Serious injury of a 6-week-old boy in October 2013. Baby I was made the subject of an emergency protection order following an examination that revealed he had sustained two broken ribs and a knee fracture. Mother and Father had been in a relationship for 3-months before Mother became pregnant with Baby I. Paternal history of: drug misuse; suicide attempt in adolescence; aggressive behaviour and referral to anger management services; and self-reported vivid images and thoughts of dropping Baby I or crushing his windpipe to stop him crying. Maternal history of: psychotic depression, previous suicide attempts and incidents of self harm. Father was recorded as mother's carer. Issues identified include: over estimation of mother and father's resilience and ability to cope individually and as a couple; focus of interventions and risk assessments on the parents; insufficient exploration and understanding of the impact of high energy drink consumption on father's mood and anger responses; and practitioners' belief that father belonged to a particular sub-culture possibly inhibiting them from challenging father's behaviour as they wished to appear non-judgemental. Makes various recommendations. Uses some elements of the Social Care Institute for Excellence (SCIE) Learning Together model.
      
 Title:  Baby I (Case I13): serious case review: overview report. LSCB: Bury Safeguarding Children Board Author: Clare Hyde 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    Bury Safeguarding Children Board  Serious Case Review  Baby I (Case I13)   SERIOUS CASE REVIEW  OVERVIEW REPORT  Report Author:   Clare Hyde Date:     28 January 2015 Signed:  Clare Hyde   Date: 28/01/15    Commissioned by: Bury Safeguarding Children Board 2  I can confirm that the Serious Case Review on Baby I (Case I13) was submitted to the Extraordinary Bury Safeguarding Children Board (BSCB) meeting on Wednesday 28 January 2015.  BSCB members agreed to accept the Serious Case Review Report and multi-agency action plan for submission.  I can confirm that BSCB endorse the recommendations made in the overview report and that the BSCB Business Group will monitor their implementation.                       Gill Rigg       Independent Chair of BSCB     Signed: Date: 28 January 2015 3  CONTENTS  CONTENTS ...................................................................................................................................... 3 1. INTRODUCTION AND CONTEXT .................................................................................. 4 2. METHODOLOGY ................................................................................................................. 5 3 THE STRUCTURE OF THE CONVERSATIONS .......................................................... 6 4 CHILD I’S FAMILY: AN OVERVIEW ............................................................................. 7 5 THE INTEGRATED CHRONOLOGY ............................................................................... 8 6 ANALYSIS AND RECOMMENDATIONS ....................................................................... 8 7 AREAS OF GOOD PRACTICE ....................................................................................... 62 8 SUMMARY OF KEY LESSONS AND ASSOCIATED RECOMMENDATIONS ..... 62 9 GLOSSARY ......................................................................................................................... 66 10 MULTI-AGENCY ACTION PLAN ................................................................................... 68     4  1. INTRODUCTION AND CONTEXT  1.1 Child I was made the subject of an emergency protection order on 28th October 2013 following an examination, which revealed that he had sustained two broken ribs and a fracture to his left knee. Child I was six weeks of age.  1.2 Child I was the first child of MCI (mother) and FCI (father) and lived with them in Bury.  1.3 MCI and FCI moved to Bury from Peterborough in June 2013.  1.4 MCI and FCI each had significant difficulties, which were indicators of risk to Child I and these are explored fully in this report.  1.5 The case was considered by the BSCB Screening Panel on the 26th November 2013.    1.6 The Independent Chair of BSCB agreed with the Screening Panel’s recommendation that the case met the criteria for holding a serious case review on 27th November 2013.  (The serious case review was then put on hold on 24th March 2014 due to the criminal proceedings and was restarted on 17th October 2014).  1.7 The BSCB Serious Case Review Sub Group recognised that the review would need to be as robust and transparent as the former SCR process and should be measured by the extent to which it would make a difference and improve Bury’s multi-agency safeguarding response.  1.8 Consequently, the BSCB Serious Case Review Sub Group made a recommendation that the BSCB should conduct a serious case review to address how agencies had worked together; identify any additional learning and aggregate lessons from individual organisations and ensure that an improvement action plan was put in place.  1.9 The Serious Case Review (SCR) was commissioned by the Bury Safeguarding Children Board (BSCB) in line with its statutory reviewing functions as defined in ‘Working Together to Safeguard Children: A guide to inter-agency working to safeguard and promote the welfare of children’ (2013).  1.10 It was agreed that the period of time covered by the SCR would be from the date that MCI’s pregnancy with Child I was known to Bury agencies which was 1st June 2013 up until 25th October 2013 which was the date 5  that Section 20 of the Children Act 1989 was used to accommodate Child I in foster care.   1.11 The government has indicated that it supports changes recommended by Professor Eileen Munro that serious case reviews should be conducted using systems based learning methodology and it was agreed that important learning could be gained by conducting a whole system review of Case I13 in order to conceptualise how services routinely operate and to identify what is working well or where there are problematic areas.  2. METHODOLOGY  2.1 The Serious Case Review was designed and led by Clare Hyde, independent reviewer, from The Foundation for Families (a not for profit Community Interest Company). Ms. Hyde developed a review model that would enable participants to consider the events and circumstances, which led up to the injuries to Child I being discovered.  2.2 The analysis in this report uses some elements of the framework developed by SCIE to present key learning within the context of local systems.  This also takes account of recent work that suggests that an approach of developing over prescriptive and SMART recommendations have limited impact and value in complex work such as safeguarding children. For example, a 2011 study of recommendations arising from serious case reviews 2009-2010, (Brandon, M., Bailey, S., Belderson, P., Gardner, R., Sidebotham, P., Dodsworth, J., et al. (2009). Understanding Serious Case Reviews and their Impact: A Biennial Analysis of Serious Case Reviews 2005-07. London: Department for Children, Schools and Families) calls for a limiting of ‘self-perpetuating and proliferation’ of recommendations. Current thinking about how the learning from serious case reviews can be most effectively achieved is encouraging a lighter touch on making recommendations for implementation through over complex action plans.    2.3 A serious case review panel was convened of senior and specialist agency representatives to oversee the conduct and outcomes of the review.  2.4 The panel agreed specific terms of reference that provided the key lines of enquiry for the SCR in addition to the terms of reference described in national guidance. The key lines of enquiry included:  • Was risk to Child I recognised? • How was risk assessed and responded to?  6  2.5 The panel established the identity of services in contact with the family during the time frame agreed for the review.   2.6 The SCR aimed to provide an innovative ‘whole system’ approach involving key front line practitioners (and their line managers) who worked with Child I and adults of Child I’s family in structured conversations with the Independent Lead Reviewer.  In this way, Child I’s ‘story’ was to be central to the review. In preparation for the structured conversations; practitioners were asked to complete a chronology identifying key practice episodes and describing:  • What could / should have been done differently? • What worked well and how was this evidenced?  2.7 The structured conversations took place with identified key frontline practitioners some of whom were accompanied by their managers. The conversations were led by the Independent Lead Reviewer and notes of the conversations were taken by individuals who had no involvement in the case.   2.8 Other practitioners  were identified who it was felt could provide additional insight and potential learning in this case but whose involvement with the family was peripheral and these practitioners were asked to complete a Reflective Individual Management Report.  3 THE STRUCTURE OF THE CONVERSATIONS  3.1 The following questions provided the structure for the conversations with the practitioners:  A. Please can you describe the parents’ presentation when you met with them? B. Do you think that this had a bearing on how professionals responded to them? C. How much were you influenced by other professional’s actions or judgements? D. What is your understanding of the CAF process and the lead professional role? E. Were you were aware that a CAF had been completed in Peterborough?  F. Would it have been usual practice to call a Team Around The Child (TAC) meeting? G. What was your understanding of the risk in this case? 7  H. What were you looking out for when assessing risk and who was the focus of your risk assessment? I. Do you think that the risk to the baby was not seen by some practitioners? J. What procedures were you following in your work in this case? K. What do you see as your responsibility in respect of assessing parental capacity for families where there are unborn babies, babies, children and young people? L. What is the significance of the mental health diagnosis and what impact does it have on the ability to parent? M. Is there anything you would like to add that you feel is important to the serious case review or for future practice?  3.2 Not all of the questions were relevant to all of the practitioners.  3.3 The responses provided by the practitioners together with the Reflective Individual Management Reports and the Individual Agency Chronologies provided the substance and context for this serious case review and are reflected in the analysis and recommendations given at section 6.   4 CHILD I’S FAMILY: AN OVERVIEW  4.1 Child I and his family raise a number of practice issues, both for individual agencies and for the BSCB; particularly in relation to families with complex and/or multiple needs and risk factors.  4.2 It is important to note that MCI and FCI had been in a relationship for only 3 months before she became pregnant with Child I.  4.3 Although the time frame of the review covers the period 1st June 2013 to 25th October 2013, agencies held relevant information about MCI and FCI which pre-dated this period. • FCI admitted to previously using cannabis, cocaine and ketamine. (During the time scale of the serious case review he reported using cannabis 4 or 5 times per week). • FCI reported that he had attempted suicide by hanging at the age of 15. • FCI had a difficult relationship with his step father which related to his step father’s abuse of FCI’s mother. • FCI had been referred for an ‘anger management’ intervention prior to moving to Bury. • MCI was being treated for psychotic depression prior to becoming pregnant with Child I 8  • MCI reported that she had previously attempted suicide on 3 occasions. These attempts were self-reported and occurred approximately 3 years before MCI’s pregnancy with Child I.  5 THE INTEGRATED CHRONOLOGY  5.1 The review attempted to identify how agencies and organisations responded to the needs of Child I and his family between 1st June 2013 and 25th October 2013.  5.2 Participating agencies carried out reviews of their records and materials including: • Electronic records  • Paper records and files  • Patient or family held records  5.3 The integrated chronology is referred to below. Key practice episodes were identified and provide an account of the most significant events and decisions from the different services involved during the timeframe of the Serious Case Review. The practitioners or managers completing the chronologies were encouraged to reflect on their agencies actions and decision making and consider ‘what could or should your agency have done differently?’ and ‘what worked well and how was this evidenced?’  6 ANALYSIS AND RECOMMENDATIONS  6.1 This section sets out an analysis of key findings and associated recommendations that are designed to offer challenge and reflection for the BSCB and partners.  6.2 The key lines of enquiry for the SCR were explored through the process of the structured conversations and considered together with the details submitted in individual agency chronologies and reflective individual management reports.  6.3 Individual risk factors are explored in more detail later in this section, however, it is important not to lose sight of the whole picture and to consider the opportunities available to practitioners to recognise accumulating concerns over a relatively short period of time and assess the potential risk to a very young baby. There were a number of factors present in this case which are well known to be associated with risk to children, yet these were not adequately assessed as a whole or acted on when known. 9  Was Risk to Child I recognised?  6.4 Child I was born into a relationship dynamic which had inherent risk factors and to two individual parents who had current and historical difficulties which were indicators of risk to Child I. In other words, MCI and FCI’s individual difficulties may well have been compounded by them coming together as a couple.   6.5 The two adults were, in the main, the focus of professional concern and this had serious implications for Child I.  6.6 Complexity of risk and need was not well recognised or understood and there was an over estimation of MCI and FCI’s resilience and ability to cope as individuals and as a couple.  6.7 Crucially, there was an over reliance on FCI’s ability to remove himself from any situation involving Child I in which his anger might overwhelm him.  6.8 Fortunately Child I did not die however his injuries were serious and numerous and had occurred in the first few weeks of his life. His most recent injuries at the time of his medical examination were estimated to be between 2 and 4 weeks old.  6.9 Learning from other serious case reviews where children have died or been seriously injured provides a useful reference for identifying and responding to risks. For example, analysis of 183 child homicides in 83 different local authority areas was carried out in 2009 by Freguson and Oborne  (Freguson L, Oborne P, The Children Britain Betrayed (2009) Channel 4 Media Publications).  This analysis revealed that: • Children under the age of one are the most vulnerable – one third of all cases (34%). The analysis also revealed that babies are significantly more likely to be killed in the first three months of their lives – 51% of the sample of under ones. • Domestic violence was a background factor in 41% of the cases   • In the majority of such cases, there had been a prior history of domestic violence (69% of cases). • There were 37 cases where the killer had a pre-diagnosed mental health problem. These 37 killers were responsible for 50 child deaths – 1 in 3 of the child homicides in the study sample. 10  • Depression was a pre-existing diagnosed mental health problem in 19 – 50% of cases where a mentally ill parent or carer killed a child. The majority (63%) of these killers were women. • 30% of the parents and carers who killed children had substance abuse problems – 20% drug abuse and 11% alcohol abuse.  • In 11 cases, the killer told someone in advance that they would kill the children. • In 32% of cases where the killer had planned the homicide, the killer was described in the press, quoting people who knew them well or by coroners at inquests, as ‘devoted’ parents.  6.10 Child I’s parents shared many of these characteristics and risk factors. However, it appears that the majority of practitioners failed to recognise or understand risk and consequently failed to carry out a comprehensive child focused risk assessment.  6.11 As risk in this case was not fully recognised or understood the family was not offered targeted ‘early’ help or assessed using the common assessment framework (CAF).  6.12 There were several vital missed opportunities to recognise and assess risk and therefore to intervene in this case. These are detailed below:  The family’s transfer from Peterborough to Bury   6.13 MCI was referred to the Advanced Midwifery Practitioner for Mental Health Issues in Peterborough, who carried out a home visit on 15th March 2013. MCI had, at that point stopped taking her anti-psychotic and anti- depression medicine because of her pregnancy.  6.14 The midwife noted that MCI needed support with housing issues and benefit problems and was receiving this support from a local service the CAMEO team. The midwife planned to liaise with the CAMEO* Team in respect of MCI’s mental health needs. The midwife recorded that a CAF should be completed to help with those concerns. FCI was present at this visit. *The CAMEO Team is a mental Health Team within Peterborough, which is there specifically to give one to one support for a two year period for all young people under the age of 25 with psychotic illness.  6.15 At this time, MCI and FCI were living with FCI’s stepfather and the relationship between the couple and the stepfather was problematic.  11  6.16 The midwife’s suggestion that Antenatal Care be provided by the Rainbow Team, a team of Advanced Midwifery Practitioners who provide additional support and monitoring to women who have been identified as having additional complex needs, was rejected by MCI who requested that she continued her antenatal care with her Community Midwife as she preferred to be seen out of the home (this was due to the relationship problems with FCI’s stepfather).  6.17 MCI’s pre-existing severe and enduring mental illness and previous self-harming indicated that a pre-birth assessment should have been carried out to assess the likely impact on her parenting and to identify any risk to the baby.  6.18 Furthermore, FCI discussed his anger issues at the very first antenatal visit and he stated this was due to the housing problems. FCI stated that he had been to see his GP about his anger problems. FCI also stated he smoked cannabis weekly. The midwife felt that FCI had a full understanding of MCI’s condition. When asked, FCI stated he had no previous convictions. FCI was also open and advised the midwife that he was claiming carer’s allowance for MCI. This information was not identified as potential risk to the unborn baby or to MCI herself. The relationship dynamic was not explored specifically to establish whether or not a man with anger issues, who smoked cannabis and was also the carer of a pregnant woman with severe mental health problems, was in fact a protective factor.  6.19 MCI attended one further ante natal appointment with the advanced midwife, which was also attended by a support worker from the CAMEO team. FCI was present at this appointment. It was noted that MCI was able to attend the housing department to apply for hostel accommodation and that she was thinking of moving to Manchester to be with family.  6.20 The Peterborough midwife liaised with the Bolton midwife to transfer MCI’s care when the family moved. A pre-Common Assessment Framework (CAF) was completed and this seemed to relate to the couple’s housing needs. A pre-CAF assessment rather than a full assessment was carried out because of the couple’s imminent move to Bury.  6.21 Whilst still living in Peterborough but shortly before the couple moved to Bury, FCI was referred to the Improving Access to Psychological Therapies (IAPT) service by his GP but was deemed not suitable for this service and was referred to the Intake and Treatment Team (Mental Health) but as he was shortly to leave the area FCI did not access this service.   12  6.22 There is no evidence that Peterborough mental health practitioners or the GP recognised risk to FCI’s unborn child and consequently no identification of risk was alerted to Bury when FCI’s records were transferred to Bury.  Recommendations   6.23 Peterborough Safeguarding Children Board should share the learning from this serious case review with the Midwifery Service and in particular ensure that midwives are able to identify, assess and respond to risks to unborn and newly born babies. These responses would include pre-birth assessments, multi agency risk assessment conference, and referral to children’s social care. The Family’s arrival in Bury  GP  6.24 FCI was referred to the IAPT service by his new GP on 3rd July 2013 for support with anger management issues.  6.25 The GP referral stated that: • FCI had irritability and anger issues; stemming from the separation of his parents as teenager. • FCI stated that he used to be violent to others but now punches inanimate objects. • He was drinking litres of high energy drinks daily - now reduced. • He uses marijuana - one ‘spliff’ daily. • His partner is six months pregnant. • He is worried that his anger may worsen when the baby arrives. • He was referred for anger management in previous location but did not attend due to house move.   6.26 The GP referral requested an intervention linked to FCI’s own concerns that he may not be able to contain his emotions enough to maintain safety of the baby.  6.27 The GP referral did not mention that FCI was a carer of a woman with a major mental health diagnosis.   13  6.28 The GP did not recognise the issues described by FCI as a risk to MCI or the unborn baby and did not make an appropriate referral to children’s services.  6.29 On 22nd October 2013, MCI and FCI telephoned the GP surgery as they were concerned about Child I being constipated and having dark urine.  6.30 MCI and FCI brought Child I to the GP surgery for a consultation with an Advanced Nurse Practitioner (ANP) the same day. The ANP took Child I’s history and carried out an examination.  6.31 The ANP prescribed Lactulose and referred Child I to Community Paediatric Nurses (this referral was rejected as the Community Paediatric Nurses will not see children under the age of 2 who are constipated – they will be seen instead by the Health Visiting service).  6.32 On 24th October 2013, MCI took Child I to the GP practice and saw a GP who recorded presumed haematuria & weight loss reported by mother.  Recommendations  6.33 Using learning from this and other serious case reviews the Bury Clinical Commissioning Group should assure itself and the LSCB that GPs understand the risk factors of domestic abuse, physical abuse, drug or alcohol use and mental health for unborn babies and children and make appropriate referrals to Children’s Social Care and assure itself that the outcome of those referrals is also appropriate.  The baseline could be based on CIN census 2013/14.  This might require a specific focus upon developing a simple method of quantifying and qualifying GP referrals to children’s social care and identifying the most appropriate people within the health community to carry out this work.    Mental Health  6.34 On the 10th June 2013 MCI was visited at home by a Community Psychiatric Nurse CPN1 from Pennine Care Foundation NHS Trust (PCFT). CPN1 carried out a mental health initial risk assessment. CPN1 had sight of the pre CAF document, which had been completed by the Peterborough midwife. Although this document mentioned FCI’s cannabis use and anger issues, this did not trigger CPN1 to initiate a full CAF himself or to consider the appropriateness of FCI being MCI’s carer or the impact of pregnancy on the mental health of MCI.  6.35 Also present at this home visit were FCI and a student nurse. It would not therefore, have been possible to ask MCI about her relationship with FCI 14  (who was also her carer) and any concerns she may have about FCI within the relationship.  6.36 CPN1 referred FCI to the carer’s service for a carer’s assessment at this visit. The fact that FCI was MCI’s carer was not identified as a possible additional stress factor for either of them.  6.37 The referral from FCI’s GP to the IAPT service was made on 3rd July 2013. This referral was screened by a panel of 3 practitioners and FCI was referred for an anger management workshop with an IAPT worker.  6.38 There was no recognition that the nature of the issues described in the GP’s referral indicated multiple safety issues for a newly born infant, which would require a multi-agency intervention and an urgent unborn baby risk (pre-birth) assessment.  6.39 The referral from the GP should have prompted an immediate referral to children’s services either by the Single Point of Entry for mental health services or by the GP.  6.40 The next available date for an intervention for anger management was in any case in 2 months time at a date very close to the expected date of delivery. This in turn indicated a lack of recognition by the practitioners involved about the vulnerability of a new born baby and the significant danger posed by a parent with a violent past and concerns around his own ability to contain his violent thoughts around a baby.  6.41 On 8th July 2013, FCI was assessed by the Carer’s Service and during the assessment was offered a referral to the Substance Misuse Service for his cannabis use.  (FCI declined the referral). Although FCI was open about his cannabis use, it did not trigger the Carer’s Service practitioner to consult with CPN1 about potential risks to the unborn baby.  6.42 CPN1 and a student nurse carried out a further visit to MCI on 16th July 2013. At this visit MCI was alone as FCI was visiting family. MCI was very tearful on arrival and felt she was not coping since FCI had left the previous day.  6.43 MCI reported an increase in thoughts of self-harm but denied any intension of self-harming behaviour.  6.44 MCI expressed her concerns about her risk of post natal depression and was aware that her mental health issues may impact on her ability to care for her baby.  15  6.45 MCI was also at this time experiencing back pain and a physiotherapy appointment had been cancelled, which caused her stress and impacted on her mood.  6.46 MCI also stated that she did not like to ask family and friends for help as she did not like to be a burden on them. Her mother, however, was arranging to spend some time with her.  6.47 All of the indicators during this home visit by CPN1 were that MCI’s mood was fluctuating and this together with MCI’s three previous suicide attempts should have prompted multi-agency liaison with other services and an escalation to children’s services in relation to the unborn baby.  6.48 On the 29th July 2013 MCI attended a Psychiatric Outpatient’s appointment with a consultant psychiatrist (Dr1).  Also present were CPN1, FCI and a student nurse.  6.49 Information from Peterborough (and Wigan where the couple had lived prior to moving to Peterborough) had been forwarded to Dr1 prior to the appointment. This detailed the three self-reported suicide attempts and overdoses for which MCI did not seek medical attention. There was a family history of depression and her grandmother had committed suicide. MCI had previously used cannabis, cocaine and ketamine.  6.50 A referral had been made by the Peterborough Early Intervention Team (psychosis) for a multi-agency view on assessing the risk of harm to the unborn.  6.51 Dr1 confirmed that MCI was at high risk of depression and psychosis following the birth.  6.52 Arrangements were agreed for CPN1 to liaise with the specialist mental health ‘mother and baby’ unit at Wythenshawe Hospital in case MCI needed post natal care as an in-patient.  6.53 MCI expressed no current intent to self-harm and her medication was resumed.  6.54 Dr1 focused on the presenting psychiatric issues and risk of relapse and the focus of Dr1’s risk assessment in this case was MCI and her unborn baby, primarily around the effects of medication and he undertook a risk/benefit analysis on the restarting of medication.  This was done jointly between himself and MCI.  6.55 There was an active decision not to address any potential past indicators of abuse or trauma as it was felt this may destabilise MCI.  However, 16  understanding past history is crucial in assessing risk of harm to the baby and would be a normal component of a core assessment for an unborn baby risk assessment.  6.56 On 31st July 2013, CPN1 made a telephone call to Bury Primary Care Psychological Therapies who confirmed that FCI was on the waiting list for an anger management workshop. This call was to confirm what CPN1 had been told by MCI, ie that FCI was seeking appropriate help for his anger management issues.  6.57 On 1st August 2013 an IAPT Service administrator received a call from CPN1 enquiring about when the date of the next anger management group would be.  The caller explained that FCI’s partner was due to have a baby in September and that they would like FCI to be seen before then if possible. The caller explained that MCI was receiving a service from EIT and that CPN1 was MCI’s care coordinator. The only information that Primary Care Mental Health services had received was from the GP referral.  However, the GP had not received the historical Peterborough GP records at that time. This telephone call should not have been left to an administrator to deal with but should have been escalated to a practitioner.  6.58 On 13th August 2013, FCI was contacted and offered a place on an Anger Management workshop which was running on 6th September 2013.  FCI declined this offer and requested to be seen one to one. FCI’s referral was re-screened by a Clinical Psychologist and referred to a low intensity worker. This re-screening was a further opportunity to assess the needs of the unborn baby or follow multi-agency procedures by analysing the referral more closely and the potential risk of harm to a new born baby.  6.59 On 21st August 2013 a further home visit was carried out by CPN1 to MCI.  MCI was immobile and in pain and had had a 4cm abscess on her right thigh removed.  6.60 MCI stated that she was feeling overwhelmed and depressed and was currently taking anti-depressants but reluctant to take pain relief because of the effect on the unborn baby.  6.61 MCI stated that she was not sleeping well and that she had increased ideas of self-harm but no intention to act. There is no reference in the information provided to the serious case review panel to indicate how great an increase this was.  17  6.62 CPN1 planned to refer MCI to the mental health Home Treatment Team (HTT) for relapse prevention and additional support and to discuss MCI with Dr1.  6.63 The increase in MCI’s distress and her feelings of being ‘overwhelmed’ should again have triggered a referral to children’s social care and an assessment of whether her carer (FCI) could meet her increased and dynamically changing needs.    6.64 On 23rd August 2013 the first visit was carried out by the HTT and an initial assessment of MCI was completed.  FCI was present. The HTT worker discussed triggers to low mood including physical problems.  MCI had stopped taking anti-depressants due to being pregnant but had recently re-commenced them.  MCI expressed concerns about becoming a mother.  The HTT worker completed a mental state examination and determined that MCI was low in mood and anxious, but with no suicidal thoughts or thoughts to harm others.  6.65 The focus of the HTT worker was MCI with the specific aim of support to prevent a relapse. The HTT worker did not assess the potential risk to the unborn baby and did not therefore contact children’s social care to request an unborn baby (pre-birth) risk assessment.  6.66 The HTT worker carried out two further visits to MCI on the 29th August and 1st September 2013. MCI described intermittent negative thoughts about how she would cope with the baby such as what if the baby hated her and was still feeling frustrated about not being able to do things. FCI appeared to be supportive.  Time was given for MCI to ventilate her feelings about the baby’s arrival. On the whole it appeared that she was looking forward to the baby being born.  The HTT recorded that there was no change to the previous mental state examination. Again, the focus of these two visits was MCI and MCI’s risk of relapse and not any potential risk to the unborn baby.  6.67 On 2nd September 2013 Dr1 reviewed MCI’s case and ensured that contingency plans were in place for MCI to access perinatal maternal mental health with midwifery services and that there was bed availability for the ‘mother and baby’ unit.   6.68 On 5th September the HTT worker carried out a visit to MCI. MCI described intrusive worrying thoughts regarding her ability to cope with a new born baby. MCI denied current thoughts to harm herself or others.  The HTT deemed MCI to be a low risk of harm to self or others during this contact. That MCI had described anxiety and intrusive thoughts about coping as a mother at each of the HTT worker’s visits did not prompt the HTT worker 18  to contact children’s services to either seek advice or to ask for an unborn baby assessment.  6.69 On 6th September 2013, following supervision with his line manager, CPN1 telephoned the assessment team (social services) to discuss child safeguarding concerns.  6.70 CPN1 discussed the case with the duty social worker (assessment team) and detailed the current issues, what plans were in place and FCI’s anger issues.  6.71 The duty social worker felt that MCI would be well monitored via the health visiting service following the birth and no further action would be taken by children’s services.  6.72 This was a failure by the practitioners to recognise the risk factors and follow multi-agency safeguarding procedures. Furthermore, no liaison with the Health Visiting service took place despite this being identified as a method of monitoring the baby’s safety.  6.73 On 11th September 2013 FCI attended the IAPT service for an assessment with the IAPT Therapist. FCI was the IAPT Therapist’s first client after a 3 year career break.  6.74 FCI reported that he had been “having anger issues” for pretty much all his life, that he felt angry and irritable but it varies and some days he is fine.  FCI said that he can then be quiet for days.  He distracts himself by playing computer games and talking to his partner who calms him down. Other issues identified were:-  • General anger issues • Has issues being verbally aggressive with partner • Punches pillows, walls, shouts & picks arguments with his partner-name calls • Feeling scared something bad was going to happen to him or others • Partner pregnant (almost full term) • Full time carer for partner who has psychotic depression • He has family history of depression • Thoughts of suicide x 1 per week intensity 8/10 • Thoughts of harming strangers, dependant on triggers, on any day intensity 8/10 • Previous suicide attempt by hanging at 15 years of age; a friend talked him down • Best friend committed suicide at 16 years of age. • Problems with step father related to his treatment of his mother • Difficulty managing anger towards strangers, used to get into fights • History of self-harming with piercing and stretching with piercings • Uses marijuana 4-5 times per week  19  • FCI identified factors decreasing the risk of him being violent were consequences such as going to prison and new baby on the way • FCI denied feeling paranoid due to drug use.  6.75 The IAPT Therapist arranged to see FCI in 2 weeks (the baby was due the following week) and in the meantime FCI agreed to work on identifying and managing his anger.  6.76 The list of issues described by FCI and recorded by the IAPT Therapist should have triggered an immediate referral to children’s social care and triggered internal safeguarding processes.  6.77 The IAPT Therapist despite this being her first client after a significant gap, did not have access to supervision and because she did not recognise the risk presented by FCI, neither did she seek the advice of her colleagues about FCI and his risk to the unborn baby.  6.78 Child I was born on 17th September 2013 and FCI sent a text message to the HTT to let them know.  6.79 The HTT worker carried out a further home visit on 19th September 2013.  MCI was feeding the Child I and she appeared relaxed and happy.  No change to MCI’s mental state was reported.  However FCI talked about his own mental state and said he was struggling with his own issues and that things had not been too good since the birth of his son.  He said he did not want to go too deeply into it as it triggered all his bad thoughts. The HTT worker discussed making a referral to the mental health access team for a mental health assessment and FCI agreed to this.  6.80 Although the HTT worker’s case notes did not detail what FCI’s thoughts were in relation to Child I, the referral the HTT worker made to a CPN within the access team states that he had thoughts to harm the baby.  6.81 This should have prompted the HTT worker to use internal organisational escalation processes and to make an urgent referral to children’s services.  6.82 On 23rd September 2013, FCI was seen by the Mental Health Access & Crisis team worker (ACTW) for a mental health needs and risk assessment. This was 4 days after the HTT worker had made the referral following FCI’s statement that he had thoughts of harming the baby. The ACTW recorded that FCI presented as a pleasant young man reacting to the birth of his son and the impact it was having on him, MCI and their whole situation.  FCI did not express any thoughts to harm himself or others.  FCI had commenced counselling and the access team sent a copy 20  of their assessment to the primary care mental health team and the home treatment team.  6.83 At this point Child I was only six days old and FCI had four days previously, expressed his thoughts of harming Child I.   6.84 A student nurse accompanied the ACTW for the visit. She recalls FCI having thoughts of dropping Child I in order to stop him crying. He described his anger issues and that he was having counselling for this. However, FCI presented as engaging and calm.  6.85 In summary the ACTW could determine no signs of mental illness in FCI but did not identify major indicators for the likelihood of significant harm to Child I and consequently made no safeguarding referral.  6.86 On 25th September 2013 CPN1 carried out a home visit and noted that MCI was to be discharged from the Home Treatment Team on the 29th September due to her stable mental health.  6.87 CPN1 observed that MCI and FCI appeared to be overjoyed by their new baby.  However, MCI highlighted that FCI had felt overwhelmed by the arrival of the baby and had subsequently been referred to the access and crisis assessment service. CPN1 noted that FCI appeared calm and relaxed and changed Child I’s nappy during his visit.  6.88 MCI minimised the imagery and thoughts expressed by FCI in the previous days (two days earlier FCI had described to the ACTW his thoughts of dropping the baby when he cried).  CPN1 accepted MCI’s presentation of the situation and did not liaise with the ACTW to discuss this with them.  6.89 On 27th September Child I was taken by MCI and FCI to the family GP with suspected sepsis and was immediately admitted to hospital.  6.90 On the same day FCI’s IAPT Therapist received a letter written on 23rd September 2013 by the ACTW who had visited FCI and carried out a mental health assessment on that date. The ACTW’s notes, within the letter, stated that FCI had been “referred by the Home Treatment Team who are involved with client’s partner – had expressed some frustrations and stress and made comments/thoughts of harming new baby – six days old”.   The IAPT Therapist ascertained from these notes that The Home Treatment Team had encountered FCI, whilst visiting MCI at their home. Concerns had been raised at this time by the Home Treatment Team regarding FCI’s thoughts of harming Child I. The ACTW’s letter also stated that at the time he assessed him, FCI did not express any thoughts to 21  harm his child. The ACTW also reported that in his assessment ‘little alcohol was indicated and FCI denied any drug use’.  6.91 Management advice and internal escalation should have been sought on receipt of this letter. A multi-disciplinary team should have been convened following internal escalation and information shared with the mental health practitioners involved with the family.  6.92 On 28th September 2013 MCI sent a text message to the HTT worker to say that Child I had been taken into hospital and would be staying in until Monday so the next planned home visit was cancelled.  The HTT worker sent a text message back to MCI advising her to ring at any time and to provide updates on baby and herself.  6.93 On 29th September 2013, MCI telephoned the Rapid Assessment, Interface & Discharge Team (RAID) who are a psychiatric liaison service that has been commissioned to manage all of the mental health problems presenting within the Royal Bolton Hospital.  6.94 The RAID team advised HTT that MCI had rung in the early hours of the morning in a tearful and distressed state and explained that she was in Royal Bolton Hospital, where her son was being treated for an infection.  During this phone contact MCI said that she was frustrated due to FCI’s lack of support whilst in hospital and that she was “having to do it all”.  She also reported that FCI had anger management problems and was currently seeing a therapist to address this.  6.95 This telephone call from a distressed MCI, who has a serious psychotic illness during which she described her partner’s anger management problems in the context of her very young baby’s hospital admission should have raised concerns about the safety of both MCI and Child I and triggered a safeguarding response from the HTT.  6.96 On 2nd October 2013 prior to the appointment she had arranged with FCI, the IAPT Therapist raised her concerns with a Primary Care Mental Health Nurse (PCMHN) within the IAPT service about the incongruence between what FCI had reported to her, to the ACTW and the information received from FCI’s referring GP in relation to FCI’s drug use.  6.97 The IAPT Therapist was also concerned about the potential impact of any drug use on FCI’s thoughts about harming the baby and was advised by the PCMHN to telephone the ACTW to seek clarity about FCI’s comments/thoughts about harming the baby.  22  6.98 The IAPT Therapist telephoned the ACTW but he was on leave and she was then advised by the PCMHN to telephone the Multi Agency Advice and Assessment Hub (MASH).  6.99 At around 10.15am on 2nd October 2013, the IAPT therapist telephoned the MASH and spoke to a social worker (SW1) and explained that she did not have a full name or date of birth for Child I as he had been born in between the first and second appointment with FCI.  6.100 The IAPT Therapist explained that she had received a letter from an ACTW written on 23rd September 2013, which stated the baby was 6 days old. SW1 advised the IAPT Therapist to find out the contact details of Child I’s Health Visitor and Midwife.   6.101 The IAPT Therapist asked for SW1’s advice regarding managing risk for Child I given that she was due to see FCI that day (2nd October 2013) at 12:00. The IAPT Therapist read the contents of the ACTW’s letter to SW1.   6.102 SW1 asked the IPAT Therapist to complete a Common Assessment Framework document (CAF) and once this was done to arrange a "child in need meeting" with Child I’s parents and all the professionals involved.  6.103 The IAPT Therapist again spoke to the PCMHN who is a more senior member of the team for advice and guidance. The PCMHN confirmed that normally the practitioner completing the CAF would be the Health Visitor, who the IAPT Therapist intended to contact following her appointment with FCI later that day.  6.104 During the appointment with FCI the IAPT Therapist gathered more information about FCI’s thoughts about harming Child I.  6.105 The IAPT Therapist specifically asked about the content and intensity of his thoughts when he had seen staff from the HTT and the current content and intensity of his thoughts regarding harming Child I.  6.106 FCI confirmed that when he spoke with the HTT he had thoughts of "crushing the baby's windpipe" or "dropping him" so that he would stop crying. FCI said he had vivid images/thoughts at that time and he rated the intensity of these as 10/10 with 1 being the lowest and 10 being the highest intensity.  6.107 FCI confirmed that when he is stressed or low in mood he still gets these thoughts and rated their intensity as 6/10, with 1 being the lowest and 10 being the highest intensity, at those times. FCI said he did not have such vivid images as he did before.  23  6.108 FCI reported that his current coping mechanisms included grinding his teeth. He also reported that he and MCI thought that his thoughts were irrational and that he did not really want to harm the baby. He reported having good support from his partner.  6.109 The IAPT Therapist explained to FCI that she needed to share this information with Child I’s Health Visitor and FCI’s GP. The IAPT Therapist also explained that the purpose of this disclosure was to ensure that he and his family would receive the right support.  6.110 The IAPT Therapist also told FCI that she was going to discuss the information regarding his thoughts of harming the baby with a senior member of staff in her own team to reconsider whether he needs an alternative therapy to the type currently provided (guided self-help intervention based on Cognitive Behavioural Therapy principles).  6.111 At approximately 3.30pm on 2nd October 2013 following her appointment with FCI, the IAPT Therapist telephoned the Health Visitor’s Team and ascertained, which health visitor was assigned to Child I.  6.112 The IAPT Therapist then spoke to the health visitor (HV) and passed on information regarding the disclosures FCI had made that day regarding his thoughts of harming Child I and the content of the letter received from the ACTW.  The HV informed the IAPT Therapist she would be seeing the family the next day and that they may need something more than a Common Assessment Framework carrying out.  The HV requested a copy of the letter sent by the ACTW.  6.113 At 5pm on 2nd October 2013, once she had seen her other clients, the IAPT Therapist went to the Health visitor’s office in the Radcliffe Primary Care building to give the HV a copy of the letter that ACTW had written.  The HV had left for the day, but the IAPT Therapist was able to speak to her colleague (another Health Visitor) who informed her that the Duty Social Worker (DSW) (no identity given) had assessed the case due to the concerns about Child I’s safety.  The IAPT Therapist was then advised by the HV to contact the Duty Social Worker which she attempted to do. As the Duty Social Worker was unavailable for her to speak to, she left a message for the Duty Social Worker to contact her that evening.  6.114 On the evening of 2nd October 2013 the DSW contacted the IAPT Therapist and advised her that he had carried out an assessment at FCI’s home earlier that day and that he had no urgent concerns.  The DSW reported that there was no history of harm to others.   The DSW also reported that FCI had admitted consuming cannabis during the week but that he did not do this in front of the baby. The DSW reported that he was happy with the 24  support MCI (FCI’s partner) is receiving from her family and from the Health Service. The DSW also said he would write a referral for FCI for the carer’s services requesting a carer’s assessment for him.  6.115 Also on 2nd October 2013, CPN1 carried out a home visit and recorded that Child I had been unwell over the weekend due to eye infection and had been admitted to Bolton Hospital.  FCI mentioned that he and MCI had both been stressed regarding the illness of the baby and this had caused them to worry about the baby.  6.116 Additionally MCI reported that she had mastitis and had taken advice from health visitor and midwife who will visit the next couple of days.  6.117 MCI also reported that she had not taken her psychotic medication but that her mental state was stable.  6.118 CPN1 discussed issues regarding sleep, parenting and domestic chores with the couple and agreed to contact the HTT to request a further visit.  6.119 CPN1 did not liaise with the midwife or health visiting service after this visit.  6.120 In summary the IAPT Therapist escalated her concerns on reviewing FCI’s records prior to the appointment. The advice she was given by SW1 at the MASH team is explored in more detail below. Briefly, however, the advice to carry out a CAF was not appropriate given the level of potential harm and risk to Child I.  6.121 The IAPT Therapist throughout the 2nd October 2013 persisted in escalating her concerns and shared these appropriately with children’s services and the HV.  6.122 On 3rd October 2013 the IAPT Therapist telephoned the Child Safeguarding Team at Bury Borough Pennine Care NHS Foundation Trust and gave her a description of the events, which had occurred the day before.  6.123 Also on 3rd October 2013 CPN1 liaised with the HTT and a further visit was arranged.  6.124 The HTT noted that MCI was likely to be discharged but could be re-referred.  6.125 CPN1 also liaised with SW2 ETD who had received referral via social services to visit the family because of FCI’s thoughts and imagery of crushing Child I’s windpipe.  25  6.126 SW2’s impression was that this was a thought without intent and was due to lack of sleep and pressure of having an unwell new born baby.  6.127 CPN1 did not challenge SW2’s assessment or seek further safeguarding advice from within his own organisation.  6.128 At 4pm on 3rd October 2013 the HV telephoned CPN1 and explained that she had spoken with FCI’s IAPT Therapist and that FCI had expressed vivid imagery of crushing baby’s windpipe and rated the intensity of his thoughts as 6/10. The HV also repeated that FCI had previously attempted suicide.  6.129 CPN1 agreed to liaise with the HTT as FCI may require additional support.  6.130 It was noted that stressors were likely to make MCI more vulnerable with increased risk of relapse.  6.131 This exchange was adult focused and did not assess the immediate risk to Child I.  6.132 The HTT worker telephoned MCI on 3rd October 2013. MCI reported that she was fine and that she was getting on well with FCI and she sounded bright in manner.  The HTT worker agreed to a home visit on 4th October 2013 and to consider discharge from the service at this visit.   6.133 MCI contacted the RAID team on 4th October 2013. The RAID team then contacted the HTT stating that MCI had told them that police and social services were involved with the family and that MCI wanted FCI to leave the property but professionals had advised her to keep the family together.  MCI had requested to proceed with admission to the mother and baby unit at Wythenshawe hospital.  6.134 The HTT worker then left a message for CPN1 in order to update him about MCI’s telephone call to the RAID team.  6.135 Also on 4th October 2013, MCI herself telephoned the HTT worker. MCI was upset regarding the police and social care visit from the previous day and discussed her feelings of guilt and persecution for requesting help for FCI.  MCI told the HTT worker that Social Services were to contact her this morning.  MCI assured the HTT worker that she could keep herself and Child I safe until the HTT home visit.  6.136 CPN1 returned the HTT worker’s earlier phone call and agreed to a joint home visit.  26  6.137 The HTT worker accepted MCI’s assurance that she could safeguard herself and Child I despite the fact that FCI was her carer and had expressed violent thoughts and imagery.  6.138 At 11am on 4th October 2013, CPN1 conducted a joint home visit with a worker from the HTT.  6.139 MCI and FCI described the visit the previous evening by SW3 and the CPO due to FCI’s thoughts to harm the baby. SW3 and the CPO considered the risk to be low but wanted to request a mental health assessment of FCI.  6.140 MCI and FCI explained that they had been told that FCI should not be with the baby alone. And that he now felt that he had no option but to return to Peterborough leaving MCI and the baby alone in Bury.  6.141 The HTT worker agreed to continue support for MCI.  6.142 MCI and FCI were unclear about who would carry out the mental health assessment of FCI or when this would take place.  6.143 CPN1 agreed to carry out the mental health assessment of FCI as he wanted to ensure that MCI and baby were not at risk and that MCI would not be left alone with Child I if FCI did return to Peterborough as the stress of FCI leaving could trigger a relapse of MCI’s psychosis.  6.144 CPN1 then carried out the mental health assessment of FCI.  6.145 It was agreed that FCI would leave house should his thoughts become intense and MCI agreed that she would contact police if she had any concerns.  6.146 The midwife and MCI’s family also planned to visit to provide further support.  6.147 CPN1 telephoned SW3 and confirmed his assessment of FCI and faxed a copy of the assessment to her.  6.148 CPN1’s decision to conduct a mental health assessment of FCI was not safe practice and was not independent as he had been intensively involved with the family.  6.149 CPN1’s rationale for undertaking the assessment was to ensure that the family unit could stay together in the absence of clear risk factors from a mental health perspective. He was drawn into issues around the timely pursuance of an assessment and felt under pressure to conduct this outside of normal processes. 27   6.150 Furthermore, there was confusion about the request for a mental health assessment and about what the result might be. Specifically FCI had recently had a mental health needs and risk assessment (carried out on 23rd September 2013 by the Mental Health Access & Crisis team worker) which found no evidence of mental illness.  However, there were issues of past violence and of violent thoughts.  6.151 CPN1 confused the outcome of his assessment with one which meant no thoughts of violence to others as meaning no risk of harm to Child I. This risk assessment should only be used in the context of mental illness.   However FCI was not deemed to be mentally ill, therefore, the application of the assessment formulation was flawed.  6.152 All mental health interventions rely on factors which increase or decrease risk. In this case FCI offered some actions that he would employ to reduce his risk, such as leaving the property. Such a thought process would be unlikely to succeed due to the self-reported strength of the overwhelming thoughts 8/10-10/10. It would be unlikely, in the event of his thoughts returning, that he would have the emotional containment to reduce the likelihood of acting on those impulse thoughts.  6.153 This assessment in turn gave a false reassurance to children’s services that the risk of violence was low. It was only low in the context of a mental health problem, which he did not have. It was inappropriate to predict a low risk of likelihood of harm within a child safeguarding context.  6.154 The request to undertake a mental health assessment should not have been accepted as an assessment of the risks posed to Child I. Any assessment of risk to Child I should have been considered via a social care children’s assessment of the likelihood of harm due to violence.  6.155 The HTT worker who attended the home visit with CPN1 reported that both MCI and FCI were attentive to the baby’s needs.  The HTT worker reported that MCI was concerned that the baby could be taken into foster care due to FCI’s thoughts of harming him.  MCI did not feel that FCI would act on these thoughts and said if she was fearful for baby’s well-being then she would remove him from the family home. The HTT worker noted that risk to self or others was assessed as low at time of contact.  MCI also said she had concerns that FCI may be requested to leave the family home.  MCI said if this was to happen she would be unable to cope on her own.  6.156 The HTT worker did not disagree with the course of action taken by CPN1 to assess FCI’s mental health and remained focused on MCI’s needs rather 28  than on risk to Child I. The HTT worker was overly optimistic about MCI’s ability to keep Child I safe.  6.157 Also on 4th October 2013 CPN1 spoke to the IAPT Therapist who explained that she had made an urgent referral for a mental health assessment and had been advised to complete a social services referral. CPN1 advised her that children’s social care were already involved with the family.  6.158 CPN1 further liaised with SW3 who invited him to a meeting on 9th October 2013.  Police recommended family member (this is thought to have been MCI’s mother) remains with MCI and baby over weekend.  6.159 The HTT worker telephoned MCI later on 4th October 2013.  MCI reported that CPN1 had assessed FCI’s mental state and had liaised with children’s services who felt that risk and concerns about FCI could be downgraded and the family could be able to stay together.  MCI reported that her only concerns currently were that she was feeling tired.  She also stated that her mother was staying with them.  6.160 At 3 pm on 4th October 2013 CPN2 who had received an urgent referral to carry out a mental health needs and risk assessment on FCI spoke to CPN1 as she wanted to understand CPN1’s involvement.  6.161 CPN1 outlined his involvement with the family and confirmed that the recent assessment of risk in respect of FCI was low.   6.162 CPN2 questioned why CPN1 had conducted assessment and what her input would be.  CPN1 felt that CPN2’s input would still be required.  6.163 Also on 4th October 2013 the IAPT Therapist discussed FCI’s case with the manager on duty, the Bereavement Project Lead (BPL). The BPL advised the IAPT Therapist to call FCI and ask for permission to share information related to him and his partner.  The IAPT Therapist also discussed making a referral for FCI to see a Community Mental Health Nurse within her own service, as the case was more complex and needed a higher level of intervention, for further risk assessment and management of risk.  6.164 The IAPT Therapist agreed to keep her appointment with FCI on 9th October 2013).  She and the BPL then retrieved from the National Computerised Records System (NCRS) details of the professionals recently involved with MCI and found that MCI was receiving treatment from the Early Intervention Team (CPN1) and that she has recently been seen by the Rapid Access Interface Discharge Team (RAID).   6.165 On 4th October 2013, the IAPT Therapist also telephoned the HTT who informed her about the joint visit carried out with CPN1 the previous day. 29  The HTT worker also told the IAPT Therapist that when she visited the family home MCI and FCI had told them that police in plain clothes and Social Services had visited them the previous night. MCI was told that a social worker would ring her at 10am on 4th October 2013.  However, the HTT worker said that when she and CPN1 at 11:00am MCI said that she had not been telephoned by Social Services.  6.166 On finishing her call to the HTT, the IAPT Therapist immediately telephoned CPN1.  She was unable to speak to him but left a message with another member of staff at the Early Intervention Team requesting that CPN1 contact her urgently.  CPN1 rang the IAPT Therapist back shortly afterwards and told her that he had carried out a mental health assessment on FCI and had liaised with SW3.   CPN1 also informed the IAPT Therapist that there was to be a meeting next week to discuss what had been going on with the family but that the IAPT Therapist was not obliged to attend.  6.167 The IAPT Therapist informed CPN1 that she was making a referral to Social Services that day.  CPN1 responded by telling her that Social Services had done their assessment and it was not necessary for her to write the referral.  Minutes after this telephone call the IAPT Therapist spoke to a Community Mental Health Nurse (South Team) about the assessment CPN1 had carried out. The Community Mental Health Nurse then also spoke to CPN1 and requested a copy of the mental health assessment that he had completed for FCI.  The Community Mental Health Nurse also advised the IAPT Therapist to attend the meeting that CPN1 had said she was not obliged to attend.  6.168 On 4th October 2013 at 4.30pm the IAPT Therapist did make the referral to Social Service.  The reason for referral was that FCI had told her that when he saw the Home Treatment Team he was having thoughts of “crushing the baby’s windpipe” and “dropping him” so that he would stop crying. FCI said he had vivid images/thoughts at that time and that he had rated the intensity of these thoughts as 10/10, 1 being the lowest and 10 being the highest intensity.  FCI said during his appointment with her that when he is stressed or low in mood, he still gets these thoughts and rated their intensity as 6/10, 1 being the lowest and 10 being the highest intensity.  The IAPT Therapist requested in the referral that an assessment be carried out regarding Child I’s safety.  6.169 The IAPT Therapist also completed an internal incident form and completed an internal referral for FCI to be seen by a Primary Care Mental Health Nurse within her team.  30  6.170 The IAPT Therapist was persistent in pursuing her growing concerns about the safety of Child I and did not accept CPN1’s reassurance but sought advice from colleagues. She also specifically requested that Children’s Services assess Child I’s safety and was specific about her concerns.  6.171 Also on 7th October 2013, CPN1 carried out a home visit and undertook a review of MCI’s care plan. CPNI felt that MCI had been open and honest in the social care assessment.  6.172 MCI denied that FCI had shown any anger towards Child I and CPN1 amended MCI’s care plan accordingly.  6.173 CPN1 faxed a copy of MCI’s mental health review to SW3 that same afternoon.  6.174 On 8th October a HTT worker carried out a home visit. MCI was bright and expressed that child and family services were happy with the situation currently and were happy with the level of support in place.  MCI was being supported by the HV, midwife, family and the HTT. MCI felt that she and FCI were coping well with the baby and had been shocked when social services had mentioned fostering the baby.  The HTT worker noted that MCI’s mental state was stable.  No further concerns were identified.   6.175 CPN1 carried out a further home visit on 9th October 2013 and noted that FCI was to attend anger management sessions (CPN1 contacted the IAPT Therapist to confirm this) and that FCI had not been allocated a CPN as yet.   6.176 Also on 9th October 2013 FCI attended his third appointment with the IAPT Therapist. FCI reported that he had had a stressful week because of children’s services visiting his house. He also said he had a visit from CPN1 (his partner’s Community Psychiatric Nurse – Early Intervention Team) who had assessed him and referred him to see Dr1 (Consultant Psychiatrist).  6.177 FCI also said that a “lady” from Children’s Services would be visiting him on 11th October. He could not recall her name or position. He was also still awaiting the completion of his carer’s assessment.  6.178 The IAPT Therapist completed a full Trust Approved Risk Assessment (TARA) with FCI. He reported that he did not have thoughts of suicide/self-harm during the last week. He reported he had thoughts about harming others “random people” by “punching them in the face but nothing gruesome”. He rated the intensity of these thoughts as 5/10, with 1 being the lowest and 10 being the highest intensity. The factors 31  identified as increasing the risk of harm to “random people” was dealing with different triggering situation e.g. people with no manners. The factors identified as decreasing risk were that he reported not constantly having these thoughts, and that he feared the consequences of acting on these thoughts (e.g. being arrested).  6.179 In regard to drug use FCI reported that during the week prior to his appointment he had smoked “one or two or maybe three joints.” He reported that when he smokes cannabis, he does this in the top bedroom with the window open.  He then takes his clothes off and washes his hands before he takes the baby in his arms. He identified stress as a factor which can increase his drug use although he said that during the week prior to his appointment he had not smoked that much because of “lack of time” (he then qualified the amount over the last week as one and a half joints). He identified keeping himself busy by looking after his partner and baby and distracting himself by playing computer games and going out for walks as factors decreasing his drug use.  6.180 FCI reported having had no alcohol for over a year.  6.181 FCI reported he did not have any thoughts about harming Child I during the week prior to his appointment.  6.182 FCI reported that his partner was getting full support from her care co-ordinator CPN1 and that he had engaged with the Carer’s Service.  6.183 During the session the IAPT Therapist also discussed the components of anger on the ABC-E model of emotion (Autonomic, Behavioural, Cognitive and Environmental factors) with FCI and asked him to write, as a home task, what the triggers for his anger are and what the physical, behavioural, cognitive and emotional cues were.  6.184 FCI reported that he was still waiting to hear from his CPN at the Bury IAPT Primary Care Mental Health Team.  6.185 The IAPT Therapist arranged her next appointment with FCI for 24th October 2013 (she was on annual leave in the period in between).  It does not appear that the IAPT Therapist liaised with Children’s Social Care to pass on the details of this appointment so that this information could be used to contribute to the Children’s Social Care assessment.  6.186 On 12th October 2013 the HTT worker carried out a home visit. MCI said that child and family services had been round yesterday and were pleased with the family’s progress.  She said that a multi-disciplinary team meeting had been arranged. FCI described feeling much better and 32  attributed this to the support that had been put in place.  They both felt very well supported by extended family and services.  6.187 During this visit it was documented (at a later date) that the HTT worker had observed FCI bouncing the baby in his hand above his head at arm’s length.  The worker asked FCI not to do this as the baby was too young and could strain his neck.  He immediately put the baby down and gave him to MCI.  6.188 On 15th October 2013, the HTT worker carried out a home visit.  MCI answered the door.   FCI was upstairs with Child I asleep.  MCI reported feeling very tired but well in herself.  The baby had been a bit “niggly” with wind over the last few days.  She said she was intending to buy some medication for colic as advised by the midwife.   She said there was a meeting with child and family services on 25th October 2013 and then the case would be closed, which MCI and FCI were pleased about.  MCI said she had been a little irritable due to being tired but overall felt okay.  6.189 Also on 16th October 2013 CPN1 carried out a home visit at which HV1 was also present.  6.190 CPN1 noted that MCI and FCI’s presentation was calm and relaxed.  6.191 FCI confirmed that he was having an assessment on 17th October 2013 via primary care and continues to receive anger management input.  6.192 FCI denied any recent thoughts re harm to baby and was observed to have bonded well with the baby.  6.193 MCI denied any mental health concerns but that she was happy for additional support to be put in place via an EIT support worker input.  6.194 MCI expressed that she was happy with the level of support she had received from CPN1.  6.195 On 17th October a further assessment of FCI was carried out by a Primary Care Mental Health Worker and CPN3.  FCI stated he had long standing history of anger issues and he said he would contact services if he felt he would harm Child I.   6.196 On 23rd October 2013 CPN1 carried out a home visit with the EIT support worker. There was a gap of 2 weeks between this visit and CPN1’s last visit on 9th October 2013.  6.197 MCI reported that she had been concerned about Child I over the weekend as he had held his breath and was not himself. MCI told CPN1 33  that they had taken Child I to hospital after MCI had contacted NHS Direct for advice.  6.198 The EIT support worker introduced herself.  6.199 MCI said that she was keen to access Sure Start and wanted to discuss referral with the health visitor.  6.200 MCI confirmed attendance at outpatient department on 24th October 2013 and safeguarding meeting on 25th October 2013.  6.201 Also on 23rd October 2013 the HTT worker telephoned to see if she could re-arrange a visit planned for 24th October until the weekend. MCI and FCI both agreed as they said they were taking the baby to be weighed as he had lost weight recently.  6.202 On 24th October CPN1 escorted MCI and baby to the psychiatric outpatient’s department.  6.203 MCI told CPN1 that she and FCI were concerned as there had been blood in the baby’s saliva and an ambulance was called and they had been taken to Royal Bolton Hospital.  6.204 At the outpatient’s appointment MCI recounted recent events and that she remained stable and a further appointment was arranged for three months.  6.205 Also on 24th October 2013 FCI attended his fourth appointment with the IAPT Therapist. FCI reported that he had been to the hospital with Child I because he had coughed a “red liquid” but he was reassured as at the hospital they were told that there was nothing to worry about as it was reflux.  He told the IAPT Therapist that he had found out today that Child I has a viral infection and that all this has meant that FCI and his partner have not had much sleep.  6.206 The IAPT Therapist shared with FCI her report for the initial Child Protection Conference due to be held the following day 25th October 2013.  FCI said that he was fine with the report. During the session the IAPT Therapist reviewed the work FCI had completed at home and the parts he had struggled to complete. FCI was able to identify certain situations and events that triggered his anger, such as confrontation and briefly discussed his current coping mechanisms such as going to the gym or ringing his mother.  6.207 The IAPT Therapist introduced the use of the “time out” technique which consists of agreeing in advance with a loved one (in his case his partner) 34  that if feeling angry he would leave the situation to avoid it escalating. However, the agreement includes that he would come back to talk about the event once he feels calmer.  6.208 It was apparent that FCI had minimised the nature of Child I’s illness by referring to the blood in his saliva as ’red liquid’.  6.209 A further appointment was made for 7th November 2013.  6.210 On the 25th October 2013 CPN1 received 3 text message from MCI stating that:  • She and FCI would not be attending the child protection meeting as Child I was in hospital with a suspected urinary tract infection. MCI informed CPN1 that hospital staff were not concerned and Child I should be discharged later.  • In the 2nd text MCI informed CPN1 that Child I was to remain in hospital another night as there were 2 random bruises on his torso.  • In the 3rd text MCI states that FCI has had to leave hospital whilst hospital liaise with social services.  6.211 On 26th October 2013 the HTT worker carried out a home visit. FCI was just about to leave to go to Peterborough to gain some support from his parents.  MCI presented as very distressed and anxious and she agreed to take the prescribed promazine to help reduce her anxiety. MCI discussed the events that had happened at the hospital and that the photographer had been to take photos of the injuries to Child I but he had said he could only see one faded bruise on the baby’s torso so had asked the doctor exactly what he was meant to photograph at which point she said the doctor had left the room.  6.212 The HTT worker stayed with MCI until her mother arrived as FCI was leaving and provided anxiety management during this time.  MCI’s mother arrived and they were going to stay at the hospital overnight.  Summary Analysis of Mental Health Agencies Involvement  6.213 A minimum of 12 different mental health practitioners (IAPT service x 4, CPN x 3, HTT x 2, Carer’s Service x 1, Consultant Psychiatrist x 1, ACTW x 1, EIT Support worker x 1, Primary Care Mental Health Worker x 1) were involved with MCI and/or FCI upon the family’s arrival in Bury.   35  6.214 It is apparent that the majority of mental health practitioners involved with both MCI and FCI were focused on the two adults’ mental health needs. In MCI’s case this was in order to manage her existing serious mental health condition and specifically to prevent a relapse of her psychotic depression with little awareness demonstrated that mental health practitioners were aware of the impact of maternal mental illness on children.  6.215 The risks of relapse were high because of MCI’s pregnancy and arrangements were put in place once the family moved to Bury for a bed in a ‘mother and baby’ mental health unit should a relapse occur.  6.216 Given the known risk of relapse and what is known about the risk of having a parent (and particularly a mother) with a psychotic illness, MCI’s condition warranted a full unborn baby (pre-birth) assessment but this was not considered by any of the mental health practitioners.  6.217 FCI’s presentation to his GP led to a referral for anger management to primary care mental health services. This referral detailed several well known risk factors to children/unborn babies namely domestic abuse, previous aggression and violence and drug use and was screened by three IAPT workers, who did not recognise the risks.  6.218 The IAPT Therapist also did not immediately recognise what FCI told her as a risk to the unborn baby or to MCI. However, as soon as she learned of his specific thoughts and imagery, she responded quickly, sought advice, escalated her concerns and persisted in doing so.  6.219 CPN1’s involvement with both MCI and FCI blurred professional boundaries and led to unsafe practice particularly his mental health assessment of FCI.  6.220 The outcome of the mental health assessment of FCI was not an indicator of potential risk to Child I.  Most fathers/men who harm children do not have a mental illness but a significant majority do have a history of violence and aggression (including domestic abuse) and drug use. CPN1’s assessment of risk in this case was fundamentally flawed and offered reassurance to other professionals about the threat to Child I’s safety.  6.221 The Home Treatment Team workers involved with MCI also failed to recognise the potential risks to Child I.  6.222 MCI and FCI were, on occasion, open about their cannabis use and about FCI’s violent thoughts and anger issues. None of the mental health practitioners sought advice from or consulted with other practitioners 36  involved with the family about what impact this might have on Child I’s safety.  6.223 None of the mental health practitioners considered calling a Team Around the Child meeting or S17 Child in Need meeting to discuss the unborn baby despite the fact that the pre-CAF assessment carried out in Peterborough had been transferred with MCI’s health records.  6.224 Dr1 saw MCI three times as an outpatient.  It is clear that time is a factor in the management of cases from any professionals perspective.  In cases such as this that have complex multi-agency involvement, further complicated by the move to another area during the latter stages of pregnancy, a key time of stress for the family, it would not be unreasonable to expect that historical information would be sufficiently shared, discussed and reviewed in order to support effective and accurate decision making.  6.225 However, Dr1’s expectation was that CPN1 would have reviewed the MCI’s referral and other documentation and clarified the pertinent areas of history and risks.  This is a reasonable operational requirement especially in view of Dr1’s case number compared to a generic outpatient team.  6.226 None of the mental health practitioners routinely informed the midwife or health visitor about FCI’s thoughts of harming Child I.  6.227 Tolerance and thresholds of risk to Child I before and after he was born were viewed, understood and responded to through an adult mental health perspective.  Recommendations  6.228 The learning from this serious case review should be disseminated to mental health practitioners as soon as possible and via a variety of means eg for community based psychiatric nurses or care co-ordinators there should be specifically tailored training and awareness raising activities using this serious case review as a case study.  Any briefings or training needs to specifically include the impact of parental/adult health difficulties on children and risk assessment processes where children are in the household.  6.229 The supervision of community based mental health practitioners should be reviewed in light of the learning from this serious case review to ensure that supervision policy and practice focuses consistently upon child safeguarding.  Particular emphasis should be placed on the needs of newly qualified staff or staff returning to practice. 37   6.230 Learning from this serious case review should be used to inform community based mental health practitioners about the nature and importance of multi–agency safeguarding arrangements and their responsibilities to share information with others when it concerns risks to a child and the crucial role they play in contributing to TAC, CAF and CPP arrangements.  6.231 The impact of FCI’s cannabis use and high energy drink consumption on his mood and significantly his anger responses was not challenged or explored by any practitioner.  It was noted by the serious case review panel that services who are equipped to respond to such use are extremely limited or none existent for adult clients.  Given wide anecdotal evidence that high energy drinks are now commonly used BSCB should satisfy itself that the potential risk to children living with parents who use emerging (and better known) substances of abuse should be understood by all partner agencies.   The notion of self-reported use and potential for disguised compliance in treatment services should be a focus of this understanding. Midwifery Service  6.232 MCI was transferred by Peterborough Midwifery service to the Bury Midwifery Service and attended her first appointment on 17th June 2013. At that point MCI was 26 weeks pregnant. MCI brought her ‘hand held notes’ to this appointment which gave details of her previous antenatal care and the pre-CAF completed by the Peterborough midwife.  6.233 The Midwife (Midwife 1) at this visit made a referral to the Royal Bolton Hospital to initiate transfer of hospital care and booking, requesting consultant led care due to MCI’s history of psychotic depression and sudden cessation of medication.  6.234 The pre-CAF completed by Peterborough specialist midwife was forwarded to Bury Children’s Services at this appointment.  6.235 Midwife 1 also completed a ‘Special Circumstance’ form to be filed in MCI’s back up notes at the Royal Bolton Hospital.  6.236 Bolton NHS Foundation Trust midwifery service received the referral from the community based midwife on 22 June 2013.  6.237 The risks identified were MCI’s mental health, which was assessed on two separate occasions in the antenatal period by a doctor in antenatal clinic. This is documented in the records.  38  6.238 FCI was viewed as a protective factor as he had previously been assessed and approved as an appropriate carer for MCI.  6.239 Midwife 1 failed to further investigate MCI’s cannabis use as disclosed at the booking appointment in Bolton.  6.240 The information from the Pre-CAF received from Peterborough on 10th June 2013 regarding FCI’s anger issues would have helped to ensure a more comprehensive risk assessment.  6.241 No CAF was completed by Bolton NHS Foundation Trust.  6.242 MCI attended an ante-natal appointment at the hospital on 2 August 2013.  She did not attend an arranged appointment on 16 August 2013.   6.243 On 18th September 2013 when Child I was 1 day old Midwife 2 carried out a home visit following MCI’s discharge from hospital the day before.   Midwife 2 carried out a postnatal check and MCI informed her that she was able to recognise when her mood was deteriorating and knew how to seek support if that happened. FCI told Midwife 2 that he knew the relevant contact numbers if he had any concerns. Midwife 2 was aware that CPN1 and the mental health crisis team were aware of Child I’s birth and had visits arranged. Midwife 2 expressed no safeguarding concerns following this visit.  6.244 On 19th September, Midwife 2 carried out a home visit and in direct contrast to the HTT worker’s home visit to the couple the same day during which FCI reported his thoughts of harming the baby, Midwife 2 described MCI as tired following an unsettled night with baby and feeling a little emotional from tiredness but otherwise well. Child I was noted to be feeding well. MCI had made an appointment with her GP as baby has a slightly ‘sticky’ eye. MCI and FCI appeared very happy and talkative. Midwife 1 had no concerns from that visit.  6.245 On the 23rd September 2013 Midwife 2 carried out a home visit and reported that MCI was feeling tired but well and appeared in good mood. MCI informed Midwife 2 that the mental health crisis team had visited and were visiting again on 25th October 2013. No concerns were recorded from that visit. It does not appear that Midwife 2 explored why the crisis team had visited (this was in relation to FCI’s thoughts of harming Child I) or that she liaised with CPN1 or the HTT worker to check what this visit was in relation to.  6.246 On 1st October, 2 days after Child I’s discharge from the Royal Bolton Hospital, Midwife 2 carried out a home visit and recorded that MCI was very tired and feels physically unwell with symptoms suggesting mastitis 39  and that MCI’s GP had been contacted to arrange treatment. MCI informed Midwife 2 that she had been in touch with the crisis team over the weekend whilst Child I was in hospital as she started to feel that her mood was deteriorating with the stress of the baby being unwell.  6.247 Midwife 2 reported that Child I was feeding well and that his ‘top to toe’ check was normal. He was reweighed whilst in hospital and his weight had increased as expected.  6.248 Midwife 2 did not contact CPN1 or the HTT worker to discuss MCI’s deteriorating mood and current illness.  6.249 On 8th October 2013 Midwife 2 visited the family at home. They were alone with baby. Parents both appeared well and in a good mood. Midwife 2 carried out a ‘top to toe’ check of Child I and all was normal. Child I’s weight was increasing as expected.  6.250 Immediately following this visit Midwife 2 telephoned SW3 as she was under the impression that MCI and FCI should not be alone unsupervised with the baby. SW3 informed the midwife that following the strategy meeting yesterday an assessment was received from CPN1 and the safety plan was no longer needed as FCI is considered to be ‘low-risk’ of harming baby and MCI’s mental health is currently stable. The midwife was advised that the social worker had the next visit arranged for 11th October 2013.  6.251 On 14th October 2013 Midwife 2 carried out a home visit. MCI and FCI both appeared well and in good mood. The midwife carried out a ‘top to toe’ check of baby and all was normal. Midwife 2 liaised with HV1 and SW3 that no concerns were noted during today’s visit.  6.252 On 21st October 2013, Midwife 2 carried out a home visit to discharge from midwifery care. MCI and FCI reported feeling well and appeared in good mood.  6.253 MCI and FCI informed the midwife that Child I was admitted to A&E by ambulance overnight on the 19th October with constipation and a floppy episode and that he was reviewed by a doctor and was discharged home the same night with no follow-up required.  6.254 Child I appeared well and the midwife carried out a ‘top to toe’ check and all was normal.  6.255 Child I was discharged from midwifery care.  6.256 Midwife 2 informed HV1 and SW3 of the discharge from midwifery care and of the hospital admission that had taken place. 40  Summary analysis of the Midwifery Service involvement   6.257 The transfer of information from Peterborough midwifery service included a copy of the pre-CAF. The information from the pre-CAF regarding MCI’s serious mental health condition and FCI’s anger issues plus FCI’s disclosure about his cannabis should have triggered a safeguarding response and a full CAF should have been carried out.  6.258 The midwives involved in the care of MCI and Child I were reassured by the presentation of MCI and FCI who were described as ‘nothing out of the ordinary’, articulate and well presented.  6.259 From reading the agency chronologies however it is apparent that MCI and FCI were selective about what they told practitioners eg MCI and FCI did not mention anything concerning during Midwife 2’s home visit on 19th September 2013 following FCI’s disclosure the same day to the HTT worker that he had thoughts of harming the baby.  6.260 Neither of the midwives involved in MCI’s care recognised that there were indicators that domestic abuse was taking place within the family and that FCI’s role as MCI’s carer could be a source of extra abuse and certainly would make MCI more vulnerable.  6.261 Communication between the midwifery service and the health visiting service was not good initially and the health visiting service were not made aware of FCI’s anger issues or cannabis use or the severity of MCI’s mental health condition.  6.262 The midwifery service has recently engaged an Outreach Midwife whose role it is to work with women who have known vulnerabilities. MCI would have been allocated to this midwife had she been in post at the time. Supervision arrangements are in place to ensure that supervision policy and practice gives all midwives the opportunity to discuss families where there are concerns present with a specific focus on child safeguarding.  Recommendations   6.263 The midwifery service should use the learning from this serious case review to refresh midwives awareness of the combined impact of drug use, parental mental illness and violence on pregnant women and unborn and newly born babies.  6.264 Management of midwives should also audit and promote the use of CAF or Team around The Child meetings.  41  6.265 Communication between the midwifery and health visiting service should be reviewed to ensure that families with risk factors such as mental illness, substance misuse, physical or learning disabilities, or domestic abuse are ‘red flagged’ so that the health visiting service have all possible information and can prioritise their caseloads.  Health Visiting Service 6.266 The Health Visiting Service received a notification of Child I’s birth on 19th September 2013 from the Midwifery Service.  However, this notification gave no indication of MCI’s mental health status or FCI’s anger management issues and cannabis use.  6.267 As a result, the case was allocated at the allocations meeting as a normal primary visit and a letter was sent by the health visitor (HV) to MCI and FCI arranging the primary visit on 3rd October 2013.  6.268 Had the information regarding MCI’s mental health and FCI’s cannabis use and anger issues been known when the case was being allocated, then a HV would have would have been allocated to visit the family earlier and would have been alerted to potential risks to the baby.  6.269 On 2nd October 2013 the HV received a telephone call from FCI’s IAPT Therapist, who reported that FCI had been seen by the team on the 11th September 2013 for anger issues but that subsequent appointments were missed due to the birth of Child I.  6.270 The IAPT Therapist reported that FCI had been seen by the HTT worker when Child I was 6 days old and had expressed thoughts and made comments about harming the baby.   6.271 The IAPT Therapist also advised HV1 that FCI had attempted suicide as a teenager.  6.272 The IAPT Therapist had met with FCI earlier in the day, and stated that FCI had disclosed having previous and current vivid thoughts and imagery around crushing the baby’s windpipe to stop him crying.  6.273 FCI reported that support was available from extended family.   6.274 The IAPT Therapist had contacted the multi-agency advice and assessment hub (MASH), who requested that a CAF be completed. The IAPT Therapist had subsequently been advised by her manager to contact the HV as the mental health service would not complete CAFs or manage Child in Need processes.  42  6.275 Immediately on receiving this information, the HV contacted the safeguarding team and made a referral to social care due to the risk of significant harm.  6.276 On 3rd October 2013 the maternal and baby transfer of care was received by the health visiting service from midwifery services (16 days post-delivery).  6.277 Child I’s information stated that mental health services were involved but no details were documented.  6.278 MCI’s information stated that she had Psychotic Depression. Further information in the maternal discharge summary described MCI on discharge as a ‘well woman’ with baby breast feeding well at the time of discharge.   6.279 Expected timescales for the transfer of information from midwifery service to health visiting services is 10 days from the birth of a baby. The information transferred did not detail FCI’s anger management issues or cannabis use. This delay in transferring information and the lack of relevant information detailing risk issues was below standard.  6.280 The HV contacted the MASH and left a message for the social worker and specialist HV to contact her for an update as she was due to visit the family the same day.  6.281 The HV also liaised with the outreach midwife who advised her that a CAF was completed pre-birth and sent to the MASH.   The MASH and Early Help Team, who maintain a database of CAFS, have no record of this CAF.  6.282 At 2.30pm the HV accompanied by Midwife 2 carried out a primary birth visit at the family home.  6.283 Both parents were present and no concerns regarding the presentation or care of Child I or the home environment were observed during the visit. Child I was being fed by FCI as MCI reported that she had given up breast feeding.   6.284 MCI and FCI discussed the recent admission of Child I to Royal Bolton Hospital. Both MCI and FCI presented as calm with good eye contact and engaged in discussion.  6.285 The HV discussed the referral to social care and MCI and FCI said they had been visited by a social worker the previous evening. Both expressed shock at how quickly this had happened but said they were willing to work with services for support. 43   6.286 MCI described multiple health issues including psychotic depression and a back condition. She is currently under the care of the HTT and on medication for her mental health issues. MCI presented as tearful at times and reported to be feeling low that day. MCI stated that she was aware of hearing voices.  6.287 MCI reported that her family live locally and she has daily phone contact with her mother.  She reported that her family are not aware of all her health issues.  6.288 MCI also said that she and FCI talk openly and he discussed his thoughts about harming Child I and that his referral to mental health services was via CPN1.   6.289 MCI reported that she is aware of FCI’s anger issues but is aware of not ‘pushing’ him and causing additional stress.   6.290 Despite this statement the HV reports that no domestic abuse was disclosed although this is a clear indicator that MCI was taking responsibility for managing FCI’s anger.  6.291 Both MCI and FCI reported no alcohol use and no other drug use apart from MCI’s medication. FCI reported infrequent cannabis use and both parents felt that this was not a problem.  6.292 Actions agreed by the HV included: • HV to continue to liaise with midwifery, GP and social care. • HV to liaise with mum’s CPN.  (The HV contacted CPN1 after this visit and he reported that he was unaware of FCI’s issues prior to contact with social care earlier that day).  • CPN1 to liaise with colleagues regarding a referral for FCI for a mental health assessment. • Case discussed with safeguarding team who advised to refer to social care. • Specialist HV MASH to be contacted.  • Support offered re breast feeding.  6.293 It does not appear that HV1 or Midwife 2 notified CPN1 that MCI had reported hearing voices at their visit.  44  6.294 On 14th October 2013 HV1 received a notification that Child I had been admitted into Royal Bolton Hospital on 27th September 2013 with suspected sepsis requiring IV antibiotics. He was also prescribed eye drops for and eye infection and that he was discharged home on the 30th September 2013.  6.295 On 16th October a further Home visit was made by HV1. Both MCI and FCI were present with Child I. Both were described as calm and engaging.  6.296 Feeding issues continue due to MCI’s medical issues and both MCI and Child I are suffering from thrush making feeding difficult. MCI was also experiencing back pain from a previous condition. MCI reported that Child I was struggling to open his bowels, but gaining weight well.  6.297 Both MCI and FCI discussed involvement of social care as positive and they feel supported.  6.298 On 20th October 2013, HV1 received notification that Child I had attended the Accident and Emergency Department at Royal Bolton Hospital at 01:37am. His parents had called 999.  6.299 Child I was reported to have had constipation for 1 week and a suspected breath holding episode when crying. Child I was seen with both parents and a suppository was given and advice to MCI and FCI to access their GP if symptoms persist.  6.300 On 22nd October 2013 MCI attended a baby clinic with Child I and he had a notable weight loss and MCI and FCI were asked to return with him to be reweighed in 2 days.  6.301 On 23rd October 2013 MCI and FCI were contacted by a health visitor requesting that they bring Child I to the clinic to be weighed. A message was left on the home answer phone.  6.302 At 9:50am HV1 made a further call to MCI and left a message on her mobile phone arranging a home visit for later in the day.  6.303 At 11:55am MCI and FCI were seen on the street by HV1 on her way to visit them at home. MCI and FCI reported that they were on their way to the GP as Child I was irritable and had a cold. HV1 arranged to see Child I in the clinic after the GP appointment.  6.304 Child I was seen by HV1 at 12:50pm and a student HV after the GP appointment. GP had reviewed Child I (and diagnosed a viral illness and advised ibuprofen for 3 days).  45  6.305 HV1 discussed feeding with both parents and parents reported that Child I was having wet and dirty nappies.   6.306 Child I was undressed by FCI on the changing mat and was moving all 4 limbs. He was reported to be alert, with good colour and tone noted but when weighed, further weight loss was noted.  6.307 HV1 said that she would monitor Child I’s weight and that he should be re-weighed on 31st October 2013 on the same scales.  6.308 HV1 also discussed symptoms and when to seek medical advice eg reduced fluid intake, reduced wet nappies, lethargic or irritable and any changes from his normal pattern.  6.309 HV1 shared the case conference report with MCI and FCI.  MCI read the report and requested no changes.  6.310 On 25th October 2013 at 2.20pm HV1 received a telephone call from the midwife informing her that a Strategy Meeting would be held at the Royal Bolton Hospital that afternoon. HV1 was unable to attend and attempted to call the social worker and the staff nurse on the children’s ward in Bolton however both were unavailable.  6.311 At 4.45pm on the same day HV1 contacted the children’s ward and spoke to the staff nurse caring for Child I who reported that the police were liaising with his parents and maternal grandparents. Child I was to remain on the ward over the weekend and a legal planning meeting is to be held on 28th October 2013.   6.312 The staff nurse confirmed that they were awaiting the results of the skeletal survey and scans and that FCI is to have no contact whilst MCI could have supervised contact on the ward.   6.313 It was planned for Child I to be discharged to his maternal grandparents on 28th October 2013.  Summary analysis of Health Visiting Involvement  6.314 HV1 acted immediately upon receiving the telephone call from FCI’s IAPT Therapist on 2nd October 2013. She made an immediate and appropriate referral to children’s social care.  6.315 HV1 was also persistent in ensuring that Child I was brought to the clinic to be weighed when it seemed as if MCI and FCI were delaying or avoiding doing so.  46  6.316 Although HV1 described FCI’s behaviour of punching, throwing and smashing objects and she also recorded that MCI attempted to manage FCI’s anger by not causing him additional stress she did not identify this as domestic abuse (nor did any other practitioner).  Recommendations  6.317 There are no service specific recommendations for the Health Visiting Service but recommendations in relation to domestic abuse at section 7 below do include the service. The Multi Agency Advice and Assessment Hub (MASH)  6.318 On 2nd October 2013 a telephone call was received at the MASH from the IAPT Therapist who had seen FCI in relation to his anger management. She relayed concerns from the Mental Health Access & Crisis team worker about FCI, who had voiced some concerns about his own thoughts to harm Child I. The IAPT Therapist also told the MASH that FCI smoked cannabis. The IAPT Therapist spoke to a MASH Social Worker Social Worker (SW1).  6.319 The IAPT Therapist was unaware of the name and date of birth of Child I, and did not know the midwife or health visitor’s details. A search on the name of FCI produced no results and SW1 advised the Therapist to  speak with a health visitor and gather the relevant information on a CAF form for one of two purposes – either to make a referral to children’s services using a CAF or to hold a Team around the Child meeting (TAC).  6.320 As the details of Child I were not known at this point by the referrer so a contact could not be recorded, the subsequent case note was added later.  6.321 Although the IAPT Therapist had very little information about the identity of the actual child, it should have been possible to use the multi-agency nature of the MASH to find out the Child I’s details and to proactively seek out the information about the referral from other agencies as information was known about the parents and their address.  6.322 If the health visitor had not called back later that day then a number of days may have elapsed before any action was taken.  Summary analysis of the MASH involvement  6.323 Given the nature of the initial call made to the MASH SW by the IAPT Therapist, the response give to the IAPT Therapist was inappropriate. The risk of potential harm to a new born baby was significant and asking the 47  IAPT Therapist to find out more information and then complete a CAF would have delayed safeguarding Child I.  Recommendations   6.324 Using this serious case review as a case study; the MASH team should ensure that their response processes are appropriate and timely.  6.325 At the end of any consultation with MASH there should be an agreement that both parties understand what actions are to be taken and whose responsibility the actions are. The MASH team members must take particular care where the referring practitioner appears to have little or no understanding of children’s safeguarding process or terminology eg TAC, CAF, CPP.  Children’s Social Care  6.326 On 2nd October 2013, a referral was received from the Health visitor. This was a detailed and clear referral and resulted in an Emergency Duty Team (EDT) worker visiting the family’s home that evening.  6.327 The home visit was carried out at 6pm on 2nd October by the EDT worker to check on the welfare of Child I. MCI, FCI and Child I were all seen at the visit.  FCI reported that his negative feelings were now 6/10 as opposed to 10/10 in the week after Child I’s birth.  FCI said he was having input from the Crisis Resolution Home Treatment mental health team.  FCI disclosed that he had made attempts of suicide as a teenager.  MCI disclosed that she was prescribed medication for psychotic depression but was not taking this due to breast feeding.  Both parents were involved with mental health services and both admitted to using cannabis.  6.328 Later that evening the EDT worker returned a telephone call to the IAPT Therapist and explained to her that he had no urgent concerns about the safety of Child I. The EDT summarised his assessment thus: • Dad is a cannabis user.  • Social care had no antenatal information regarding the family.  • The family were visited by a social worker the previous evening and dad was reported that his thoughts to harm Child I were 6/10 the previous evening.  • Dad had attempted suicide as a teenager and moved from Peterborough due to relationship difficulties with his stepfather. 48  • Mum is currently on no medication due to breast feeding. • Mum reports that dad is not violent towards her and is remorseful when he becomes angry. • Dad is mums carer and mum receives a carer’s allowance. • Case for an initial assessment by social care.  6.329 On 3rd October 2013, the EDT worker attempted to refer FCI to the Carer’s Service and discovered that he was already known to the service. He also learned from them that FCI considered himself a “connoisseur” of cannabis. The EDT worker endeavoured to speak to CPN1 but he was not in, so the Community Support Worker (CSO) said he would update him later, which she did.   6.330 The EDT Worker did not recognise the significant risk to Child I despite FCI rating his current thoughts of harming the baby at 6/10.  FCI’s thoughts and imagery of ‘crushing the baby’s windpipe’ or ‘dropping him’ to stop him crying were specific and would have been fatal or life threatening to a two week old baby.  6.331 The EDT worker also failed to recognise that there were very few, if any, protective factors in the family for Child I in that MCI had a serious mental illness, was in a critical post natal period and that FCI, who struggled with his anger and used cannabis, was her carer.  6.332 On 3rd October 2013 the referral of Child I to children’s social care was actioned as an initial assessment but a home visit was not undertaken.  6.333 A strategy discussion was also planned but this was not held for a further four days as it was a weekend.  6.334 On 4th October 2013 a further home visit was undertaken by Children’s Social Care Advice and Assessment Social Worker (SW3) and a CPO from the PPIU. This home visit records that the risks were explored and the concerns about Child I’s safety were reduced and he was seen to be safe and well. It was also noted that the CPN from the Crisis team had also visited. There is reference to a family friend staying and this being a protective factor over the weekend, thus ensuring safety until the strategy discussion on Monday 7th October 2013.  6.335 It is not clear from the records of this visit whether or not it was known that the family friend was only planning to stay for one night.  49  6.336 On 7th October a Strategy Meeting was held and chaired by the Team Manager from the Advice and Assessment Team.  6.337 The Issues discussed at the strategy meeting included: • Inconsistencies in the information that parents had provided to various professionals regarding their relationship, cannabis usage and FCI’s anger issues. • MCI reports that she uses cannabis as a pain relief for back pain. Dad has minimised their cannabis use. • The couple reportedly met in Peterborough where FCI is from and MCI had moved there following the breakdown of a previous relationship. The couple were only together for 3 months when MCI became pregnant. • MCI’s previous history of self-harm and 3 previous suicide attempts.  • FCI is reported to have a poor understanding of MCI’s condition. • FCI is MCI’s carer. • When FCI was assessed as a carer for MCI, he reported that he had no mental health issues.  • Both MCI and FCI had given different accounts of FCI’s mental health status.  • The HV and MW reported that MCI had disclosed that FCI became angry quickly and throws, smashes and punches objects.  6.338 The actions agreed at the strategy meeting included: • Further mental health assessments of both parents. • Safety plan to be put in place until mental health assessments had been completed  • FCI was not to be left unsupervised with Child I. • Child Protection Case conference to be booked (this was later booked for 25th October 2013).  6.339 The meeting had multi-agency representation however CPN1 did not attend.  50  6.340 The meeting focused on the risks and protective factors in the situation for Child I. Although there was a clear recommendation that there was a risk mitigation or management plan involving the family friend or MCI and Child I moving to her parents’ home, the action regarding further mental health assessments of both parents does not reflect any understanding that the risk to Child I was not posed by FCI’s possible or undiagnosed mental illness but by his history of violence and aggression, his current imagery of harming Child I, his current aggressive behaviour towards MCI and his (and MCI’s) cannabis use.  6.341 It is not clear how the family friend staying with MCI and FCI would be monitored.  6.342 Following the strategy meeting SW3 telephoned CPN1 to ask why he had not attended (no record of his response was available). SW3 also requested a fax copy of CPN1’s assessment of FCI as this had not arrived.   6.343 On 8th October 2013, a home visit and case discussion was held by SW3 and the Team Manager of the Advice and Assessment Team.  6.344 Further liaison with CPN1, suggested that FCI is unlikely to act on his thoughts to harm his son, and MCI was stable and had insight. It was agreed that the family member or friend staying over is not, therefore, required. It would appear that a range of professionals, visiting and speaking with parents about their thoughts and feelings concluded that the risk was lessening and the management of risk plan is relaxed.  6.345 Less than 48 hours after stipulating that MCI and FCI should not be left unsupervised with Child I this requirement was felt to no longer be necessary. However; the indicators of potential risk had not changed, FCI had anger management issues, both MCI and FCI used cannabis, MCI had a severe mental illness and FCI, who admitted being angry and aggressive with MCI, was also her carer. It is difficult to reconcile these facts with the judgement that risk was lessening.  6.346 On 9th October 2013 a further telephone call took place between SW3 and CPN1. CPN1 reiterated that he believed that the risks remained low that FCI would harm his son. SW3 stated that she agreed. Then it is noted that  CPN1 would send over his reasons for this assessment. It appears that SW3 had therefore expressed her agreement with CPN1’s assessment without reading his reasoning.  Perhaps this was explained sufficiently to her in the phone call or perhaps there was a lack of challenge to the CPN about his low risk assessment.  51  6.347 Risk assessment formulation has to be conceived in relation to the likelihood of something happening and the seriousness of the likely event. FCI had thoughts where he visualised ‘crushing his baby’s windpipe’, acting upon such a thought may be a low likelihood of happening but the seriousness and consequences of such violence to a new-born baby means that the risk should not have been assessed as low. Additionally, FCI had never rated his own thoughts below 6/10 in intensity.  6.348 On 11th October 2013, SW3 carried out a home visit and records that she observed positive family support, positive interaction between Child I and FCI and home conditions were also positive. There was discussion of the case going to a Child Protection conference.  6.349 On 25th October 2013 at 5.40am the Children’s Social Care EDT was contacted by a staff nurse at the Royal Bolton Hospital. The Staff Nurse explained that Child I had been admitted to the ward at around 1am that morning as there were concerns about his weight loss and blood in his urine. The EDT worker spoke to the Paediatric Registrar who confirmed that Child I had been admitted due to weight loss and blood in his urine, however, upon examination some bruising had been noted on Child I.  There was a small bruise just below his left nipple and on his buttock and also some small scratch marks on the back of his neck.  6.350 The EDT worker discussed current Child Protection case conference that was due to be held and read over case history and reports and had a 45 minute discussion with Registrar.  6.351 MCI and FCI’s explanation was that the bruises were caused following a call to NHS Direct who advised that as Child I was a little unresponsive when they called for support to pinch him slightly to a small area to get him to respond.  6.352 The Registrar felt that this could be an explanation for maybe one bruise but there was evidence that this pinch may have been quite heavy and there was clear indication on the case notes that FCI had admitted thoughts/images of harming the baby by crushing his wind pipe.  6.353 The Registrar reported that FCI had left the ward due to hospital policy over 1 parent staying and MCI was with Child I.  6.354 The following plan of action was immediately implemented: • Until this can be discussed with allocated social worker and team nurses to closely observe mother and baby. • FCI not to have any unsupervised contact with baby. 52  • Maternal grandmother to be called into hospital as evidently a protective factor.  • Full skeletal surveys to happen today.  6.355 MCI and FCI were open with hospital staff about the Child Protection conference that was arranged for later that day and wanted to make sure that the allocated social worker knew that they would not be able to attend.  6.356 At 6.45am the EDT worker was again contacted by the Paediatric Registrar who informed her that FCI was actually on the ward and was asleep on the floor of the room and had not been noticed before by the staff who had gone into the room. FCI would be asked to leave the ward immediately. MCI was breast feeding the baby and it was felt that there was insufficient reason to ask her to leave at this time as the highlighted risk in respect of harm came from FCI.  6.357 The liaison and decision making between the EDT worker and the Paediatric Registrar was good.  6.358 At 9.30am on the same day the Initial Case Conference in respect of Child I was held.  6.359 The Independent Reviewing Officer (IRO) highlighted that much of the information gathered was self-reported by parents and there were discrepancies in the information provided to different professionals especially around his drug use and anger issues.   6.360 Both MCI and FCI have a history of using class ‘A’ drugs and FCI has been a heavy alcohol user in the past.  6.361 There was agreement that Child I would be placed on a child protection plan under the category of physical abuse.  6.362 Later on 25th October 2013, a second strategy meeting was held following the discovery of bruises to Child I at the Royal Bolton Hospital and the decision was made to safeguard Child I by ensuring that he remained supervised in hospital and to seek advice on protective legal action.  6.363 Child Protection Case report details that: • Child I had a nail mark at back of his neck consistent with being held too tight and a bruise below his nipple and on his buttock. 53  • It was also noted that MCI and FCI stated that NHS Direct had advised them to pinch the baby’s buttock. • The police confirmed that they would listen to recordings via NHS Direct. • FCI had been asked to leave hospital grounds. • The Health visitor informed the conference that she had examined Child I thoroughly on 24th October and had not noticed any bruising.  6.364 The outcome of the conference was recorded as: • The Chair of the conference did not consider MCI or FCI to be low risk given MCI’s mental health, joint use of cannabis and FCI’s anger/imagery. • A Child Protection Plan agreed with forensic assessment for MCI and FCI. • MCI and FCI to attend the Community Drug and Alcohol Team for random testing. • Multi-agency approach • CPN1 to provide more information about MCI’s mental health history  Summary analysis of Children’s Social Care involvement  6.365 Social care staff, on the whole, relied upon and were reassured by CPN1’s assessment of FCI as being at low risk of acting out his violent thoughts.  6.366 The other well known risk factors to children and particularly to unborn and newly born babies, which were present were not acknowledged, assessed or responded to until actual injuries to Child I had been discovered.  6.367 There were instances of good practice but these were not enough to prevent Child I from being harmed.  6.368 Social care practitioners were also reassured by MCI and FCI’s presentation and their willingness to engage.    54  Recommendations  6.369 The learning from this serious case review should be disseminated amongst social care practitioners as soon as possible.  6.370 Joint training and awareness raising with community based mental health practitioners should be considered in order to embed the lessons into practice. This training and awareness raising will enable practitioners from both disciplines to share perspectives and experiences of recognising, assessing and responding to risks to children and young people.  Police  6.371 On 3rd October 2013 the Public Protection Investigation Unit (PPIU) of Greater Manchester Police received a referral from Children’s Services regarding concerns raised about FCI having thoughts of harming his 2 week old son.  6.372 The investigation was assigned to a child protection officer (CPO).  6.373 At 3.40 pm on 3rd October 2013 the CPO and the SW3 attended at the home address of the family.  6.374 The journal page of the PPIU document details the information gathered by the CPO and social worker during the course of the home visit.  The officer comments on the general living conditions and notes “on arriving into the property it was clean and tidy, the baby appeared clean, healthy and well cared for. He was sleeping in a Moses basket in the lounge”.   6.375 The officer details the history of the family she has established, the physical ailments of MCI and the apparent mental health concerns for both MCI and FCI. She noted the involvement of a number of health care professionals involved with the family. The officers summarises by stating: “ It appears at this stage both FCI and MCI are aware of their issues and have addressed them accordingly by contacting the appropriate agencies for support”.  6.376 The officer completed all relevant police checks, which revealed that neither parent had any criminal convictions, and were not known to police in the area or in Peterborough. The agreed actions are noted: “After a review of the circumstances it was jointly agreed with SW3 and myself that a long term friend of MCI namely XX would move in overnight to address the immediate safeguarding concerns for Child I. Strategy meeting to be arranged by SW3. It is felt at this time it is likely to be a child in need care package.”  55   6.377 The officer also completes all relevant police checks on XX which reveal she is not known to police.  6.378 During this visit FCI reiterated that he had only ever had thoughts about harming Child I but that he would never do it. This seemed to be the only reassurance offered that the very specific and very violent thoughts that FCI had never rated below 6/10 in strength would not be acted out. FCI’s cannabis use was not referred to and not recognised as a possible compounding risk factor.  6.379 The police recording of the strategy meeting held on 7th October 2013 included comprehensive documentation, the information shared and action plan agreed. The officer recorded the outcome of the meeting, which included an action for mental health assessments on both parents. It was noted there was still a requirement for 24 hour supervision by either the family friend or maternal grandparents.  6.380 On 16th October 2013, the CPO recorded that a decision to take the family to Initial case Conference on 25th October 2013 had been made. She noted a decision has been made to remove the 24 hour support requirement as a result of the conclusions of CPN1.  6.381 There is no information as to whether the police had any input or discussion regarding this decision. The CPO records that there is no requirement for ongoing police investigation and requested that the document was closed. A Detective Sergeant reviewed the case and closed it on 17th October 2013.  6.382 The reality of the investigation at this point was that there have been no criminal offences committed and the officers are dealing with a parent who has expressed thoughts of what he may do.  6.383 The officer’s decision and that of her supervisor are based on the result of mental health assessments, where the risk has been deemed as low.  Summary analysis of Police involvement  6.384 Although the police officers were guided by the expert medical opinion in this case, FCI had admitted to violent thoughts and also admitted to regular cannabis use. He had also admitted to being aggressive with MCI meaning that even in the absence of a mental illness, FCI was still a potential risk to Child I. These risks were not given sufficient focus by the police officers in this case.  56  Recommendations  6.385 The learning from this serious case review should be disseminated to the relevant police officers as soon as possible with an emphasis on the combination of risk factors which existed and/or presided from shared knowledge from partner agencies with or without a mental health diagnosis for FCI.  Making Space; The Carers Service  6.386 FCI’s initial contact with Making Space was on 25th July 2013. There were further routine contacts with the service on 29th and 30th August 2013 to progress FCI’s carer’s assessment.  6.387 On 3rd October the Making Space service was contacted by SW2 who advised a Carer’s Support Worker (CSW) that he had visited the family following concerns by children’s services by the IAPT Therapist involved with FCI around anger management.  FCI had expressed ideas of harming baby.  SW2 had visited the family at 5.45 pm previous evening with no concerns regarding immediate risk.  SW2 had suggested carer support to FCI which he had expressed a willingness to accept.  The CSW discussed her involvement with FCI with SW2.  The CSW then telephoned FCI who confirmed receipt of the carer’s assessment documents but he explained that he hadn’t got back to the CSW due to the birth of his son.  He informed the CSW that Child I and MCI were well & said they were receiving lots of support.  The CSW advised FCI that she had spoken with SW2 who had visited the previous day.  6.388 FCI admitted to the CSW that he had had thoughts of pressing baby’s windpipe & that this had first happened within the first few days of him being born when Baby I was “crying for food”.  FCI informed the CSW that the thoughts had reduced.  The CSW offered additional support which was accepted & arranged to meet FCI on 10th October 2013.  6.389 The CSW did not appear to seek internal guidance or consult with a colleague or manager about what FCI or SW2 had told her. Her management of the case and contact with FCI and the family would have required specific support and supervision.  6.390 The CSW met with FCI on 16th October 2013.  FCI wished for some amendments to be made to his carer’s assessment. He spoke with the CSW about the other support the family had received.  FCI admitted the thoughts he had about Child I and that he had discussed this with police and social services.  FCI informed the CSW that he had not had any more 57  such thoughts.  He said he felt the support the family was receiving was adequate.  6.391 FCI said that he has been referred to mental health services and was awaiting an appointment from the CMHT.  FCI showed the CSW photos of Child I on his mobile phone and spoke about him with enthusiasm & affection.   Summary Analysis of Making Space Carer’s Service involvement  6.392 The CSW did not raise or share any child safeguarding concerns when FCI told her that he had thoughts of ‘crushing the baby’s windpipe’ or that he used cannabis.  6.393 Given that the CSW is likely to come into contact with families, who share some of the same characteristics as Child I’s family it is vital that she and her colleagues understand their crucial role in multi-agency working and information sharing.  Recommendations  6.394 Using the learning from this serious case review carer’s support workers should be required to attend training and awareness raising, which focuses on risk factors to children and young people.  6.395 The Making Space service should provide the LSCB with assurance about the quality and take up of safeguarding training and the awareness and competency of the service’s workforce and provide assurance that the service’s policy and process reflects the duty to safeguard children and young people.   A summary of events post 28th October 2013  6.396 The skeletal examination of Child I revealed that he had a fracture to his leg and two broken ribs.  6.397 Following this examination communication between the different agencies involved with Child I, FCI and MCI focused on: • Keeping Child I safe (an emergency care order was applied for and Child I was placed with foster carers). • Instigating a criminal investigation into a Section 20 wounding -Grievous Bodily Harm. 58  • Sharing of information. • Ensuring appropriate support was put in place for MCI.  Key Themes and Issues  The Parent’s Presentation  6.398 Some practitioners who participated in the structured conversations described MCI and FCI as ‘strange’. Other practitioners who came into contact with MCI and FCI described their presentation as credible, respectful and positive. They appeared to welcome most help, which was offered. These attributes were seen, in some instances, through a retrospective lens, and it is vital that practice and supervision enable practitioners to ‘stand back’ and reflect on families, who may not present as resistant and who can provide credible reassurance.  6.399 Despite the fact that FCI told practitioners repeatedly that he either had general concerns about how he would cope with his anger once his baby had been born or reported very specific images and thoughts of harming the baby once he had been born, practitioners were reassured by his presentation as friendly, calm and gentle.  6.400 FCI’s unusual appearance was commented on by several practitioners and it was believed that FCI identified with a particular sub culture. This sub culture identity has been associated with an over respectful/under challenging response from practitioners who wish to present as non–judgemental and may have been an influence in this case.    6.401 It was also pointed out that the relationship between the parents seems to switch dynamics.  There are some reports that it was like a mother and son relationship as MCI is older than FCI.  There are also reports that FCI was MCI’s carer and was dominant and angry towards her.  6.402 One practitioner stated that FCI was “the calmest angry man on the planet”.   6.403 MCI and FCI provided practitioners with reassurance about the amount of cannabis FCI was using and about FCI’s ability to remove himself from any situation in which he felt his anger rising and practitioners did not challenge MCI or FCI on either issue.  6.404 Lack of sceptical challenge can arise from training deficits so the practitioner may not realise there is actually something to be worried about but often it is to do with either the dynamic of the relationship of 59  the practitioner with the family or the degree to which organisational culture and ‘daily practice’ supports challenge (e.g. supervision which is challenging provides a model for work with families). Challenge can be perceived as aggressive or confrontational rather than a request for more information.  Sometimes practitioners do not challenge as they believe it will damage trust with families.   6.405 The value of taking a sceptical stance in the interests of child safety is perfectly demonstrated in this case and the challenge for BSCB and its partners is to support staff and their line managers to see the appropriateness of challenge as a search for more information.  Recommendations  6.406 It is recommended that BSCB and its member agencies consider how they can model positive challenge in the way that will help staff have the confidence to rigorously inquire into potential abuse.   6.407 Adopting a reflective approach to case management, supervision and ongoing professional development which incorporates an understanding of complex and compounding risk offers opportunities for agencies and practitioners to improve their responses to families and crucially, to enhance the safety and protection of children. Such approaches should offer opportunities for individual professionals and multi-agency groups of professionals to reconsider their work in this area; this should take into account how they understand complexity and their response to it.  Communication and Information Sharing  6.408 Ofsted’s evaluation of serious case reviews from 1 April 2009 to 31 March 2012 identifies that nationally there are problems in how information is sought and shared. Many serious case reviews identify issues in regard to the importance of securing relevant historical information in order to inform current assessments.  6.409 Good information sharing can be characterised by a clear understanding and shared knowledge about a child within the context of his/her family, as they progress through various systems of help and support that they and their families encounter.   6.410 Communication between practitioners in this case was poor. There were many occasions on which critical information should have been shared and these include:  60  • FCI’s GP did not share the information about FCI’s cannabis use or anger management issues with the midwifery service.  • The HTT worker did not share information about FCI’s violent imagery and thoughts with children’s social care or the midwifery service.  • The Midwifery Service did not share information with the Health Visiting Service about MCI’s mental health diagnosis or FCI’s anger management issues and cannabis use.  Recommendations  6.411 Using the learning from this serious case review BSCB partners should ensure that communication and information sharing between agencies is consistently and appropriately focused on describing and sharing any potential or existing safeguarding concerns.  6.412 Relevant BSCB partners should consider developing guidance for ‘cause for concern triggers’ from Midwifery to Health Visiting to ensure that triggers are commonly understood and standard responses are described.  Supervision  6.413 This serious case review demonstrates the importance of including child safeguarding as a ‘standing agenda item’ in the supervision of community mental health, carer’s support workers, primary care health workers and social care staff.    6.414 The IAPT Therapist in particular was left without supervision or clarity about who she should approach with concerns about clients despite the fact that FCI was her first client after a long absence from work.  6.415 Some practitioners described MCI and FCI as ‘strange’ but many more reported that they were ‘calm’ ‘relaxed’ and ‘welcoming’. These attributes were seen, in some instances, through a retrospective lens, and it is vital that practice and supervision enable practitioners to ‘stand back’ and reflect on families who may not present as complex or high risk.  Recommendations  6.416 BSCB has recently introduced support through a Practitioners Forum for all frontline practitioners working with children and families in Bury ensuring that they have access to extended/enhanced supervision and 61  group support to discuss themes and concerns about families with complex needs and/or multiple risk factors.   6.417 HV1 may have felt isolated in recognising and responding to the risks to Child I and the impact of this on her practice could have been detrimental had she not been confident in her assessment of the situation. It is recommended therefore that the Practitioners Forum as it develops, provides support to practitioners when they may be the ‘lone voice’ attempting to respond to or escalate child safeguarding concerns.  6.418 BSCB should seek assurance that partner agencies understand local escalation policy and that frontline staff are confident and supported to use it appropriately in order to escalate their concerns.  Domestic Abuse  6.419 Both MCI and FCI described elements of their relationship which were indicators that domestic abuse was occurring. These were significant and included FCI admitting that he ‘took things out on’ MCI and punched walls and pillows. MCI also told practitioners that she tried not to add to FCI’s levels of stress.  6.420 MCI was asked about domestic abuse as part of her ante natal screening.  However, many women do not disclose that abuse is occurring even if they are asked a direct question about it. This can be for many reasons and in some cases women do not recognise what is happening to them as domestic abuse particularly if this is not acted out with physical violence.  6.421 The way in which the relationship between MCI and FCI appeared to practitioners may also have contributed to the assessment that there were no domestic abuse was occurring or have led to no domestic abuse specific assessment being carried out at all.  Recommendations  6.422 Domestic abuse is a key indicator that children (including unborn babies) are at risk. It is recommended that BSCB contributes to the development of the Borough’s Domestic Abuse Strategy with specific focus on actions to improve safeguarding outcomes for children affected by domestic abuse. This should include advanced training for relevant practitioners eg social care staff, health visitors, midwives, community mental health teams including CAMHS.  6.423 Training, awareness raising and supervision of staff needs to reflect the increased risk to children where mental illness and substance misuse 62  (including the over use of mood altering drinks) co-exist with domestic abuse.   7 AREAS OF GOOD PRACTICE  7.1 The IAPT Therapist once informed of FCI’s thoughts and images of hurting Child I persisted in her attempts to share and escalate her concerns. She also hand delivered a letter containing vital information to the Health Visiting Service and ensured that the HV was fully informed before she undertook the primary visit the following day.  7.2 The Health Visitor in this case responded immediately and appropriately once alerted by the IAPT Therapist about FCI’s violent thoughts. The Health Visitor’s record keeping was exemplary and enabled a thorough understanding of her decision making and the actions she then took.   8 SUMMARY OF KEY LESSONS AND ASSOCIATED RECOMMENDATIONS  8.1 From the family’s arrival in Bury in June 2013 and the date that bruising was noticed on Child I’s torso on 25th October 2013, 28 different practitioners had contact with MCI, FCI and Child I.  8.2 With a few notable exceptions the practitioners did not recognise, assess and respond to the risks posed to Child I before or after he was born.  This was because:  • Practitioners were reassured by MCI and FCI’s friendly and welcoming manner and their willingness to accept help.  • The focus of the majority of interventions and risk assessments were the two adults.  • The assessment of risk posed by the potential mental illness of FCI was a ‘red herring’ and the fact that FCI had violent thoughts and anger management issues, that MCI had a psychotic illness and that both parents admitted using cannabis were not recognised as risk factors to a new born baby.  • As previously stated in this report; most men who harm their children (or the children of their partners) are not mentally ill.  63  • The contrary is true of adults with a known mental illness, in which case it is mothers who harm their children more than fathers/men.  8.3 There were several critical opportunities to protect Child I from harm, which were lost and there is important learning from this serious case review which is reflected in the recommendations summarised below.  1. Peterborough Safeguarding Children Board should share the learning from this serious case review with the Midwifery Service and in particular ensure that midwives are able to identify, assess and respond to risks to unborn and newly born babies. These responses would include pre-birth assessments, multi agency risk assessment conference, and referral to children’s social care.  2. Using learning from this and other serious case reviews the Bury Clinical Commissioning Group should assure itself and the LSCB that GPs understand the risk factors of domestic abuse, physical abuse, drug or alcohol use and mental health for unborn babies and children and make appropriate referrals to Children’s Social Care and assure itself that the outcome of those referrals is also appropriate.  The baseline could be based on CIN census 2013/14.  This might require a specific focus upon developing a simple method of quantifying and qualifying GP referrals to children’s social care and identifying the most appropriate people within the health community to carry out this work.    3. The learning from this serious case review should be disseminated to mental health practitioners as soon as possible and via a variety of means eg for community based psychiatric nurses or care co-ordinators there should be specifically tailored training and awareness raising activities using this serious case review as a case study. Any briefings or training needs to specifically include the impact of parental/adult health difficulties on children and risk assessment processes where children are in the household.  4. The supervision of community based mental health practitioners should be reviewed in light of the learning from this serious case review to ensure that supervision policy and practice focuses consistently upon child safeguarding. Particular emphasis should be placed on the needs of newly qualified staff or staff returning to practice.    5. Learning from this serious case review should be used to inform community based mental health practitioners about the nature and importance of multi–agency safeguarding arrangements and their responsibilities to share information with others when it concerns risks to 64  a child and the crucial role they play in contributing to TAC, CAF and CPP arrangements.   6. The impact of FCI’s cannabis use and high energy drink consumption on his mood and significantly his anger responses was not challenged or explored by any practitioner.  It was noted by the serious case review panel that services who are equipped to respond to such use are extremely limited or none existent for adult clients.  Given wide anecdotal evidence that high energy drinks are now commonly used BSCB should satisfy itself that the potential risk to children living with parents who use emerging and better known substances of abuse should be understood by all partner agencies.   The notion of self-reported use and potential for disguised compliance in treatment services should be a focus of this understanding. 7. The midwifery service should use the learning from this serious case review to refresh midwives’ awareness of the combined impact of drug use, parental mental illness and violence on pregnant women and unborn and newly born babies.  8. Management of midwives should also audit and promote the use of CAF or Team around The Child meetings. 9. Communication between the midwifery and health visiting service should be reviewed to ensure that families with risk factors such as mental illness, substance misuse, physical or learning disabilities, or domestic abuse are ‘red flagged’ so that the health visiting service have all possible information and can prioritise their caseloads. 10. Using this serious case review as a case study; the MASH team should ensure that their response processes are appropriate and timely.  11. At the end of any consultation with MASH there should be an agreement that both parties understand what actions are to be taken and whose responsibility the actions are. The MASH team members must take particular care where the referring practitioner appears to have little or no understanding of children’s safeguarding process or terminology e.g. TAC, CAF and CPP. 12. The learning from this serious case review should be disseminated amongst social care practitioners as soon as possible. 13. Joint training and awareness raising with community based mental health practitioners should be considered in order to embed the lessons into practice. This training and awareness raising will enable practitioners from both disciplines to share perspectives and experiences of recognising, assessing and responding to risks to children and young people. 65  14. The learning from this serious case review should be disseminated to the relevant police officers as soon as possible with an emphasis on the combination of risk factors, which existed and/or presided from shared knowledge from partner agencies with or without a mental health diagnosis for FCI. 15. Using the learning from this serious case review carer’s support workers should be required to attend training and awareness raising which focuses on risk factors to children and young people. 16. The Making Space service should provide the LSCB with assurance about the quality and take up of safeguarding training and the awareness and competency of the service’s workforce and provide assurance that the service’s policy and process reflects the duty to safeguard children and young people. 17. It is recommended that BSCB and its member agencies consider how they can model positive challenge in the way that will help staff have the confidence to rigorously inquire into potential abuse.  18. Adopting a reflective approach to case management, supervision and ongoing professional development which incorporates an understanding of complex and compounding risk offers opportunities for agencies and practitioners to improve their responses to families and crucially, to enhance the safety and protection of children. Such approaches should offer opportunities for individual professionals and multi-agency groups of professionals to reconsider their work in this area; this should take into account how they understand complexity and their response to it. 19. Using the learning from this serious case review BSCB partners should ensure that communication and information sharing between agencies is consistently and appropriately focused on describing and sharing any potential or existing child safeguarding concerns. 20. Relevant BSCB partners should consider developing guidance for ‘cause for concern triggers’ from Midwifery to Health Visiting to ensure that triggers are commonly understood and standard responses are described. 21. BSCB has recently introduced support through a Practitioners Forum for all frontline practitioners working with children and families in Bury ensuring that they have access to extended/enhanced supervision and group support to discuss themes and concerns about families with complex needs and/or multiple risk factors.  22. HV1 may have felt isolated in recognising and responding to the risks to Child I and the impact of this on her practice could have been detrimental had she not been confident in her assessment of the situation. It is recommended therefore that the Practitioners Forum as it develops, 66  provides support to practitioners when they may be the ‘lone voice’ attempting to respond to or escalate child safeguarding concerns.    23. BSCB should seek assurance that partner agencies understand local escalation policy and that frontline staff are confident and supported to use it appropriately in order to escalate their concerns. 24. Domestic abuse is a key indicator that children (including unborn babies) are at risk. It is recommended that BSCB contributes to the development of the Borough’s Domestic Abuse Strategy with specific focus on actions to improve safeguarding outcomes for children affected by domestic abuse. This should include advanced training for relevant practitioners e.g. social care staff, health visitors, midwives, community mental health teams including CAMHS. 25. Training, awareness raising and supervision of staff needs to reflect the increased risk to children where mental illness and substance misuse (including the over use of mood altering drinks) co-exist with domestic abuse.  9 GLOSSARY  Child I Subject of Serious Case Review (Case I13) MCI Mother of Baby I FCI Father of Baby I   ACTW Mental Health Access & Crisis Team Worker  ANP Advanced Nurse Practitioner BPL Bereavement Project Lead BSCB Bury Safeguarding Children Board CAF Common Assessment Framework CAMEO Team Mental Health Team within Peterborough, which supports young people under age 25 with psychotic illness CAMHS Child & Adolescent Mental Health Service CPN Community Psychiatric Nurse CPN1 Community Psychiatric Nurse who was care co-ordinator for MCI CPN2 Community Psychiatric Nurse CPN3 Community Psychiatric Nurse CPO Child Protection Officer (Police) CPP Child Protection Plan CSO Community Support Worker (Mental Health) CSW Carer’s Support Worker Dr1 Consultant Psychiatrist for MCI DSW Duty Social Worker EDT Emergency Duty Team (Social Care) EIT Early Intervention Team (Mental Health) 67  GP General Practitioner HTT Mental Health Home Treatment Team HV Health Visitor HV1 Family’s Health Visitor IAPT Improved Access to Psychology Therapies IRO Independent Reviewing Officer LSCB Local Safeguarding Children Board MASH Multi-agency Safeguarding Hub Midwife 1 Ante-natal midwife Midwife 2 Post-natal midwife MW Midwife NCRS National Computerised Records System (Mental Health) PCFT Pennine Care Foundation NHS Trust PCMHN Primary Care Mental Health Nurse PPIU Public Protection Investigation Unit (Police) PSCB Peterborough Safeguarding Children Board RAID Mental Health Rapid Assessment, Interface & Discharge Team SCIE Social Care Institute for Excellence SCR Serious Case Review SW1 Social Worker 1 (MASH Team) SW2 Social Worker 2 (Emergency Duty Team) SW3 Social Worker 3 (Advice & Assessment Team) TAC Team Around the Child TARA Trust Approved Risk Assessment (Mental Health) 68  10 MULTI-AGENCY ACTION PLAN  On behalf of Bury Safeguarding Children Board the implementation of all recommendations will be monitored by the BSCB Serious Case Review Sub Group on a quarterly basis. This will be reported to the BSCB Business Group.  Auditing of compliance with procedures is undertaken by the BSCB Monitoring and Evaluation Sub Group.  No. Recommendation Key Actions Evidence  Key Outcome Lead Agency/ Personnel Completion Date Peterborough Safeguarding Children Board 1. Peterborough Safeguarding Children Board should share the learning from this serious case review with the Peterborough Midwifery Service and in particular ensure that midwives are able to identify, assess and respond to risks to unborn and newly born babies.  These responses would include pre-birth assessments, multi-agency risk assessment conference, and referral to children’s social care.           1.1 Letter to be sent to Peterborough Safeguarding Children Board to request that they oversee this action and that they provide feedback once the action has been completed. Feedback from Peterborough Safeguarding Children Board Midwives are made aware of issues which have arisen from this SCR. Peterborough Safeguarding Children Board 1.1 31 March 2015 69  No. Recommendation Key Actions Evidence  Key Outcome Lead Agency/ Personnel Completion Date Bury Clinical Commissioning Group 2. Using learning from this and other serious case reviews the Bury Clinical Commissioning Group should assure itself and the LSCB that GPs understand the risk factors of domestic abuse, physical abuse, drug or alcohol use and mental health for unborn babies and children and make appropriate referrals to Children’s Social Care and assure itself that the outcome of those referrals is also appropriate.  The baseline could be based on CIN census 2013/14.  This might require a specific focus upon developing a simple method of quantifying and qualifying GP referrals to Children’s Social Care and identifying the most appropriate people within the health community to carry out this work.    Working with the Local Authority establish the baseline number of current referrals and contacts from GPs to Children’s Social Care over a 6 month period and benchmark against statistical neighbours  Commission a qualitative audit of a series of GP referrals to MASH  If the data evidences that Bury GPs are outliers in referral rates, additional targeted work will be considered.  Provide the BSCB with current training figures for GPs and outline of the content of the sessions which will incorporate the learning from SCRs. The number of predicted and actual contacts/ referrals.                Training figures submitted to BSCB. Copies of actual powerpoints and annual training programme submitted to LSCB Comparable referral rates to statistical neighbours      An understanding of the reasons that GPs refer to CSC Bury CCG End of September 2015 70  No. Recommendation Key Actions Evidence  Key Outcome Lead Agency/ Personnel Completion Date Pennine Care Foundation NHS Trust 3. The learning from this serious case review should be disseminated to mental health practitioners as soon as possible and via a variety of means eg for community based psychiatric nurse or care co-ordinators there should be specifically tailored training and awareness raising activities using this serious case review as a case study.  Any briefings or training needs to specifically include the impact of parental/adult health difficulties on children and risk assessment processes where children are in the household. 3.1  BSCB to prepare briefing on learning from SCR.  3.2  BSCB to ensure report received from agencies, which details how and when the learning from serious case review has been disseminated to staff.   NB:  Actions 3, 7, 10, 12, 14 & 15 are linked.  3.3   PCFT to liaise with other local acute and community health providers in Bury to develop specific training and awareness raising events for mental health practitioners regarding recognition and response to risks to babies and children.  3.4  PCFT to develop ‘walking in their shoes’ events involving 3.1  Briefing sheet    3.2  Report           3.3  Training figures submitted to BSCB.  Copies of actual powerpoints and annual training programme submitted to LSCB      3.4  Training figures submitted to BSCB.  Copies Practitioners are made aware of the learning from this SCR.            Practitioners better able to recognise risk to infants and children and respond appropriately      Practitioners better able to recognise risk to BSCB    Pennine Care Foundation NHS Trust         Pennine Care Foundation NHS Trust          Pennine Care Foundation NHS Trust End Feb 2015    End June 2015           End June 2015            End June 2015 71  No. Recommendation Key Actions Evidence  Key Outcome Lead Agency/ Personnel Completion Date frontline staff involved in this case sharing their experiences and reflections on this case  of actual powerpoints and annual training programme submitted to LSCB infants and children and respond appropriately  4. The supervision of community based mental health practitioners should be reviewed in light of the learning from this serious case review to ensure that supervision policy and practice focuses consistently upon child safeguarding.  Particular emphasis should be placed on the needs of newly qualified staff or staff returning to practice. 4.1  PCFT to review the current supervision model for Community Mental Health teams alongside the Tier 4 group Community Mental health services  4.2  PCFT to ensure that community mental health teams are included in the wider review of safeguarding supervision in CSB.  Include opportunities for emphasis on the needs of newly qualified and staff returning to practice within supervision  4.3  The PCFT Safeguarding Team to complete random audits of the TARA (risk assessment) 4.1  Report to PCFT safeguarding lead and BSCB to update on findings and detailed actions from review  4.2  Report to PCFT safeguarding lead and BSCB to update on findings and detailed actions from review       4.3  Report to PCFT safeguarding lead and BSCB   Practitioners have access to good quality supervision that is inclusive of consideration of the risks and vulnerabilities of infants and children Pennine Care Foundation NHS Trust June 2015 72  No. Recommendation Key Actions Evidence  Key Outcome Lead Agency/ Personnel Completion Date that asks all mental health staff to consider child safeguarding to ensure that risks are accurately recognised and responded to. 5. Learning from this serious case review should be used to inform community based mental health practitioners about the nature and importance of multi-agency safeguarding arrangements and their responsibilities to share information with others when it concerns risks to a child and the crucial role they play in contributing to Team Around the Child (TAC), Common Assessment Framework (CAF) and Child Protection (CP) arrangements.       5.1  Ensure that compliance with child safeguarding training is met within community mental health services to the levels indicated within the intercollegiate document.  This is inclusive of attendance at LSCB multi agency training.  5.2  The safeguarding team to work alongside the early help provision within the local authority to support awareness raising within adult mental health services of recognition and response to risks to vulnerable infants and children including CAF, 5.1  Training figures to be submitted to BSCB         5.2  Evaluate learning at regular intervals (3-6 months) post training to ensure competence as well as compliance Practitioners are able to understand the provisions for early help and recognise their responsibility to participate and contribute with multi-agency arrangements to safeguard children Pennine Care Foundation NHS Trust June 2015 73  No. Recommendation Key Actions Evidence  Key Outcome Lead Agency/ Personnel Completion Date TAC and CP arrangements within adult services.  NB:  Actions 5 & 13 are linked. BSCB 6. The impact of FCI’s cannabis use and high energy drink consumption on his mood and significantly his anger responses was not challenged or explored by any practitioner. It was noted by the serious case review panel that services, who are equipped to BSCB Parental Substance Misuse Course to be updated to include information on emerging substances and the risk of self-reporting and disguised compliance. Updated course materials Practitioners are made aware of up-to-date information and learning from this SCR in relation to substance misuse BSCB T & D Sub Group End March 2015 74  No. Recommendation Key Actions Evidence  Key Outcome Lead Agency/ Personnel Completion Date respond to such use are extremely limited or non-existent for adult clients.  Given wide anecdotal evidence that high energy drinks are now commonly used, BSCB should satisfy itself that the potential risk to children living with parents who use emerging (and better known) substances of abuse should be understood by all partner agencies.  The notion of self-reported use and potential for disguised compliance in treatment services should be a focus of this understanding.  Bolton NHS Foundation Trust Midwifery Service 7. The Midwifery Service should use the learning from this serious case review to refresh midwives’ awareness of the combined impact of drug use, parental mental illness and violence on pregnant women and unborn and newly born babies.  7.1  BSCB to prepare briefing on learning from SCR.  7.2  BSCB to ensure report received from agencies, which details how and when the learning from serious case review has been disseminated to staff.  7.1  Briefing sheet    7.2  Report       Practitioners are made aware of the learning from this SCR.        BSCB    Bolton NHS Foundation Trust Midwifery Department    End Feb 2015    End June 2015       75  No. Recommendation Key Actions Evidence  Key Outcome Lead Agency/ Personnel Completion Date NB:  Actions 3, 7, 10, 12, 14 & 15 are linked.  7.3  All midwives attend mandatory training which includes safeguarding.  Training from January 2015 will highlight the issues and raise awareness of substance misuse, domestic abuse and mental health whilst also highlighting the learning from this review    7.3  % of midwives attending mandatory training.  Safeguarding audit undertaken bi-annually    7.3  Raised awareness and appropriate management of these complex cases    7.3  Bolton NHS Foundation Trust Midwifery Department & Pennine Acute Hospitals NHS Trust Midwifery Department    End Dec 2015 8. Management of midwives should also audit and promote the use of Common Assessment Framework (CAF) and Team Around the Child (TAC) meetings. Matron and team leader will monitor statistics and promote within the team. Statistics collected for safeguarding include no of CAFS initiated and on-going and all TAC meetings Appropriate use of CAF as indicated.  TAC meetings arranged when other professionals involved.  Safeguarding supervision already in place. Bolton NHS Foundation Trust Midwifery Department/ Pennine Acute Hospitals Trust Midwifery Department March 2015   Ongoing/ March 2015 76  No. Recommendation Key Actions Evidence  Key Outcome Lead Agency/ Personnel Completion Date 9. Communication between the midwifery and health visiting service should be reviewed to ensure that families with risk factors such as mental illness, substance misuse, physical or learning disabilities, or domestic abuse are ‘red flagged’ so that the health visiting service have all possible information and can prioritise their caseloads. Continue with monthly meetings which already occur with outreach midwife. Other team midwives to meet monthly as a minimum.  Special Circumstance form will be sent as communication when risk factors identified.  Booking summary taken by midwifery services extracted from Euroking system sent to HV by 20 weeks      Recorded on special circumstance form.  Team Leader will seek feedback from health visiting service Improved communication and information sharing Royal Bolton Hospital Midwifery Department/ Pennine Acute Hospitals Trust Midwifery Department March 2015 Children’s Social Care (MASH) 10. Using this serious case review as a case study; the MASH team should ensure that their response processes are appropriate and timely. 10.1  BSCB to prepare briefing on learning from SCR.  10.2  BSCB to ensure report received from agencies, which details how and when the learning from serious case review has been disseminated to staff.   NB:  Actions 3, 7, 10, 12, 10.1  Briefing sheet    10.2  Report Practitioners are made aware of the learning from this SCR. BSCB    Children’s Social Care/MASH End Feb 2015    End June 2015 77  No. Recommendation Key Actions Evidence  Key Outcome Lead Agency/ Personnel Completion Date 14 & 15 are linked. 11. At the end of any consultation with MASH there should be an agreement that both parties understand what actions are to be taken and whose responsibility the actions are.  The MASH team members must take particular care where the referring practitioner appears to have little or no understanding of children’s safeguarding process or terminology eg TAC, CAF and CPP. 11.1  CAF form is no longer used as a mechanism for referral   11.2  MASH Team Manager to brief MASH staff regarding the need to confirm with callers that they are clear on the next steps to take following the contact with the MASH Team. 11.1 Amended CAF form / separate referral form  11.2 Confirmation from MASH Team Manager to BSCB that briefing has taken place 11.1 Revised referral system in place  11.2 Callers to the MASH Team are clear on the next steps being taken and understand the actions they are responsible for and are reminded that they have a duty to seek clarification if they are unsure of what is expected Children’s Social Care/MASH 11.1 Already completed   11.2  End April 2015 78  No. Recommendation Key Actions Evidence  Key Outcome Lead Agency/ Personnel Completion Date from them Children’s Social Care 12. The learning from this serious case review should be disseminated amongst social care practitioners as soon as possible. 12.1 BSCB to prepare briefing on learning from SCR.  12.2 BSCB to ensure report received from agencies, which details how and when the learning from serious case review has been disseminated to staff.  NB:  Actions 3, 7, 10, 12, 14 & 15 are linked. 12.1  Briefing sheet    12.2  Report Practitioners are made aware of the learning from this SCR. BSCB    Children’s Social Care End Feb 2015    End June 2015 13. Joint training and awareness raising with community based mental health practitioners should be considered in order to embed the lessons into practice.  This training and awareness raising will enable practitioners from both disciplines to share perspectives and experiences of recognising, assessing and responding to risks to children and young people. The safeguarding team to work alongside the early help provision within the local authority to support awareness raising within adult mental health services of recognition and response to risks to vulnerable infants and children including CAF, TAC and CP arrangements within adult services.  NB:  Actions 5 & 13 are linked. Evaluate learning at regular intervals (3-6 months) post training to ensure competence as well as compliance Practitioners are able to understand the provisions for early help and recognise their responsibility to participate and contribute with multi-agency arrangements to safeguard children Pennine Care Foundation NHS Trust June 2015 79  No. Recommendation Key Actions Evidence  Key Outcome Lead Agency/ Personnel Completion Date Greater Manchester Police 14. The learning from this serious case review should be disseminated to the relevant police officers as soon as possible with an emphasis on the combination of risk factors, which existed and/or presided from shared knowledge from partner agencies with or without a mental health diagnosis for FCI. 14.1 BSCB to prepare briefing on learning from SCR.  14.2 BSCB to ensure report received from agencies, which details how and when the learning from serious case review has been disseminated to staff.  NB:  Actions 3, 7, 10, 12, 14 & 15 are linked.  14.3  GMP to disseminate learning from the findings of this serious case review      14.4  Evaluate by means of reviewing feedback from training inputs and PPI reviews, to be bespoke in nature to mental health 14.1  Briefing sheet    14.2  Report          14.3  Toxic Trio training         SCR input/ case study and early learning sharing  14.4  PPI dip sample results/ audit and quality assurance days   Practitioners are made aware of the learning from this SCR. BSCB    GMP          GMP        GMP End Feb 2015    End June 2015                  End August 2015 80  No. Recommendation Key Actions Evidence  Key Outcome Lead Agency/ Personnel Completion Date Making Space 15. Using the learning from this serious case review carer’s support workers should be required to attend training and awareness raising which focuses on risk factors to children and young people. 15.1 BSCB to prepare briefing on learning from SCR.  15.2  BSCB to ensure report received from agencies, which details how and when the learning from serious case review has been disseminated to staff.   NB:  Actions 3, 7, 10, 12, 14 & 15 are linked.  15.1  Briefing sheet    15.2  Report Practitioners are made aware of the learning from this SCR. BSCB    Making Space End Feb 2015    End June 2015 16. The Making Space service should provide the LSCB with assurance about the quality and take up of safeguarding training and the awareness and competency of the service’s workforce and provide assurance that the service’s policy and process reflects the duty to safeguard children and young people. Letter to be sent to Making Space to request that they provide the required information and assurances. Response received from Making Space Making Space Workers are aware of their duty to safeguard children and young people. Making Space 31 March 2015 BSCB 17. It is recommended that BSCB and its member An audit to be undertaken on the impact of the BSCB Audit report Understanding of impact of BSCB Training & Development Sub End September 2015 81  No. Recommendation Key Actions Evidence  Key Outcome Lead Agency/ Personnel Completion Date agencies consider how they can model positive challenge in the way that will help staff have the confidence to rigorously inquire into potential abuse. professional challenge course being held in May 2015 training on practice Group 18. Adopting a reflective approach to case management, supervision and ongoing professional development which incorporates an understanding of complex and compounding risk, offers opportunities for agencies and practitioners to improve their responses to families and crucially, to enhance the safety and protection of children.  Such approaches should offer opportunities for individual professionals and multi-agency groups of professionals to reconsider their work in this area; this should take into account how they understand complexity and their response to it. Links to existing work on reflective supervision.  Audit to be undertaken as part of rolling programme of multi-agency audits. Audit report Understanding of level of reflective supervision available to frontline practitioners BSCB & partner agencies End September 2015 82  No. Recommendation Key Actions Evidence  Key Outcome Lead Agency/ Personnel Completion Date 19. Using the learning from this serious case review BSCB partners should ensure that communication and information sharing between agencies is consistently and appropriately focused on describing and sharing any potential or existing child safeguarding concerns.  Constituent partners reassure the BSCB that protocols are in place for sharing concerns regarding the welfare of children.  Copy of information sharing forms/ referral forms Potential and existing child safeguarding concerns are shared between agencies so appropriate services can be identified and provided BSCB & partner agencies 31 March 2015 20. Relevant BSCB partners should consider developing guidance for ‘cause for concern triggers’ from Midwifery to Health Visiting to ensure that triggers are commonly understood and standard responses are described. A request to be made to Greater Manchester Safeguarding Partnership for work to be undertaken on a Greater Manchester protocol regarding the use of ‘cause for concern/special circumstance’ forms. Protocol All health agencies in Greater Manchester area working to same protocol GMSP End September 2015 21. BSCB has recently introduced support through a Practitioners Forum for all frontline practitioners working with children and families in Bury ensuring that they have access to extended/enhanced supervision and group Monitor attendance at BSCB Practitioners Forum over 12 months. Trainer reports on Practitioners Forum to BSCB T & D Sub Group Oversight of take-up of opportunity to attend practice forums BSCB T & D Sub Group 31/01/16 83  No. Recommendation Key Actions Evidence  Key Outcome Lead Agency/ Personnel Completion Date support to discuss themes and concerns about families with complex needs and/or multiple risk factors.   22. It is recommended that the Practitioners Forum as it develops, provides support to practitioners when they may be the ‘lone voice’ attempting to respond to or escalate child safeguarding concerns. ‘Lone voice’ to be theme for forthcoming Practitioners Forum Flyer for Practitioners Forum Practitioners supported and encouraged to respond or escalate child safeguarding concerns BSCB End September 2015 23. BSCB should seek assurance that partner agencies understand local escalation policy and that frontline staff are confident and supported to use it appropriately in order to escalate their concerns. 23.1  Updated GMSP escalation policy to be circulated to all BSCB agencies 23.2  The escalation policy to be included in professional challenge course, parental substance misuse course and Practitioners Forum 23.3  BSCB partner agencies to provide reassurances that their staff are aware and supported to use policy 23.1  E-mail    23.2  Updated course materials    23.3 response from partner agencies Staff are aware of escalation policy and supported to use it BSCB End January 2015   End March 2015      End March 2015 84  No. Recommendation Key Actions Evidence  Key Outcome Lead Agency/ Personnel Completion Date 24. Domestic abuse is a key indicator that children (including unborn babies) are at risk. It is recommended that BSCB contributes to the development of the Borough’s domestic abuse strategy with specific focus on actions to improve safeguarding outcomes for children affected by domestic abuse.  This should include advanced training for relevant practitioners (eg social care staff, health visitors, midwives, community mental health teams including CAMHS). BSCB to review/comment on draft domestic abuse strategy Domestic Abuse Strategy Domestic Abuse Strategy includes focus on safeguarding children BSCB End June 2015 25. Training, awareness raising and supervision of staff needs to reflect the increased risk to children where mental illness and substance misuse (including the use of mood altering drinks) co-exist with domestic abuse. Links to ongoing work on toxic trio as outlined in BSCB Business Plan   BSCB End September 2015   