors that influence the individual and identifying which factors make it easier or harder for workers to perform well. This SCR has attempted to understand the context in which professionals practised and to reflect this in its identification of learning and recommendations for action.   2.0  REASONS FOR THE SERIOUS CASE REVIEW  2.1  At the age of one year and nine months the subject child was taken by ambulance to their local hospital in a state of collapse and subsequently transferred to a specialist paediatric intensive care unit. Tests revealed that the child had suffered severe and un-survivable brain damage and the child died on 28/2/12.  2.2  Although the cause of death was later identified as ‘head injury’, there remained uncertainty about how this had occurred. By September 2012, expert medical evidence was beginning to indicate that the child’s head injury had been caused non-accidentally. Medical experts subsequently agreed that non-accidental blunt 3  force trauma to the child’s head had resulted in brain damage which led to the child’s death. Evidence available to West Yorkshire Police showed that the child had suffered the head injury at some time during the night or early morning of 26th and 27th February 2012 when at various times the child’s mother, her partner at the time (not the child’s father) and the child’s maternal grandmother were at the family home.  3.0  TERMS OF REFERENCE AND THE SERIOUS CASE REVIEW PROCESS   3.1  The SCR Overview Panel  3.1.1  KSCB SCR Workstream established a SCR Overview Panel to conduct the SCR. The Overview Panel comprised independent senior professionals from relevant agencies none of whom had any direct involvement in providing services to the child and their family. The SCR Workstream also identified an independent Chairperson, and an independent author to write the overview report as required in Working Together (2010: 8.16 and 8.33). The independent chairperson was Bron Saunders who is also the independent chairperson of KSCB and the independent author was Dr Carole Smith neither of whom had any prior involvement with the agencies providing services to this family.   3.2  Individual Management Reviews (IMRs)  3.2.1  IMRs refer to enquiries about intervention and service delivery, including inter-agency working, in agencies/services that have had a significant degree of involvement with children who are the subjects of a SCR and their families. Such enquiries should focus on what happened and why from a professional and agency perspective and are incorporated into an IMR report. They should aim ‘to look openly and critically at organisational and individual practice’ (HM Government 2010: 8.35) to identify learning, determine what improvements can be made and specify how such changes should be effectively implemented to protect children from harm. In this case the authors of IMR reports were expected to follow guidance in Working Together (HM Government 2010) and the Individual Management Review Handbook provided by KSCB.   3.2.2  In order to provide the SCR Overview Panel with comprehensive information about this case, IMRs including detailed chronologies, were requested and received from the following agencies/services:   Mid-Yorkshire Hospitals NHS Trust   Locala Community Partnerships   NHS England West Yorkshire Area Team and North Kirklees Clinical Commissioning Group   Family Support and Child Protection Service, Kirklees Council   West Yorkshire Police   West Yorkshire Probation Trust   Lifeline Kirklees  3.2.3  Additionally, summary reports were requested from the following agencies / services: 4    Kirklees Neighbourhood Housing / HOSS   NHS Direct  Local Care Direct  Specialist paediatric intensive care unit  Action for Children  Adult Social Care   Yorkshire Ambulance Service  South West Yorkshire Partnership Foundation Trust  3.3  Important issues in identifying learning from this SCR  3.3.1  Some issues which appeared to be significant from early information available to the SCR Workstream assumed less importance as the Overview Panel conducted its enquiries and other information, while helpful for the learning of individual agencies/services, was not considered appropriate for publication. The SCR Overview Panel thus identified the following issues as requiring particular scrutiny in IMRs and during the Review and as being appropriate for inclusion in the overview report:   The child’s needs: were professionals sensitive to the child’s needs and aware of factors that might have a detrimental impact on the child’s wellbeing? Were professionals knowledgeable about indicators of abuse and/or neglect and about what to do if they had concerns about a child’s wellbeing?  Mental health issues: to consider mental health concerns where relevant. How far were professionals aware of these issues and how did professionals evaluate their significance in terms of the mother’s parenting capacity and the child’s wellbeing?  Significant adults: to consider dates of changes in partners and whether these relate to incidents of mother’s depression/low mood. Were professionals sufficiently alert to the possible impact of changes in the mother’s partners on her mood and parenting capacity and did they explore the parenting capacity of the mother’s partners and their role in family life?  Parenting issues: to consider the impact of her own upbringing on the mother’s parenting capacity and her request for help with parenting. Were professionals sufficiently aware of the relationship between the mother’s experience of family life as she was growing up and her parenting capacity?  Information sharing and inter-agency communication: to consider whether key information was shared appropriately between agencies and professionals, whether the significance of information was clarified and understood and whether agencies and professionals responded effectively to information.   The organisational context: were there any factors in agencies/organisations which acted to impede good practice relating, for example, to resource issues, professional supervision and development, effective management oversight, communication and recording systems?   5  3.4  Time period to be covered by the SCR  3.4.1  The KSCB Workstream concluded that the most appropriate period to be considered by the SCR was from July 2009 when the mother’s pregnancy with the subject child began until late February 2012 which was when the subject child died.   4.0  SUMMARY OF AGENCY INVOLVEMENT WITH THE SUBJECT CHILD AND FAMILY  4.1  The subject child was born in May 2010. Information relating to 2010 indicates that the community midwifery and health visiting services had no concern about the mother and her baby’s wellbeing. The baby was developing well. Although the mother had sought anti-depressant medication from her GP in April, when midwifery and health visiting professionals asked her directly the mother did not report any symptoms of low mood or depression. Mother and baby regularly visited the ‘drop-in’ well baby clinic until September 2010 and spent a considerable amount of time at the local Family Centre. Records indicate that the mother took her baby for appropriate consultations with the GP and also contacted Local Care Direct and NHS Direct for advice when necessary. The only cause for (minor) concern was that the baby’s immunisation schedule was suspended following two missed appointments, although attendance had not been problematic for earlier immunisations. This was remedied by March 2011 when the delayed immunisation was administered.  4.2  Sometime after June 2010 the mother separated from her partner (the subject child’s father) and around October 2010 she began a relationship with another partner who moved in to live with the mother and subject child. The subject child’s father and paternal grandparents maintained frequent contact with the subject child.   4.3  In March 2011 the subject child suffered burn blisters to their hand for which there was no explanation, although the mother took the child to the Emergency Department of her local hospital and attended two appointments for treatment at the follow-up review clinic. The mother and child subsequently visited a medical Walk-in Centre for treatment to the child’s burn. The subject child’s father and paternal grandmother expressed concern to health visitors about the burn, and a bruise which had been observed near the child’s ear some weeks earlier. A health visitor sought advice/consultation from Children’s Social Care (Duty and Assessment) about the paternal grandmother’s concern. Given that the child was receiving treatment and there were no other concerns about the child’s wellbeing, CSC took no further action.  4.4  In June the subject child’s immunisation schedule was suspended for a second time following non-attendance at appointments, although by December outstanding immunisations had been completed. The mother’s GP prescribed a one-month supply of anti-depressant medication for her in June but she did not attend the GP Practice for a further prescription at this time. In July 2011 the 6  mother told a health visitor about the very difficult family circumstances in which she had grown up.  4.5  During 2011 health professionals detected no indication that the mother was depressed, although she admitted to occasionally feeling tearful and low. Apart from the subject child’s burn, health professionals’ records suggest that the child was well cared for and there were no concerns about health, development or wellbeing.  4.6  In January 2012 the mother was again prescribed anti-depressant medication by her GP. Shortly after this a health visitor made an urgent home visit in response to information that the mother was very distressed. The mother told the health visitor that she had been feeling low for months and felt unable to cope. With the mother’s consent, the health visitor consulted Children’s Social Care but given that the health visitor was satisfied there were no immediate safeguarding concerns and had referred the mother to community mental health services, Children’s Social Care took no further action. Information from two subsequent visits by the health visitor and the mother’s further consultation with her GP suggested that her mental health was much improved and she continued to take anti-depressant medication. The health visitor’s observation of the child did not indicate any cause for concern about their wellbeing.  4.7  The subject child was admitted to hospital on 27/2/12 and died early the next day.  5.0  LEARNING FROM THE SCR  5.1  Before the Chairperson of KSCB made a formal decision to conduct a SCR, the Designated Nurse NHS Greater Huddersfield and NHS North Kirklees Clinical Commissioning Groups, completed a review of NHS agencies/services which had been involved with this family. Much of the learning from this SCR was anticipated by this review completed in May 2012, which has already resulted in action to improve practice. Learning from the health review and subsequently from this SCR is summarised below:   When health or social care professionals become aware that a very young pre-verbal child has suffered an unexplained injury, they should ask questions about the child’s developmental capacity (for example, mobility and dexterity) in relation to the likelihood of its non-accidental occurrence. This should be undertaken with reference to local and national safeguarding procedures and guidance.  Professionals should look out for any loss of focus on the child’s wellbeing, which may be prompted by parental distress or other parent/carer characteristics. They should remain alert to the possibility that their concern about a child’s wellbeing may be diminished by their positive perception of the ways in which parents/carers present themselves to professionals.   Although health and social care professionals should be familiar with evidence-based knowledge about the potential association between parental family history, mental health and parenting capacity they also need to 7  recognise when such knowledge is relevant and can enhance their understanding in individual cases.  Professionals should remember that parenting capacity and the quality of family life are not only related to maternal wellbeing but also to the involvement and wellbeing of fathers/partners and sometimes of extended families and friends. When, as in this case, partners/fathers are relatively invisible, professionals need to adopt an inquisitive attitude about their role in family life. Similarly, professionals should explore parents’/carers’ assertions that they have good support from their extended family and friends.   Professionals need the time and opportunity to reflect on case histories so that they can better understand patterns and developments over time in relation to the assessment of parents’ and children’s wellbeing and future planning. They also need to think about how information from other agencies/services might contribute to a full understanding of case history.  The Burns, Bruises and Scalds Protocol used by MYHT needs revision so that it is clear and leads to effective practice and it should be re-launched to ensure that newly appointed staff are aware of this guidance.   GPs should be encouraged to consider repeated parental episodes of depression in relation to broader issues of family life, parenting capacity and children’s wellbeing. In this context they should ensure (within the constraints of patient consent) that other health care professionals, particularly health visitors, have access to relevant information. GPs should recognise the importance of proactively cross-referencing information with that held by community health professionals in relation to their role in a network of universal health care providers.  6.0  GOOD PRACTICE  6.1  Practice in relation to expected professional standards is identified throughout the overview report. However, the following are notable instances of good practice:   When the mother attended the Walk- in Centre following the subject child’s burn, the community nurse sought advice from the hospital Burns Unit about the most appropriate treatment and informed the health visiting service and GP about the child’s attendance and the lack of an explanation for the child’s injury.  On receipt of information about the mother’s distressed condition in January 2012, the health visitor immediately made a home visit to assess the mother’s mental health and any safeguarding issues for the child.  7.0  RECOMMENDATIONS ARISING FROM THIS SCR  7.1  Much of the learning from this SCR has already led to changes which are designed to improve practice and which are given detailed consideration in the overview report. Not all of the recommendations arising from this SCR have been included in the overview report because either the identified learning has already led to remedial action or because to do so would require the disclosure of information which is inappropriate for publication. The remaining recommendations are listed below:  8  Recommendations for the Mid-Yorkshire Hospitals NHS Trust:   In order to provide clearer direction to professionals when dealing with a bruise, burn or scald in a non-ambulant child, the Safeguarding Team should re-launch the Bruising, Burns and Scalds Protocol to ensure all staff employed since the initial launch in August 2011 are aware of the Protocol. In addition, staff should be reminded of the NICE guidance ‘When to Suspect Child Maltreatment’ which indicates that an unexplained burn should prompt suspicion of child maltreatment.   Recommendations for NHS Greater Huddersfield and NHS North Kirklees Clinical Commissioning Groups:   SystmOne team should arrange for an alert/flagging/safeguarding node system to be available for use on GPs’ patient records so all children with concerns can easily be identified with regard, for example, to a failure to attend appointments, failure to attend for immunisations and other appointments such as psychology services when referrals are issued, attendance at hospital Accident and Emergency, parental mental health issues, parental substance abuse and domestic violence.   With the assistance of the alert/flagging system currently under development, GPs should adopt a proactive approach to identifying children and parents/carers where potential child safeguarding concerns may be indicated. This should inform consultation at meetings with the link health visitor so that healthcare information can be shared effectively and should also support piloting and scoping the introduction of a model - the Child Safe Global Trigger Tool – for safeguarding children in primary care.    Briefing sessions should be delivered to General Practice clinicians that focus on the increased vulnerability of children and young people when they are living in households where there is parental mental ill-health, parental substance misuse or domestic abuse.  Recommendation for NHS England West Yorkshire Area Team:   NHS England West Yorkshire should do everything it can to ensure that all Kirklees GP Practices routinely request that their patients consent to their health visitors having access to GP health records relating to children and their parents/carers.  Recommendation for NHS England:   NHS England should consider how best to enhance GPs’ ability to think critically and reflectively about a patient’s history in relation to the way in which this may affect parenting capacity and the identification of safeguarding concerns regarding children.  Recommendation for Locala Community Partnerships:  9   A timescale for review of Accident and Emergency notifications by health professionals should be introduced into health visiting and school nursing operational guidelines.   8.0  CONCLUSION  8.1  Although the SCR Overview Panel and the independent author concluded that professionals could not have foreseen or prevented the subject child’s death, this does not mean that this SCR has not identified learning which should lead to improvements in practice.  8.2  At the heart of this learning, as has been identified in so many other SCRs, lies a professional ability to remain alert to safeguarding issues and to sustain a reflective capacity in the midst of routine professional activities. For those professionals who deliver universal services this is a significant challenge when they will come across safeguarding issues in a minority of their cases while occupying professional roles that bring them face-to-face with early signs of parenting problems and child abuse.     