Death of a 21-month-old boy from serious injuries in June 2011. Following the child's death, the mother's boyfriend was sentenced to eight years for manslaughter and the mother to 15 months for child cruelty. Mother had recently moved out of maternal grandmothers home into her own tenancy, and her new partner spent significant amounts of time there. Mother had a history of: mental health problems, childhood sexual abuse and abusive relationships. Partner had a history of substance misuse. Issues identified include: the failure of GPs to consider safeguarding issues when treating parents of vulnerable children and inadequate screening of referrals of concern to childrens social care. Identifies a number of improvements to practice since the interim findings of the review were published, including: improved GP engagement in the child protection process and the development of the Multi-Agency Safeguarding Hub. Recommendations include: that the Safeguarding Board should routinely evaluate measures taken by Childrens Social Care to improve the screening of referrals and that the Mental Health Trust should promote guidance on protecting children and young people for doctors who treat adult patients. Includes Birmingham Safeguarding Children Boards response to the review, their judgement that the report was unfairly unbalanced and their decision not to fully accept the reviews findings and recommendations.
      
 Title:  Board Response to Case Number  BSCB 2011-12/1: overview report LSCB: Birmingham Safeguarding Children Board  Author: Alan Ferguson Date of publication: 2016  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. Birmingham Safeguarding Children Board has chosen to include identifying details of the children and the perpetrators as this information has been in the public domain.                            Final Overview Report  BSCB 2011-12/1   1            Birmingham Safeguarding Children Board Response to Case Number BSCB 2011-12/1              Final Overview Report  BSCB 2011-12/1   2  Case Number BSCB 2011-12/1 The tragic death of Kieron Barley 23.06.2011 Birmingham Safeguarding Children Board Response  Introduction  1.1 As Independent Chair, I am responding to, and commenting on behalf of Birmingham Safeguarding Children Board, regarding a Serious Case Review (SCR) into the tragic death of Kieron Barley, in June 2011, when he was aged 21 months. Due to the circumstances of Kieron’s death, the Birmingham Safeguarding Children Board commissioned a Serious Case Review in September 2011, in order to establish what could be learnt from this tragedy.  1.2 The covering report has been agreed by the Board. In addition the Board has agreed a publication process designed to minimise additional distress for Kieron’s extended family whilst ensuring the learning is made publically available. It is also quite clear that the Board accepted the learning that emerged at the time of the original review, and has acted accordingly. There is good evidence this has generated changes in practice for the better.  1.3 The review has taken nearly five years to be published. Much of what it addresses relates to services and practices that have significantly changed during that unacceptably long period of time. The reasons for the delays are set out below and relate to three key factors: • A very long and complex criminal investigation by West Midlands Police;  • The delay in the release of crucially important facts about Kieron’s death as part of the criminal investigation until the trial, necessitating a second stage to the review which took nearly a year; and  • Significant and extensive efforts to improve the analysis and identification of learning in the report in the interests of natural justice, balance and objectivity.  Final Overview Report  BSCB 2011-12/1   3  1.4 It is important to recognise that Kieron’s death was neither predictable, nor preventable. Despite this, and despite the fact that the agencies involved with Kieron and his family, did not contribute to his death (as is established by the Review on the basis of the evidence available, there is undoubtedly considerable learning for all agencies, which was applied by them after the first stage of the review, and which is still very relevant.   1.5 The most important and relevant message from this review, is that professionals must assess and understand the nature of parenting relationships from the point of view of both (or all) the adults involved, rather than focussing solely on the mother of a child and her capacity to parent. The other relevant message is that collusion between adults can be very convincing, and successful, when there is no evidence to indicate such collusion is taking place and no reason to be concerned.  1.6 In addition, as we understand more about the nature of coercion and control within relationships, largely through work and research relating to domestic violence, we can use the learning to inform the work we do with families where there are concerns about how well a child is being cared for.  The report 1.7 This summary report and response from the Board is intended to explain the delays and inform the public about what has happened to improve things, where required, since June 2011.  1.8 We wholly agree that Kieron’s death was a tragedy and are clear his death was caused by his mother’s boyfriend. We know that Kieron was a much loved child within his family and for the first 20 months of his life, he lived with his mother and maternal grandmother. His mother formed a relationship during this period with the man who was found guilty in April 2014 of the manslaughter of Kieron. In the last six weeks of his life, Kieron and his mother were living in their own house. His mother’s boyfriend spent significant amounts of time at that house Final Overview Report  BSCB 2011-12/1   4  and during that period, Kieron received a series of significant injuries leading ultimately to his untimely death.   1.9 Unfortunately his family have not been able to see the eventual Serious Case Review, until now. This is for a number of complex reasons. The first stage of the SCR process was completed in November 2012 and presented to the Board as an ‘interim SCR’, as it could not be finalised or published until the court case was concluded. Despite the barrier to publication, each of the agencies involved completed their own action plans after it had been agreed as an interim report.  1.10 The court case did not conclude until April 2014 (nearly three years after Kieron’s death). During the long and complex criminal investigation, the police were unable to provide significant pieces of information about the case to the lead reviewer relating in particular to Kieron’s injuries. This information was also not known to any of the agencies involved with Kieron and his family.   1.11 It would be fair to say that as a consequence, the interim report drew conclusions based on partial, erroneous and inaccurate information. Significant progress was however made in implementing the learning from individual agency reports and the interim report. During this period Birmingham City Council, and its partners, also went through a very turbulent period of change and transition as it worked to improve services.   1.12 After the trial, where it was established that Kieron had sustained a fracture to his back as well as the injuries previously known, it was clear that the interim SCR needed to be fully reviewed and consideration needed to be given to whether there were further lessons which could be learnt from the new information available to the SCR panel. It was also important for the SCR to be informed by the fact that culpability for Kieron’s death was clearly to be attributed to the man found guilty of manslaughter. His mother was found guilty of criminal neglect, relating to her failure to recognise the degree of harm Kieron was experiencing, and her failure to be honest when he presented to the hospital with injuries in the first of two visits just before he died.  Final Overview Report  BSCB 2011-12/1   5   1.13 The second stage of the review took place and the final report is published with this covering report and response. It was considered by Birmingham Safeguarding Children Board in November 2015 and further discussed until finalised for publication in March 2016.   1.14 Regrettably the Board were unable to fully accept the report’s findings and recommendations. The Board takes the view the report is unfairly unbalanced in the emphasis it places on the role of Birmingham and Solihull Mental Health NHS Foundation Trust. It also does not meet the required standards in terms of accuracy, the presence of clear hindsight bias and objective analysis based on evidence.   1.15 This does not negate the very real fact that there was much to be learnt from why and how Kieron died In addition, how professionals from a range of organisations worked with and responded to Kieron, his family and his mother’s boyfriend. The Board is very clear that much of the practice set out in the report was undoubtedly poor quality, and that action to improve was clearly required; including the learning in relation to what happened when the child was presented at Birmingham Children’s Hospital NHS Foundation Trust and to why the referral made to children’s social care was not acted on.  1.16 The Board has concluded that: • There is no doubt that some things could have been done differently, in order to improve Kieron’s life experiences, but this would have had no direct bearing on his death; • There is valid and important learning for the Board and its partners as a result of the review; • That much of the report demonstrates hindsight and author bias, is not well evidenced and, in places, is inaccurate • There is good evidence all the Individual Management Reports (IMR) recommendations have been implemented and learning achieved;  Final Overview Report  BSCB 2011-12/1   6  • There is external assurance from both Birmingham Cross City Clinical Commissioning Group (CCG) and the Care Quality Commission (CQC) about practice improvement in relation to safeguarding at the Birmingham and Solihull Mental Health Foundation Trust (despite the fact that poor practice had no impact on Kieron’s death);  • That the review is now very old and there has been significant change since it took place; and  • There is a need to move on and publish the report. 1.17 Because the learning is important, the Board has taken steps before this publication of the SCR to assure itself on the actions taken in response to the findings and recommendations in the report. A set of reports has been received clearly stating what each agency has done, how they monitor this activity and assure themselves of its effectiveness and how they have applied the learning to improve current practice. This has informed the Board’s final response to the report recommendations as follows Recommendation 1  That Birmingham Women’s Hospital NHS Foundation Trust (BWH) take actions to satisfy itself and BSCB that: its staff are adequately skilled and knowledgeable about safeguarding children procedures; procedures are sufficiently robust to ensure that all pregnant vulnerable women are identified and appropriate assessments undertaken in respect of any risks to their unborn children and; that safeguarding referrals are made when necessary.   The Board now has robust assurance mechanisms in place to monitor how well the BWH addresses its safeguarding responsibilities. Close relationships with their lead safeguarding staff are supplemented by the work on their section 11 audits. In addition, they are partnering with the Birmingham Children’s Hospital NHS Trust and sharing professional knowledge and support. We are satisfied that the BWH understands what it has to do, and is addressing areas for improvement on a Final Overview Report  BSCB 2011-12/1   7  consistent basis. The Board is satisfied that the reasons for this recommendation have been addressed. Recommendation 2  That BSCB exercise its monitoring and evaluation function (paragraph 3.28 to 3.29 Working Together to Safeguard Children 2010) to routinely evaluate measures taken by Children's Social Care to improve the screening of referrals of concern about children. There has been significant work over the last two years in terms of referral practice and the development of the Multi-agency Safeguarding Hub (MASH). A monthly multi-agency audit of referrals takes place and is reported to the Board. The Board is satisfied that the reasons for this this recommendation have been addressed. Recommendation 3 and 4  That BSCB carry out a thematic audit of Birmingham and Solihull Mental Health Foundation Trust (BSMHFT) compliance with internal and multi-agency safeguarding children procedures and their commitment to local child protection systems.   That BSMHFT robustly promote the GMC guidance (July 2012) ‘Protecting Children and Young People – A Guide for Doctors Who Treat Adult Patients’ to their staff and establish an ongoing quality assurance process to monitor its implementation and effectiveness.   The Board does not accept this finding. Whilst BSMHFT has identified the need to address a range of issues arising from the SCR, there was and remains no evidence that Kieron’s mother’s poor mental health had any direct causal relationship with Kieron’s death. The impact of her mental health problems made it harder for her to parent, but she recognised this and lived with her mother for most of Kieron’s life so Final Overview Report  BSCB 2011-12/1   8  she did not compromise his well-being as a result of her ill health. There is evidence that her vulnerability made her more likely to be coerced by her boyfriend. However, the role of staff at BSMHFT would not have had any impact on this either through commission or omission. The Board is satisfied that this finding was ill informed, not sufficiently well evidenced and irrelevant to our learning.  Recommendation 5 That BSCB and (now South Central and Cross City CCG’s) robustly launch and promote the above General Medical Council (GMC) Guidance to all GPs in their locality. Whilst engaged in this activity, identify and address the barriers to co-operation with child protection procedures that are identified so often in Serious Case Reviews locally.   The Board recognises that GP’s are one of the hardest professional workforce groups to engage with. This is reflected in national analysis of SCR’s, as well as in this one. Since this recommendation was drafted, major changes have taken place with regard to GP practice in Birmingham. The three Clinical Commissioning Groups have driven a coordinated, well led and assertive programme for supporting GP’s to understand their roles as regards safeguarding. A combination of well led and well managed organisational activities, including financial incentives or penalties for non-compliance, has substantially and significantly changed GP practice in the city. A well evidenced improvement plan is in place and regular monitoring and assurance of practice takes place. An inspection by the Care Quality Commission reinforces this position and the Board is assured much has changed. Recommendation 6 That Birmingham Community Health Care NHS Trust issues a practice directive to health visitors on the need to liaise with BSMHFT about the parents of vulnerable children, in order to inform assessments of need for them.  Such guidance to include information on issues related to consent/confidentiality.   Final Overview Report  BSCB 2011-12/1   9  Since the review began, there have been significant changes in the way health visitors and mental health professionals work together. The Board is satisfied these changes significantly mitigate against similar failures occurring now, although there is much still to do. Recommendation 7 That Birmingham Children’s Hospital NHS Foundation Trust place laminated copies of the chart headed ‘Patterns of Bruising in Accidental and Non-Accidental Injury’ (Doctor S Maguire 2011) in strategic locations within the hospital.   The Board is satisfied this recommendation isn’t relevant, nor will it have a direct or real impact on practice. In addition, the Board is also satisfied that there was no reason to be suspicious about a bruise given the plausible presentation by Kieron’s mother and her boyfriend at the time. In those circumstances, and given the fact that Kieron was not displaying any physical indications that would lead to suspicion about a serious back injury, there were no clinical or social reasons to trigger a skeletal x-ray. There are very detailed protocols governing practice at the BCH in relation to the potential for concern and what is required of clinicians. BCH is clear that the learning is important in relation to how busy professionals understand, and are more curious about parental behaviour, and has regular training available to staff. They also understand the importance of regular monitoring and case work audit activity to mitigate the risk of professionals missing important triggers for concern. The Board will prepare a learning bulletin focussing on the learning in this SCR that remains relevant and important. It will be disseminated through every agency to front line staff for use in team and staff briefing, as well as training courses.   Final Overview Report  BSCB 2011-12/1   10  Conclusion Kieron’s death was a tragic result of the behaviour of his mother’s partner towards him, and her collusion with it (however willing or unwilling). Professionals could not have identified there was a risk to him however effective their practice. However, his death has provided us with learning, which we are committed to using to improve the experiences of children and their families in similar circumstances and to better ensure similar circumstances do not arise again.                         Final Overview Report  BSCB 2011-12/1   11       SERIOUS CASE REVIEW  BSCB 2011-12/1  In respect of the death of   Kieron Barley  Dob 22.08.2009 Dod 23.06.2011  Report of the Birmingham Safeguarding Children Board following the consideration of a Review written by:  Alan Ferguson    Final Overview Report  BSCB 2011-12/1   12  Author's Details  I am a qualified Social Worker and registered with the General Social Care Council.    In March 2009 I retired from the post of Service Development Manager (Safeguarding & Quality Assurance) within Worcestershire County Council after a career in child care stretching back 35 years.   Within that role I had written numerous management reviews on behalf of Children's Services as well as overview reports on behalf of the Local Safeguarding Children Board.  Since retirement I have become the Director of an Independent Social Work Consultancy offering a range of services including consultancy related to Serious Case Reviews.    In this period I have served on numerous Serious Case Review Panels as both Panel member and Chair and, in recent months, have taken advantage of Regional and National events to further extend my knowledge in this area and to keep abreast of recent developments.  At the time of commencing this report, I had written twelve Overview Reports for various LSCBs in the West Midlands Region.  I have no professional or personal connections with Birmingham Safeguarding Children Board.     Alan Ferguson Director Three Towers Consultancy Limited Final Overview Report  BSCB 2011-12/1   13  INDEX  OVERVIEW REPORT   1. Introduction 2. Conclusions and Recommendations 3. Reasons for Serious Case Review 4. Term of Reference (Précise) 5. Methodology 6. Summary of Family Circumstances 7. Summary of Key Events 8. Key Issues Arising From Review 9. Conclusion and Key Learning Points 10. Recommendations  Appendix 1  - Term of Reference Appendix 2  - Agencies Participating in this Serious Case Review Appendix 3  - Quality Assurance of Individual Management Reviews Appendix 4  - Action Plans (From Individual Management Reviews)  Final Overview Report  BSCB 2011-12/1   14  INTRODUCTION  1.1. The purpose of a Serious Case Review is as outlined in Chapter 8 (8.5) of the Working together to Safeguard Children 2010 (hereafter referred to as Working Together) guidance, namely to:  • establish whether there are lessons to be learnt from the case about the way in which local professionals and organisations work together to safeguard and promote the welfare of children; • identify clearly what those lessons are, how they will be acted on and what is expected to change as a result; and • as a consequence, improve inter-agency working and better safeguard and promote the welfare of children.  NB.  The above document, which was the statutory guidance in place at the time of the Kieron’s death, was updated in April 2013 and this report also takes account of the revised guidance.    1.2. The guidance goes on to describe two criteria for undertaking a Serious Case Review i.e:  • when a child dies and abuse or neglect is known or suspected to be a factor in the death, the Local Safeguarding Children Board (LSCB) should always conduct a Serious Case Review; or • where a child has been seriously harmed as a result of being subject to sexual abuse, the LSCB should consider whether to conduct a Serious Case Review (Para 8.11).  1.3. The subject of this Serious Case Review is a child aged 21 months who died in the early summer of 2011.  Due to the circumstances of Kieron’s death Birmingham Safeguarding Children Board (BSCB) commenced a Serious Case Review in September 2011 and the interim findings of that enquiry were reported to the Serious Case Review Sub-Group on 16th November 2012.   Final Overview Report  BSCB 2011-12/1   15  1.4. The reasons for these findings being described as ‘interim’ are as a consequence of a long and complex criminal investigation into the circumstances surrounding the Kieron’s death, during which the author was unable to access certain information about the death of Kieron nor was he able to contact the family to invite their participation in the Serious Case Review process as required by the guidance.     NB.  There is no suggestion that this information was inappropriately held back by West Midlands Police, it was done to prevent the complex investigation being compromised in any way.    1.5. Presenting the interim report to the Serious Case Review Sub-Group was deemed to be an appropriate action at that time as, despite the author’s inability to make contact with the family, it was considered that the information that was already available to him indicated a number of areas where urgent action was necessary to improve local services for safeguarding children.    1.6. It was not until 1st April 2014 that the criminal aspects of the case were finally resolved i.e. on that day Louise Barley (mother) and Craig Lewis (mothers partner) received significant prison sentences for their roles in the Kieron’s death (see section 3 for details).  I can now confirm that Louise Barley, Maternal Grandmother and Craig Lewis have all been interviewed by members of the Serious Case Review Panel and have made contributions to this Review.  All parties will also receive feedback on the Review’s findings from the Author.    1.7. In the wake of their sentencing, the Chair of BSCB commissioned the completion of this Serious Case Review which was then considered to be a two part task i.e:  • a review of how the recommendations of the interim report presented on 16.11.12 had been implemented; and Final Overview Report  BSCB 2011-12/1   16  • consideration of whether further lessons can be learnt by partner agencies of BSCB from the additional information that could now be released by the Police (primarily related to the last five/six weeks of the Kieron’s life).   1.8. This report is the final report into the circumstances surrounding the death of Kieron and the role of the various agencies involved in his short life.     Final Overview Report  BSCB 2011-12/1   17  2. SUMMARY OF CONCLUSIONS AND RECOMMENDATIONS  2.1. First and foremost it is the judgement of the Serious Case Review Panel that the death of Kieron was not predictable or preventable by staff in the partner agencies of BSCB who were involved in his life.  2.2. In reaching this judgement the Serious Case Review Panel has considered Kieron’s short life in two phases i.e. • the first 20 months of Kieron’s life during which there was mounting concern in respect of developmental delay exacerbated by home and environmental conditions; and • the last six weeks of Kieron’s life during which he suffered a number of serious physical assaults which ultimately led to his death.    2.3. In respect of those first 20 months, the Serious Case Review Panel has received considerable evidence to suggest that Kieron was a much loved child within his family and, while there was ongoing concern about home conditions and a lack of opportunity for stimulating play, no professional at any time considered that there was any risk to Kieron’s physical safety.    2.4. During the vast majority of this period Kieron and Louise Barley lived in the home of Maternal Grandmother, an environment that caused increasing levels of concern to the Health Visitor involved and which led her eventually to make a safeguarding referral to Children’s Social Care in March 2011 with a recommendation that Kieron be made the subject of a Child Protection Plan.  The failure of Children’s Social Care to adequately assess the situation in response (and the Serious Case Review Panel’s judgement in respect of the longer term implications of that decision) are covered in detail later in this report i.e. would subsequent actions by health personnel have been different if Kieron had been subject to a Child Protection Plan when presented at Birmingham Children’s Hospital in May 2011.  Final Overview Report  BSCB 2011-12/1   18  2.5. In the interim Overview Report presented to BSCB on 16th November 2012 the Serious Case Review Panel identified a number of weaknesses in the services provided to Kieron and his family in this period, and these findings (and accompanying recommendations) are listed in paragraphs 2.20 – 2.24 below.  2.6. The Serious Case Review Panel wishes to record at this point that significant progress has been made over the last two years in implementing these recommendations and there is confidence that services for safeguarding children locally are greatly improved as a consequence.  These remedial actions are described in more detail later in the report.   2.7. Notwithstanding these weaknesses in service provision, it can be repeated here that no professional involved with the family in the first 20 months of Kieron’s life had any reason to be concerned for Kieron’s physical safety e.g. no suspicious injuries or bruising were ever reported and there were no concerning attendances at Hospital.    2.8. One of the concerning factors identified in the history of this family was Louise Barley’s vulnerability in respect of her relationships with men e.g. Kieron’s Father was a violent sex offender, and at least two relationships during Kieron’s short life were with men described as ‘controlling and exploitative’.  No assessment was ever undertaken to address the impact of these frequently changing relationships upon Kieron’s life but it can be surmised as significant.    2.9. Louise Barley’s relationship with the man who would eventually be convicted of her son’s manslaughter began in January 2011 and initially caused no concern to family and friends who describe him as a ‘kind and caring person’ or to professionals when he attended various health appointments with Louise Barley and Kieron.  Had a Police check been undertaken at this time (which would only have happened if Kieron had been subject to a Child Protection Plan) it would have revealed nothing of concern.    Final Overview Report  BSCB 2011-12/1   19  2.10. In May 2011 Louise Barley and Kieron moved out of the home of Maternal Grandmother and into her own tenancy. Louise Barley had made application for separate housing in March 2011 following a significant and violent family row involving her brother who suffers from cerebral palsy and epilepsy.    2.11. While both Louise Barley and Craig Lewis deny that he actually moved in with her, it is clear that he spent significant periods of time staying there from the very beginning and that he played a significant part in caring for Kieron.  It would appear that Kieron suffered physical injuries within days of this arrangement commencing i.e. • on 17th May 2011 a doctor at Birmingham Children’s Hospital observed bruising on Kieron’s back; and • on 28th May 2011 Kieron was seen at Birmingham Children’s Hospital with an injury to his shoulder but it later transpired that he was also suffering with fractured vertebrae at this time (this was not identified until after his death).    2.12. The Serious Case Review Panel has addressed both these Hospital attendances in some detail later in this report and has concluded that the doctor involved on 17th May 2011 made an error of judgement in not seeking safeguarding advice from senior colleagues in respect of the bruising, but that staff involved with the consultation on 28th May 2011 could not be blamed for failing to identify the fractured vertebrae.    2.13. Although other professionals were involved with Kieron and his family in the six week period prior to his death i.e. the Child Development Centre who diagnosed him with cerebral palsy only two weeks earlier, the Health Visitor and the Children’s Centre who were trying to engage Louise Barley in a range of activities to promote Kieron’s development, it is the two attendances at Birmingham Children’s Hospital in May 2011 that offered the most realistic opportunity whereby the immediate and serious risk to his life could have been identified.    Final Overview Report  BSCB 2011-12/1   20  2.14. In the opinion of the Serious Case Review Panel there is no doubt that staff at Birmingham Children’s Hospital would have reacted differently had Kieron been the subject of a Child Protection Plan at the time of the Hospital attendances on 17th and 28th May 2011 i.e. the circumstances of Kieron’s attendance would have been shared with Children’s Social Care.   On both occasions it can safely be assumed that safeguarding action would have followed.  2.15. However, he was not subject to such a plan and later sections of this report detail the Serious Case Review Panel’s conclusions in respect of the actions of Children’s Social Care following the Health Visitor referral in March 2011 i.e. our judgement is that the screening of the referral was inadequate.   2.16. Examination of the available information indicates that Kieron’s status changed in a matter of days once he and Louise Barley moved out of Maternal Grandmother’s home and formed a family unit with Craig Lewis i.e. from being a toddler whose developmental delay was a matter of concern (and more recently of concerted action) to a child whose very existence was threatened.  None of Kieron s extended family considered Craig Lewis to be anything other than a benign and supportive figure in his life based upon his engagement and relationship with the Kieron in the preceding four months.   2.17. In these circumstances the Serious Case Review Panel had little hesitation in agreeing that Kieron’s death could not have been predicted.  The issue of preventability was more balanced but the Panel took the view that there were too many uncertainties in any sequence of events that might have led to safeguarding action to say unequivocally that Kieron’s death was preventable.    2.18. The Interim Overview Report presented to BSCB on 16th November 2012 contained six recommendations for remedial action based upon the findings of the Serious Case Review at that time.  These findings and recommendations are summarised below.  As stated earlier in this section there has been Final Overview Report  BSCB 2011-12/1   21  significant progress in implementing these recommendations and further detail in respect of that progress is provided later in this report.    2.19. A summary of additional findings arising from the reactivated Serious Case Review in 2014 and the one additional recommendation is included at the end of this section.    2.20. The first finding of the Interim Overview Report was that staff at Birmingham Women’s Hospital paid insufficient attention to Louise Barley’s troubled history, including her poor mental health and history of overdoses, when assessing the appropriate level of care during her pregnancy.    Recommendation 1:   That Birmingham Women’s Hospital take actions to satisfy itself and BSCB that its staff are adequately skilled and knowledgeable about safeguarding children procedures and that those procedures are sufficiently robust to ensure that all pregnant vulnerable women are identified and appropriate assessments undertaken in respect of any risks to their unborn children, and that safeguarding referrals are made when necessary.    2.21. The second finding was that Children’s Social Care’s screening of two referrals of concern in respect of Kieron were inadequate and based on presenting information only rather than a scrutiny of their own agency records and those of partner agencies.  A thorough assessment following the Health Visitor’s referral of March 2011 may have resulted in Kieron being the subject of a child protection enquiry which would have significantly changed the focus of Hospital staff when he was presented there in May of the same year.  Recommendation 2:   That BSCB exercise its monitoring and evaluation function (paragraph 3.28 to 3.29 Working Together to Safeguard Children 2010) to routinely evaluate Final Overview Report  BSCB 2011-12/1   22  measures taken by Children's Social Care to improve the screening of referrals of concern about children.  2.22. The third finding was that staff in the Mental Health Trust missed a number of opportunities to promote the safety and welfare of Kieron by not considering the impact of Louise Barley’s mental health problems upon her capacity to parent him safely.    Recommendation 3:  That BSCB carry out a thematic audit of The Mental Health Trust’s compliance with internal and multi-agency safeguarding children procedures and their commitment to local child protection systems.    Recommendation 4:  That Birmingham and Solihull Mental Health Trust robustly promote the GMC guidance (July 2012) ‘Protecting Children and Young People – A Guide for Doctors Who Treat Adult Patients’ to their staff and establish an ongoing quality assurance process to monitor its implementation and effectiveness.    2.23. The fourth finding of the original Overview Report was that Louise Barley’s GP missed a number of opportunities to consider various risk factors that compromised her capacity to safely parent Kieron, and failed to maintain regular liaison with the Health Visitor who was having on-going contact with the family.  Recommendation 5:  That BSCB and NHS South Birmingham robustly launch and promote the above GMC Guidance to all GPs in their locality and, while engaged in this activity, identify and address the barriers to co-operation with child protection procedures that are identified so often in Serious Case Reviews locally.   Final Overview Report  BSCB 2011-12/1   23   2.24. The final finding of the original report was that the Health Visitor failed to liaise with mental health professionals who were providing services to Louise Barley and therefore she was never in a position to understand whether those mental health problems could have a detrimental effect upon her capacity to provide safe and nurturing care for Kieron.   Recommendation 6:  That the Community Health Care Trust issues a practice directive to Health Visitors on the need to liaise with the Mental Health Trust about the parents of vulnerable children in order to inform assessments of need for them.  Such guidance to include information on issues related to consent/confidentiality.    2.25  A further finding from the updated Serious Case Review was that an opportunity to safeguard Kieron was missed on 17th May 2011 when a Doctor at Birmingham Children’s Hospital failed to implement child protection procedures after identifying bruising on his back.  The recommendation below is intended to promote greater awareness of suspicious bruising in young children by Doctors in similar situations.  Recommendation 7:  That Birmingham Children’s Hospital place laminated copies of the chart headed ‘Patterns of Bruising in Accidental and Non-Accidental Injury’ (Doctor S Maguire 2011) in strategic locations within the Hospital.     Final Overview Report  BSCB 2011-12/1   24  3. REASONS FOR SERIOUS CASE REVIEW  3.1. In early summer 2011 a 999 telephone call was made to West Midlands Ambulance Service Emergency Control Room at 1832 hours, requesting an ambulance for a child said to be in cardiac arrest.    3.2. On arrival at the given address, the ambulance crew found a small male child on the floor of the living room, not breathing, no sign of any pulse and with his mouth and airways full of vomit.  After administering immediate first aid to clear his airways, the child was transported to Birmingham Children’s Hospital and admitted to their Paediatric Intensive Care Unit.    3.3. A CT scan revealed bleeding in Kieron’s brain (an indicator of non-accidental injury) which prompted a referral to the Duty Social Work Team and West Midlands Police.  Further scans showed a fracture of the eighth vertebrae, and examination of Kieron’s eyes revealed bleeding therein, again giving rise to concern that he had been the victim of physical abuse.    3.4. For the next four days every effort was made to save Kieron, but he failed to respond to any treatment and the intensive care support was withdrawn on the fourth day on grounds of futility whereupon he died.  Kieron was only 22 months of age at the time of his death.    3.5. In view of the circumstances of his death, the matter was referred to Birmingham Safeguarding Children Board (hereafter referred to as BSCB) for consideration of undertaking a Serious Case Review.    3.6. In addition to the information provided by Birmingham Children’s Hospital (see 3.2/3.3 above) BSCB sought information from partner agencies to inform their decision regarding the threshold for a Serious Case Review.  This revealed that:  Final Overview Report  BSCB 2011-12/1   25  • Kieron was a child with developmental delay who had recently been diagnosed with cerebral palsy i.e. two weeks before his death; • Louise Barley had a history of mental health problems stretching back to her childhood; • Louise Barley was a victim of sexual abuse in childhood and again in adolescence; • Louise Barley had previously come to the attention of Children's Social Care as a victim of domestic abuse (from one of her partners but also from her brother who suffered from epilepsy and cerebral palsy); and • Kieron’s birth father was a convicted sex offender, although he was known to be in prison at the time of the Kieron’s death.  3.7. In view of the above and the available medical evidence, the Serious Cases Review Group of BSCB met on 9th September 2011 and made a recommendation that the threshold for undertaking a Serious Case Review was met.  The recommendation was formally endorsed by Eleanor Brazil (then the Chair of BSCB) on 19th September and a Serious Case Review commenced on that date.    3.8. The criminal proceedings were not completed until April 2014 when Kieron’s mother was found guilty of child neglect and Craig Lewis of manslaughter.  Both received significant prison sentences i.e. Louise Barley was sentenced to 15 months in prison for ‘child cruelty’ (this was later halved on appeal) while Craig Lewis pleaded guilty to manslaughter and was sentenced to eight years.    3.9. Following completion of these criminal proceedings the Serious Case Review was reactivated by the current Chair of BSCB, Jane Held, who authorised the drafting of this Overview Report using a new format and template approved in the intervening months.    Final Overview Report  BSCB 2011-12/1   26  4. TERMS OF REFERENCE   4.1. The original Terms of Reference for this Serious Case Review were agreed at a meeting of BSCB’s Serious Case Review Group on 9th September 2011, and these comprise two elements i.e.  • generic issues, as set out in the Working Together guidance, which should be addressed in all Serious Case Reviews; and • specific issues that have been identified by the Serious Case Review Group as pertinent to this case.  4.2. A full list of these Terms of Reference is included in this report as Appendix 1.  4.3. When the Serious Case Review was reactivated in April 2014 the Terms of Reference were also updated and the changes are listed below:  • examine what subject child’s life and experiences were like on the basis of the contact agencies had with him, his birth Mother, his extended family and his Mother’s partner;  • pay particular attention to what was known about Mother’s partner and considered in terms of his impact on subject child’s life and why the fact that he was a cocaine and alcohol user was not apparently taken into consideration by any agencies; • address exactly why Mother and subject child did not appear to have any consistent early help or family support given that his Mother was a very vulnerable adult with mental health problems and he had clear developmental delay; • establish whether organisational cultures and behaviours affected the degree to which professionals were alert to subject child’s life and experiences;  • establish whether the context in Birmingham impacted on the degree of, and quality of, professional responses and whether a clear consideration Final Overview Report  BSCB 2011-12/1   27  of appropriate interventions ever took place on a multi-agency basis and, if not, why not?;  • establish how well the process of assessment for cerebral palsy also took into account subject child’s social and economic as well as emotional circumstances;  • establish whether anyone considered the accumulation of risk factors apparent retrospectively and if not, why not?; • examine in depth the last six weeks of subject child’s life and experiences and what that can tell us about how agencies were working together to support the whole family and improve his life chances;  • explore the degree to which Mother and Mother’s partner were able to manipulate and deceive agencies, why this was able to happen and whether anything additional for frontline practitioners and professionals can be learnt from this or not; and • review whether the changes to practice in Birmingham in the last nine months addressed any of the key learning from this case already, and make any key over-arching recommendations to build on practice learning as a consequence of the case.     Final Overview Report  BSCB 2011-12/1   28  5. METHODOLOGY   5.1. Paragraph 8.5 of the Working Together guidance requires LSCBs to establish Serious Case Review Panels to ‘manage the process’ of the Review. The guidance also requires that this Panel be independently chaired i.e. not by a member of the LSCB involved, an employee of any of the agencies involved or the overview report writer.  5.2. The Chair appointed for the Serious Case Review Panel is Nicola Pettit, an Independent Social Work Consultant.  Ms Pettitt is an Independent Social Worker and Manager with 22 years’ post qualifying experience, the majority of which she has spent employed by local authorities in London and the South East, working in Children's Services.  She is an experienced Chair of Serious Case Reviews and the Author of both Individual Management Reviews and Overview Reports.  She is independent of all agencies represented on BSCB.    5.3. The author of the Overview Report, is Alan Ferguson, a Director of Three Towers Consultancy Ltd.  A brief summary of his career can be found at page 2 of this report.  5.4. The ‘Working Together’ (2010) Guidance requires that the members of the Panel as nominated by local agencies, should be identified by their designation and agency only.  For this Serious Case Review the original Panel members were:  • Detective Chief Inspector – West Midlands Police; • Designated Nurse, Birmingham and Solihull NHS Cluster; • Head of Children Protection and Review Service, Children, Young People and Families Directorate; and • Designated Doctor, Birmingham Community Healthcare NHS (Foundation) Trust.  Final Overview Report  BSCB 2011-12/1   29  5.5. However, due to staff movement it proved necessary to convene an almost entirely new Panel once the case was reactivated in April 2014 and the composition of this new Panel is  as follows:  • Designated Doctor, Birmingham Community Health Care NHS (Foundation) Trust;  • Deputy Designated Nurse (Safeguarding Children), BSC CCG;  • Head of Child Protection Services, Birmingham Children’s Hospital;   • Head of Service, South Birmingham Children’s Services;   • Lead Nurse for Safeguarding Children, BCHC;   • Named Nurse for Safeguarding Children, Birmingham & Solihull Mental Health Trust;   • Detective Chief Inspector, West Midlands Police;   • Representative from voluntary sector, Midland MENCAP; and  • two lay members.    5.6. In order to carry out its function of ‘managing the process’ the original Serious Case Review Panel met on five occasions between January and August 2012, while the later Panel met on four occasions between June and October 2014.    5.7. The Serious Case Review commenced on 19th September 2011, when the Chair of BSCB wrote to all agencies advising them of her decision to undertake a Serious Case Review and requesting that all agencies research their records about the family and complete an IMR (Individual Management Final Overview Report  BSCB 2011-12/1   30  Review) for submission by 9th November 2011.  In all cases extensions to this timescale into the New Year were requested and agreed.  5.8. Agencies were required to look critically and openly at individual and organisational practice to ascertain whether changes could and should be made and, if so how this should be achieved.  It was a requirement that a designated Senior Manager who had no previous involvement or line management responsibility for the case should complete the review and the Serious Cases Sub-Group is satisfied that this standard has been complied with by all agencies.  Guidance notes with a template were provided to all agencies, including the requirement for them to implement any internal recommendations in a timely way.  Agencies were also required to send a nil return if they could find no trace of involvement with the family.  5.9. To assist agencies in this task the letter also included:  • up-dated guidance on completing IMRs; • an updated template for the IMR and the Genogram; • a template for the Action Plan and the Chronology; • guidance on interviewing staff in connection with an IMR; • an anonymisation code; • a quality assurance checklist; and • Ofsted’s grading descriptors.  5.10. BSCB were aware of Ofsted evaluation feedback that had previously highlighted inconsistencies in the quality of IMR reports.  In response, the Board agreed to deliver IMR training for Authors and Senior Managers in December 2009, May 2010 and June 2010.  The training launched new IMR guidance, the IMR template and instructions on the interviewing of staff, together with exemplars of good practice aimed at enhancing the quality of reports.  Further quality assurance measures have been incorporated within the Serious Case Review process, with all agencies receiving evaluation Final Overview Report  BSCB 2011-12/1   31  feedback on the quality of IMRs and areas for further clarification and analysis.  5.11. A Health Overview Report has been produced by one of Birmingham’s Designated Doctor for Safeguarding.  This is in line with guidance contained in Working Together to Safeguard Children (2010) which focuses upon “How health organisations have interacted together”.  (Para 8.30)  5.12. For this Serious Case Review, IMRs were received from the following agencies on the dates shown:  West Midlands Police 19th January 2012 Children, Young People and Families Directorate 1st December 2011 Birmingham Children’s Hospital 18th January 2012 Community Healthcare NHS Trust 19th January 2012 University Hospital Birmingham Birmingham Women’s Hospital 16th January 2012 20th January 2012 NHS South Birmingham (GP) 16th January 2012 Children’s Centre 30th March 2012 Mental Health Trust 30th March 2012  NB.  When the Serious Case Review was reactivated in April 2014 all the above agencies were asked to update their IMRs to take account of the previously undisclosed information and to reconsider their involvement with Kieron in the last five/six weeks of his life.  These updates have all been received and taken into account by the Serious Case Review Panel.     5.13. Nil returns were received from the following agency on the dates shown:  CAFCASS 18th July 2011 Education Welfare Service 20th July 2011  Birmingham & Solihull Women’s Aid 21st July 2011 Royal Orthopaedic Hospital 28th July 2011 Final Overview Report  BSCB 2011-12/1   32  Family Action 4th August 2011 NSPCC 24th August 2011 Sandwell and West Birmingham NHS  14th October 2011 Staffordshire and West Midlands Probation Service 1st November 2011 West Midlands Fire Service 8th November 2011  The Sweet Project  26th March 2012   5.14. In addition to the IMRs listed on 6.6 above, the Serious Case Review Panel had the benefit of helpful information reports from the following agencies:  Connexions, Birmingham  NHS Foundation Trust (Orthoptist) West Midlands Ambulance Service NHS Direct Barnardo’s Amazon Project Salisbury Hospital  Homeless Service, Birmingham City Council  5.15. It is a requirement of BSCB procedures that all IMRs produced by partner agencies for a Serious Case Review are ‘signed off’ by a Senior Manager within that agency who, in doing so, is confirming that:  • he/she has used the BSCB quality assurance tool to ensure that the report is accurate, of good quality and reflects that agency’s acceptance of its findings; and • that all recommendations contained within the IMR will be subject to timely implementation.  5.16. Those agencies that had significant involvement with the family, and therefore were asked to complete IMRs about that involvement, are identified at paragraph 5.12 above.  The following paragraphs give a brief summary of that involvement.    Final Overview Report  BSCB 2011-12/1   33  West Midlands Police  5.17. West Midlands Police had limited knowledge of the family prior to Kieron’s death, and Louise Barley in particular was only known to them as a victim of sexual abuse.   Kieron’s birth Father was well known to Police but he has played no role in his son’s life.  There was no Police involvement with Craig Lewis prior to the death of Kieron.    5.18. A criminal investigation lasting nearly three years was undertaken into the circumstances surrounding Kieron’s death and resulted in a successful prosecution of Louise Barley and Craig Lewis.      Children, Young People and Families Directorate (BCC)  5.19. Prior to the death of Kieron, Children's Social Care had three contacts with the family i.e. July 2009, September 2010 and March 2011.  The last referral was from a Health Visitor suggesting that Kieron’s circumstances warranted him being made subject to a Child Protection Plan, but the assessment by Children's Social Care was that the threshold for a child protection enquiry (Section 47 Children Act 1989) was not met, and the case was closed.  It remained closed at the point of Kieron’s death.    5.20. Subsequent to Kieron’s death Children’s Social Care was involved with the child born to Louise Barley and Craig Lewis, and this child is now placed within the paternal family.    Birmingham Children’s Hospital  5.21. Kieron attended this Hospital on ten occasions in his life for a variety of medical reasons.  Prior to his final attendance with fatal injuries, he had been seen four times in the preceding month, once for an MRI scan as part of ongoing assessment related to his developmental delay, and three times following a fall where he had apparently only suffered minor injuries.   Final Overview Report  BSCB 2011-12/1   34   Community Healthcare Trust  5.22. This Trust provided a health visiting service to Louise Barley and Kieron throughout his life.  From March 2011 a range of specialist services were provided via the Child Development Centre, in order to investigate and assess the nature and extent of Kieron’s developmental delay.    5.23. These assessments eventually led to a diagnosis of cerebral palsy (about two weeks before Kieron’s death) and the Trust were currently involved in helping the family access a range of services appropriate to this diagnosis at the time of his death.    University Hospital Birmingham  5.24. This Trust had no contact with Kieron whatsoever, but did have a number of contacts with Louise Barley in the period set for this Serious Case Review, notably when she attended their Emergency Department in December 2008 having taken an overdose of a drug prescribed for her epilepsy.    NHS South Birmingham (GP)  5.25. This Trust provided GP services to all family members identified as relevant to this Review.  Louise Barley was registered with the same GP for 16 years and Kieron was registered at the same practice throughout his short life.  Craig Lewis was registered with a different practice that had no knowledge of his role in Kieron’s life.    Children’s Centre  5.26. Louise Barley and Kieron were first referred to the Family Support Team of this Children’s Centre in March 2011 and they had remained involved for a Final Overview Report  BSCB 2011-12/1   35  short period beyond the time of Kieron’s death in order to provide ongoing advice, support and bereavement counselling to Louise Barley.  5.27. The intention of the original referral by the Health Visitor had been to get Louise Barley and Kieron engaged in the groups and activities run by the Centre.  The Health Visitor had become concerned at Kieron’s developmental delay and the lack of stimulation he received at home.    Mental Health Trust  5.28. This Trust provided Mental Health Services to Louise Barley between November 2003 (when she was aged 16 years and displaying self-harming behaviours) until late 2011 when she was discharged back to her GP.  Louise Barley re-engaged with the Neuro-Psychiatry Service and Obstetric Service in March 2012 as she was again pregnant.    • In the period designated for this Serious Case Review Louise Barley had contact with a range of disciplines within the Trust i.e: the Neuro-Psychiatry Service and the Perinatal Liaison Psychiatry Service. Final Overview Report  BSCB 2011-12/1   36  6. SUMMARY OF FAMILY CIRCUMSTANCES   6.1. Kieron lived his whole life in the care of Louise Barley who was aged 20 years at the time of his birth.    6.2. His biological Father had never lived with Kieron indeed, according to Louise Barley, he has only seen his son on two occasions.  Information provided by West Midlands Police describes Father’s background as concerning (including offences against children) and suggests that ‘he could have been anticipated to pose a serious risk to Louise Barley and Kieron’ had they ever cohabited.    6.3. From the time of his birth (August 2009) until March 2011, Kieron and Louise Barley resided in the home of Maternal Grandmother.  This home was also shared with Maternal Uncle, a young man who suffered from cerebral palsy and epilepsy, and who was unable to live independently.    6.4. In March 2011 Louise Barley and Kieron left the family home following a reported heated argument involving Maternal Uncle.  Kieron was said to have become hysterical at this time and was removed by Louise Barley for his protection. Louise Barley and Kieron spent one night in a hostel (leaving because Louise Barley felt unsafe there) and a short period with a Maternal Aunt before moving back to Maternal Grandmother due to the Aunt having personal problems of her own.    6.5. At this time Louise Barley registered herself as homeless with the local authority and was quickly allocated a tenancy to which she moved in early May 2011.  Louise Barley’s partner soon joined her there (although both state he was not living there full time) and this address is the location of the assault upon Kieron that led to his death only six weeks later.    6.6. It is a matter of record that Louise Barley had a troubled adolescence and was regularly engaged with local mental health services as a young adult.  She Final Overview Report  BSCB 2011-12/1   37  also struggled with personal relationships and had a number of brief and unfortunate relationships with men during Kieron’s life.    6.7. Louise Barley’s relationship with the man who would eventually be responsible for the death of Kieron began in January 2011 and developed to the point that he effectively moved in with her once she obtained her own tenancy in early May of that year.  Louise Barley described him as a kind and caring man who was very fond of Kieron and enjoyed playing with him.  To this day she continues to claim that she never saw him mistreat Kieron or behave in any way towards him that caused her concern.  6.8. Louise Barley gave birth to this man’s child in 2012 but, following intervention from the local authority, the child is now living in the care of paternal family members under the legal protection of a Care Order (Section 31 Children Act 1989) in favour of Birmingham City Council.    6.9. Maternal Uncle constantly struggled with frustration at his restricted lifestyle as a consequence of his medical condition, and his occasional violent outbursts were a source of stress for the family.  A number of the IMRs submitted to this Serious Case Review comment that disability issues were a significant factor in the family’s life but, for reasons that cannot be established, insufficient attention was paid to them at the time of various family crises.    6.10. All agencies involved with the family had identified that they were white British, English speaking and non-practicing Church of England.  Local practice in identifying and recording the ethnicity of their clients is well-embedded in the practice of partner agencies of BSCB, and this was confirmed in the findings of this Review.    Final Overview Report  BSCB 2011-12/1   38  7. SUMMARY OF KEY EVENTS  7.1. This section of the report will provide a summary of key events in this family’s history i.e. events that the author considers have been significant in shaping Kieron’s life and, of course, subsequently his death.     7.2. Attention will be drawn to matters of concern or interest by use of a box entitled ‘Author’s Note’ and this will highlight issues that will receive greater attention in later sections of this report.    7.3. Although the original Terms of Reference for this Serious Case Review set a timeframe of November 2008 to June 2011, a number of agencies have helpfully provided information from earlier in Louise Barley’s life which they consider relevant.  This included a history of Louise Barley taking an overdose of prescribed medication on three occasions and subsequently receiving psychological counselling and support.      7.4. By February 2009, Louise Barley was pregnant with Kieron and had returned to live with Maternal Grandmother after a short period of living with her now ex-boyfriend.  The GP’s letter to Birmingham Women’s Hospital requesting maternity services included reference to Louise Barley’s history of involvement with Mental Health Services, but this failed to prompt any further assessment.      Author's Note  The IMR completed on behalf of Midwifery Services acknowledges that ‘more should have been done to assess Louise Barley’s vulnerability’ in the context of her history of involvement with Mental Health Services.    It cannot be acceptable practice that this vulnerable woman was allowed to take this baby back to the family home (where the two others adults resident there were known to have significant personal problems of their own) without some assessment of the risks to the child. Final Overview Report  BSCB 2011-12/1   39   7.5. Despite a threatened miscarriage late in February 2009, the pregnancy was still viable in May when the GP received a letter from the Psychiatric Clinic that was treating Louise Barley.  The letter listed a number of concerns in respect of Louise Barley’s condition e.g:  • Louise Barley had a history of depression and three overdoses; • the pregnancy was unplanned and not welcomed by Louise Barley’s family; • home conditions are overcrowded (Louise Barley sleeps in same room as Maternal Grandmother); and • Maternal Uncle (also resident in household) suffers with epilepsy as a consequence of cerebral palsy.  7.6. There is nothing documented in the GP’s records to suggest he considered this information in the context of Louise Barley’s capacity to safely care for a baby.  7.7. A further letter to the GP from a Consultant dated 18th May 2009 suggested that Louise Barley’s seizures may not be as a result of epilepsy but ‘a manifestation of distress and difficulties in coping’.  Again the GP appeared not to have considered this in the context of safeguarding the unborn child.     Author’s Note  While the GP may have been confident in respect of Louise Barley’s capacity to safely parent her expected child (based upon his knowledge of his patient and her family) it would have been reassuring to read that he had actively considered all the risk factors in this situation.    7.8. In the same month Louise Barley was asked to provide a witness statement regarding domestic abuse allegedly perpetrated by Father.  He was at that point on bail in respect of a serious sexual assault against an adult female.  Final Overview Report  BSCB 2011-12/1   40  On 23rd May 2009 Father was given a verbal warning in respect of witness intimidation and told to stay away from Louise Barley and Maternal Grandmother (there is no record of a specific incident of intimidation).    7.9. Louise Barley was referred by CAFCASS (Family Courts) to Children's Social Care in July 2009.  CAFCASS were involved with Father’s latest partner (although they were separated at that point) who was alleging sexual assault by him.  In interviews with the CAFCASS worker, this ex-partner reported that she was aware of Louise Barley and her pregnancy by Father, and CAFCASS were anxious that the local authority knew of the potential risks to her and the unborn baby.    7.10. In response Children's Social Care clarified that Louise Barley had permanently separated from the baby’s Father and decided to take no further action other than record the referral in their records in case the parents chose to reunite at some point in the future.    7.11. Kieron was born in the summer of 2009 while Louise Barley was on holiday in the south of England.  As a consequence of his prematurity (born at 33 weeks’ gestation) he suffered significant health problems and spent time in  a number of intensive care units and neo-natal units in three specialist Children’s Hospitals.  It is reported that Kieron and Louise Barley would have had significant periods of separation during these early weeks and correspondence in the GP’s case records makes reference to ‘poor bonding’.    7.12. Shortly after Kieron’s birth Children’s Social Care were contacted by West Midlands Police as Louise Barley had disclosed that his father had been convicted of offences against children and there was some concern that he may try to abduct the child.  The response of Children’s Social Care to this referral was similar to their response to the referral by CAFCASS one month earlier, i.e. they believe that:  • Louise Barley was acting appropriately; Final Overview Report  BSCB 2011-12/1   41  • it was only a problem if she attempted to make contact or resume her relationship with father; and • the Police are the appropriate agency to deal with any threat of abduction.   Author’s Note  This appears to the Author to be an inadequate response in respect of promoting Kieron’s safety and welfare.   Scrutiny of Children’s Social Care case records and a trawl of partner agencies would have revealed a range of concerning information about the family’s circumstances and should have prompted further enquiries.      7.13. On 5th September 2009 Louise Barley discharged herself from Hospital (against medical advice) leaving Kieron on the ward.  It was commented in this Trust’s IMR that mothers of pre-term babies are encouraged to stay in Hospital so they can access appropriate support in caring for a child with additional needs.  However, Louise Barley said that she was feeling depressed and insisted on leaving.  By 9th September 2009 Kieron was well enough to be discharged home where he was seen by a Health Visitor at her primary visit on 2nd October.  No concerns were identified.    7.14. Between September and December 2009 the Kieron was seen regularly by health personnel who expressed no concerns for his health and development.  It was noted that Louise Barley had ended one relationship (with a 53 year old man who was described as controlling) and had commenced a new one.  The details of this partner were obtained by the clinic nurse and appropriately recorded in the Kieron’s case record.  7.15. On 15th October 2009 the Nurse Practitioner Epilepsy (NPE) wrote to Louise Barley’s GP with a range of concerning information e.g: Final Overview Report  BSCB 2011-12/1   42   • Louise Barley had been suffering panic attacks; • she was again suffering from low moods;  • she had not bonded with the baby;  • she needed to be prompted to feed the baby at nights;  • Kieron was sleeping poorly, not eating and crying persistently; • Louise Barley was said to be ‘actively suicidal’; • she was still in a difficult relationship with a ‘controlling’ man; • she had been re-started on anti-depressants; and • they had both been referred to a Mother and Baby Unit.  7.16. However, Louise Barley was seen by her GP on 16th October 2009 for post-partum care and gave a very different story to that reported by the NPE above (NB:  the GP had not received the NPE’s letter at this point).  Louise Barley acknowledged feeling low and that she had been prescribed anti-depressants again but said she was coping well with the help of Maternal Grandmother.  She also said that she was bonding well with Kieron which was again in direct conflict with the information given to the NPE a few days earlier.    Author’s Note  There is nothing in the chronology to indicate how the GP responded to this letter or whether any consideration was given to Kieron’s safety in this situation.  The discrepancy between this interview with the GP and the letter from the NPE is striking, but is not picked up or addressed.    7.17. Between January and April 2010 Kieron was seen by health personnel on a number of occasions with minor childhood ailments e.g., coughs, sticky eye, ear infection and upper respiratory tract infections.  In early April he was admitted to Hospital with dehydration following a bout of gastro-enteritis, but made a good recovery and, after rehydration, was discharged the next day.    Final Overview Report  BSCB 2011-12/1   43  7.18. At a consultation with her GP on 28th April Louise Barley’s mood was reported to be very low.  She acknowledged thoughts of an overdose the previous night but reported that Maternal Grandmother, having reminded her that she had a baby to look after, also persuaded her to see the GP.  The GP completed a patient health questionnaire for depression and recorded a score of 22/27 which was a ‘moderately severe’ outcome.  He prescribed anti-depressants and referred Louise Barley to a local Mother and Baby Unit.   Author’s Note   This appears to have been a missed opportunity by the G.P. to refer Louise Barley and Kieron to the Health Visitor for targeted support, particularly in relation to Louise Barley’s contemplation of overdosing.   7.19. A letter from Louise Barley’s Neuro-Psychiatrist was sent to her GP on 20th July 2010, commenting that her attacks/seizures ‘were suggestive of a non-epileptic aetiology with psycho-social factors contributing’.  The Psychiatrist recommended cognitive behavioural therapy.    Author's Note  There is no consideration in the letter or the GP’s notes as to any implications for Louise Barley’s care of Kieron as a consequence of either her current mental health or her physical health e.g. the risk of seizures.     7.20. On 30th July 2010 a further letter was received by the GP from a Psychiatrist, this time at a Mother and Baby Psychiatric Unit where Louise Barley had been referred for further treatment and support.  This letter repeated Mother’s history of complex social problems (already well known to the GP) and concluded that ‘she has had a number of difficult life events that have made Final Overview Report  BSCB 2011-12/1   44  her vulnerable to episodes of low mood’.   It also described her as ‘socially isolated’ but able to care for Kieron i.e. there are no child protection issues.     Author’s Note  The evidence for saying there were no ‘child protection issues’ seems limited.  In fact there were many indicators of potential concern for Kieron’s welfare and safety.     7.21. By August 2010 it was clear that Kieron’s development was significantly delayed in a number of areas.  Other concerns identified by the Nursery Nurse involved at that time included his failure to put on weight, poor physical conditions within the family home and the unusual number of adults who seemed to be regularly present in the household.  No action under safeguarding proceedings was considered necessary at that time.    7.22. No improvement was noted by the Nursery Nurse at a visit on 3rd September 2010 when the family were warned that home conditions must improve or Kieron will be referred to Children’s Social Care for consideration of safeguarding action.  This appears to have prompted a positive response as conditions were noted to be better at a further home visit by the Nursery Nurse on 15th September.    7.23. At a home visit by the Health Visitor on 9th February 2011 it was recorded that Louise Barley had a new partner but that he did not live with her in the home of Maternal Grandmother.  The conditions in the home are again described as ‘cluttered’ and advice was given on keeping alcohol and cleaning products out of Kieron’s reach.  A referral to a Parenting Support Project was discussed and Louise Barley gave her consent to the referral being made.     Author's Note  Final Overview Report  BSCB 2011-12/1   45   Louise Barley and Maternal Grandmother have been warned many times by the Health Visitor/Nursery Nurse about the state of the home and its impact upon Kieron’s safety and general development.  In September 2010 they were warned that failure to improve would result in a referral to Children's Social Care.    With the added risk factor of ‘hazardous substances’, why was this threat not acted upon?   7.24. On 28th February 2011, the Health Visitor received a telephone call from Louise Barley’s Counsellor advising that she was meeting with Louise Barley fortnightly regarding her symptoms of low mood associated with previous trauma.  The Health Visitor agreed to re-visit the household and explore Louise Barley’s concerns.    7.25. Following a delayed 12 month developmental check Kieron was referred to the Community Paediatric Team to assess his ongoing developmental delay.  Although he was referred in December 2010 he was not seen by a Paediatrician until 29th March 2011 at which time the full extent of his problems had become more evident i.e.  • global developmental delay; • motor delay; • speech and language delay; • visual concerns; and • microcephaly.  7.26. Shortly before the above paediatric assessment was undertaken there had been a serious and violent incident within the family home.  It was reported that Maternal Grandmother’s partner and Maternal Uncle had got into an argument which developed into a physical confrontation.  Kieron was reported Final Overview Report  BSCB 2011-12/1   46  to be hysterical, leading to Louise Barley removing him from the family home and moving to stay with a friend over the weekend.    7.27. The incident was reported by Louise Barley to the Health Visitor the following day, when she was reassured that Kieron would be safe over the weekend (this was a Friday).  On the following Monday, the Health Visitor liaised with the brother’s GP (for information about his behaviour and the level of risk that he might pose to those around him) and made a referral on the appropriate multi-agency referral form to Children's Social Care.  It was noted that the Health Visitor now believed that the threshold was met for a Child Protection Plan to be made in respect of Kieron.   7.28. This referral was screened in Children's Social Care and passed to a Senior Practitioner for action.  The Senior Practitioner contacted the Health Visitor and Louise Barley by telephone to update and clarify the referral information but, although identifying some risk as a consequence of the volatile relationship between Maternal Grandmother’s Partner and Maternal Uncle, and the stress of coping with Maternal Uncle’s condition, the Senior Practitioner concluded that:  • Louise Barley had a good insight into Kieron’s needs; • she could ensure his safety; and • the significant factor in this situation was not Kieron’s safety or welfare but Louise Barley’s need for housing.  7.29. The Senior Practitioner’s recommendation was that there was no need for further action under child protection procedures and that other agencies could support Louise Barley with her housing application.  This recommendation was supported by the responsible Team Manager and the referral was signed off on 22nd March 2011.      Final Overview Report  BSCB 2011-12/1   47  Author's Note   This referral, which started with the Health Visitor suggesting that Kieron should be made subject to a Child Protection Plan, was not assessed robustly.  The IMR author for Children’s Social Care suggests a number of weaknesses in the assessment e.g.,  •••• failure to consider Kieron’s vulnerability in the light of his developmental delay; •••• a failure to consider Louise Barley’s history of mental health issues; •••• there was no strategy discussion with Police colleagues or contact with them to request any information; •••• no risk assessment particularly in respect of Louise Barley’s various partners (of whom there have been at least four since the birth of Kieron); and •••• no risk assessment in respect of any further contact between Kieron and Maternal Grandfather/Maternal Uncle.    The Senior Practitioner appeared to believe that if Louise Barley obtained her own accommodation then all risks/concerns will be reduced to manageable proportions, but this appears a massive leap of faith.  Louise Barley would be moving into her own accommodation for the first time at age 22 years with a background of concerning factors, not least having to care for a toddler whose health problems and developmental delay were only just beginning to be clarified.    The Senior Practitioner’s assessment was superficial at best and grossly optimistic in terms of Louise Barley’s capacity to safeguard Kieron, while the Team Manager’s authorisation of this piece of work is less than robust.    Also disappointing was the failure of the Health Visitor to consider using the escalation policy that was developed for just such situations i.e. she had referred the matter suggesting that a Child Protection Plan was necessary to Final Overview Report  BSCB 2011-12/1   48  safeguard Kieron, but Children's Social Care simply close the case after two phone calls.   It is the opinion of the Author that the Health Visitor’s concerns merited a challenge to that decision.   N.B.  The SCR Panel were advised that the BSCB escalation policy has subsequently been updated and re-launched.   Review of its’ on-going effectiveness is now embedded in BSCB’s Business Programme.     7.30. On 3rd May 2011 Louise Barley’s latest partner (and the man later convicted of Kieron’s manslaughter) attended his GP with Urticaria, a red itchy rash more commonly referred to as hives, for which he was prescribed anti-histamines.  He also reported a continuing history of cocaine use which he was struggling to cut down.  The GP gave him the telephone number of Birmingham Drug Line.   At this stage Craig Lewis and Louise Barley were not known to be living together so the GP had no reason to be concerned for Kieron or for any other child.  7.31. On the same day (3.5.11) Louise Barley attended her latest therapeutic counselling session.  The key issues discussed include:  • Louise Barley and Kieron were currently living with a friend but expected their own accommodation to be available within two weeks; and • the ‘whole session’ was focused upon Louise Barley’s anxiety about Kieron’s possible diagnosis which she knew may include cerebral palsy.    Author's Note  Given what was known about Louise Barley’s history of mental health problems, should the Counsellor have considered Louise Barley’s anxiety in the context of safeguarding Kieron from potential significant harm.   Final Overview Report  BSCB 2011-12/1   49   This appears to be a missed opportunity to facilitate a multi-disciplinary discussion on safeguarding children issues.  The focus appears to be exclusively on Louise Barley’s needs/problems.     7.32. Kieron attended Birmingham Children’s Hospital on 17th May 2011 as a day patient for a range of tests to determine the nature and extent of his developmental delay.  The examining Doctor documents four bruises on his back that Louise Barley and Craig Lewis say were caused by the straps on his high chair.  Despite this explanation lacking credibility, the Doctor does not discuss the bruising with senior colleagues or seek other safeguarding advice.    7.33. The Health Visitor contacted Louise Barley on 20th May and was advised that she now had her own tenancy and was in the process of furnishing and decorating it.  An appointment was arranged for the Health Visitor to visit on 9th June 2011.    7.34. At about 1700 hours on the evening of 28th May 2011 Louise Barley called an ambulance because Kieron had fallen, struck his head on the corner of a settee and has gone ‘floppy and crying’.  He was taken to Birmingham Children’s Hospital but discharged at approximately 2050 hours.  An x-ray had revealed no fracture to his shoulder and advice was given to Louise Barley.  Medical staff had wanted to keep him in for a further two hours observation but Louise Barley requested early discharge for the following reasons:  •••• Kieron seemed well again; •••• Craig Lewis had to go to work; and •••• a sibling was being looked after by a neighbour.  Author’s Note  It is clear with hindsight that Louise Barley deceived the Hospital on this Final Overview Report  BSCB 2011-12/1   50  occasion i.e. there was no sibling being cared for by a neighbour.  However, Hospital staff had no reason to doubt or query this story.    It is possible that the parents were anxious to prevent further investigation into Kieron’s health and wellbeing (it is now accepted that he had fractured vertebrae at the time of this examination) but if so that failed to work as he was taken back to Hospital a few hours later still vomiting and very distressed.    7.35. Later the same evening (at 2337 hours) Louise Barley telephoned NHS Direct for advice as Kieron had been vomiting since their return from Hospital.  The advice was that Kieron should be taken back to A&E as soon as possible.   He was, in fact, seen there again very quickly i.e. at 0016 hours on 29th May.  On this occasion he remained for several hours observation eventually being discharged home at 0845 hours.     7.36. Kieron was still unwell two days later when, at 1631 hours on 30th May, Louise Barley called NHS Direct again.  She reported that Kieron was not eating or drinking but continued to vomit and was very distressed.  Louise Barley was advised to take Kieron to A&E via her own transport, however, some three hours later (at 1949 hours) a 999 call was made to West Midlands Ambulance Service requesting an ambulance for him.  He was again taken to Birmingham Children’s Hospital where he was admitted to the Observation Ward for 12 hours during which time he tolerated oral fluids and opened his bowels after being administered a suppository.   7.37. On 6th June 2011 Louise Barley and Kieron were seen by the Community Paediatrician.  At this time, Louise Barley was advised that, following the extensive investigations including a detailed brain scan, the Paediatrician had concluded that Kieron does have cerebral palsy.  It was not recorded how Louise Barley reacted although it was noted that the CDC Co-ordinator was also present, to offer support and advice.  Final Overview Report  BSCB 2011-12/1   51  NB.  Kieron was not subject to any physical examination that might have identified the fractured vertebrae that we now know had been inflicted upon him.   The meeting was arranged solely to share the diagnosis and to consider ongoing support for Louise Barley.    7.38. An indication of Louise Barley’s reaction to the news of Kieron’s diagnosis can be found in the recording of a telephone conversation between her and her Counsellor, the Nurse Therapist, on the following day (7th June). In it Louise Barley advised that:  • she felt shocked, upset and pre-occupied; • she had been tearful and emotionally labile; and • for a while ‘she couldn’t be around Kieron’.   7.39. However, she also reported that she was starting to come to terms with the news and that her partner Craig Lewis was being very supportive.    7.40. The Health Visitor made a visit to the family on 9th June 2011, but did not see Kieron as he was asleep.   Louise Barley advised the Health Visitor that she was coming to terms with the diagnosis of cerebral palsy and confirmed that she had a realistic picture of what to expect as her brother had been living with the condition for many years.  Welfare benefits and local resources were discussed, and Louise Barley agreed to the Health Visitor referring Kieron to the Family Support Service and to the Sweet Project (this was never taken up).    7.41. The final chapter in Kieron’s life began at 1832 hours on 19th June 2011 when a 999 call was made to West Midlands Ambulance Service requesting an ambulance for a child said to be in cardiac arrest.  An ambulance arrived within five minutes and, after some basic life support input, Kieron was transported to Birmingham Children’s Hospital.    Final Overview Report  BSCB 2011-12/1   52  7.42. On arrival Kieron was confirmed as being in cardio-respiratory arrest, but was revived following cardio-pulmonary resuscitation.  He was admitted to the Paediatric Intensive Care Unit where a CT brain scan shows bleeding in the brain.  Further scans quickly revealed fractured vertebrae and an optical examination showed some bleeding into the eyes.  In view of the potentially suspicious circumstances, the Hospital Social Work Team and West Midlands Police were notified of Kieron’s admission to Hospital and current condition.    7.43. At one point on this day (19th June) the Police were notified that Kieron had died but a pulse was detected just as Hospital staff were about to turn off the life support systems.  Kieron remained on life support until 22nd June although he was critically ill with no voluntary responses throughout this period.  After discussion with the family a decision was taken to withdraw intensive care the following day on the grounds of futility.    7.44. Kieron died at 1342 hours on 23rd June 2011 following the agreed withdrawal of intensive care support – he was aged 22 months.   7.45. Initially there were no grounds for considering that his death had been other than by natural causes i.e. there were no obvious injuries or marks upon his body that would suggest non-accidental injury.    7.46. It was only following a painstaking criminal investigation, supported by complex forensic evidence, that the truth emerged i.e. that Kieron had been the victim of at least one serious assault by Craig Lewis in which fatal injuries were inflicted.    Final Overview Report  BSCB 2011-12/1   53  8. KEY ISSUES AND ANALYSIS   8.1. Any Review which considers a case with the intensity that comes with a Serious Case Review will inevitability uncover areas where individual practice fell below optimum standards and this Review is no exception.  However, as stated earlier in this report the purpose of a Serious Case Review is not to target or scapegoat individual practitioners, it is to learn lessons about how partner agencies of the LSCB can create an environment in which poor practice is less likely to occur.  This report will now consider what agencies have learnt from undertaking their own IMRs and what additional learning has been derived from an overview of all submissions to the Panel.    Children's Social Care   8.2. The author of the IMR submitted to this Review on behalf of Children's Social Care has identified a number of key learning points i.e.:  • the need to strengthen screening processes to ensure judgements are made about the need for an initial assessment taking into account previous referrals and knowledge about the family; • a need to improve case recording systems in order to make it easier and quicker for practitioners to access this information; • a need to continue to improve quality assurance measures in respect of referrals and initial assessments to ensure that, as far as possible, individual practitioner errors as identified in this review are identified and addressed; and • a need to provide specific training and regular updating briefings for staff responsible for screening referrals on relevant research and the findings of Serious Case Reviews.    8.3. The original Serious Case Review Panel considered that these were reasonable and proportionate responses to the issues raised in the IMR, but remained concerned that all these issues had been raised in previous Serious Final Overview Report  BSCB 2011-12/1   54  Case Reviews conducted by BSCB.  Clearly there were issues here about the sustainability of learning from those Reviews that presented BSCB with a significant challenge.    8.4. The response of Children’s Social Care to the Health Visitor’s referral dated 17th March 2011 can only be described as inadequate.  In response to a safeguarding referral, in which the referrer indicates her belief that the threshold for making a Child Protection Plan is met, the Senior Practitioner makes two telephone calls (one back to the Health Visitor and one to Louise Barley) and then closes the case having decided that the only issue is one of housing and that can be dealt with by other agencies.    8.5. A check of her own and partner agency records would have revealed Louise Barley’s troubled history and concerns for Kieron’s development delay, and should in the opinion of the Serious Case Review Panel have led to a strategy discussion with the Police and a child protection enquiry under Section 47 Children Act 1989.  It is entirely possible that this in turn would have led to a full multi-disciplinary discussion at a Child Protection Conference (in which mental health services would have been expected to contribute) and to concerns for Kieron’s safety and welfare being managed under a Child Protection Plan.    8.6. The Serious Case Review Panel accepts that this sequence of events is in part speculative but a thorough review of the available evidence at that time does support our position that such an outcome was likely had there been a robust child protection enquiry in response to the Health Visitor’s referral.    8.7. The implications of Kieron being subject to a Child Protection Plan in the wake of the Health Visitor’s referral seems to the Serious Case Review Panel to be significant e.g.  • the role of Craig Lewis in Kieron’s life would have been a matter of greater scrutiny;  Final Overview Report  BSCB 2011-12/1   55   • this is particularly relevant to the period following Louise Barley obtaining her own tenancy when Craig Lewis effectively moved in with her i.e. there would have been greater focus by the allocated Social Worker upon Kieron’s safety in the changed living arrangements; • Birmingham Children’s Hospital would have reported the bruising noted on Kieron at his attendance there on 17th May 2011 to Children’s Social Care; and • more robust safeguarding action (certainly involving a report to Police/Children’s Social Care) would have been taken by Birmingham Children’s Hospital following Kieron’s attendance there on 28th, 29th and 30th May 2011.  8.8. It is possible that action under any one of these bullet points might have changed the tragic outcome in this case but in particular the identification of fractured vertebrae on 28th May would have resulted in immediate safeguarding action (certainly his detention in Hospital and probably removal from his Louise Barley’s care).    8.9. In trying to identify why the referral was not progressed through the child protection process, the Serious Case Review Panel has investigated the possibility that Children’s Social Care were going through a phase in which the prevailing culture was to manage cases outside that process wherever possible (possibly due to workload issues) and, if so, whether that culture posed a wider risk to the safety of children in Birmingham.    8.10. The Serious Case Review Panel has looked at rates of children (per 10,000 of population) being made subject to Child Protection Plans in Birmingham and compared this with other similar authorities (accepting that Birmingham is very difficult to make comparisons with).  Extracts from those figures for the last four statistical years are as follows:  Final Overview Report  BSCB 2011-12/1   56  • at 31.03.10 Birmingham had 48.9 per 10,000 children subject to Child Protection Plans compared to an average of 40.1 for their statistical neighbours and 31.7 for the whole of England;  • at 31.03.11 the respective figures were 51.4, 45.5 and 38.3;   • at 31.03.12 the figures were 46.3, 40.1 and 37.8; and  • at 31.03.13 they were 37.2, 42.1 and 37.9.    8.11. From this information there seems no reason for concern at low levels of Child Protection Plans in 2010 and 2011 i.e. in the months before Kieron’s death.  The figures are consistently higher than Birmingham’s statistical neighbours and the England average which, in the view of the Serious Case Review Panel, is likely to be entirely appropriate given local demographic features.    8.12. BSCB may wish to investigate the figures recorded as of 31.03.13 which has seen Birmingham fall below both the statistical neighbours and the England average, but this issue is outside the remit of this Review.    8.13. However, the Serious Case Review Panel is satisfied that there is no obvious pattern of non-compliance with child protection processes in 2010/11 leading to an inappropriately low number of Child Protection Plans being in place at that time, and does not consider this issue to be a factor in the decisions taken following the Health Visitor’s referral in March 2011.    8.14. In the absence of any cultural or systemic failure (or indeed any concerns about the quality of information provided by the Health Visitor), it can only be surmised that the reasons for the inappropriate response to that referral are linked to poor decision making by the practitioners concerned possibly exacerbated by workload pressures. It is acknowledged in the IMR submitted on behalf of Children’s Social Care that ‘neither the Team Manager or the Senior Practitioner exercised good, evidenced professional judgement’ in Final Overview Report  BSCB 2011-12/1   57  screening this referral but, in mitigation, it also comments that there were significant pressures within the Duty Screening Team at that time due to an unprecedented volume of new referrals (also identified within an Ofsted Inspection in July 2010 that led to further re-structuring of services locally).    8.15. In 8.3 above I refer to the challenge that faces BSCB in ensuring the sustainability of learning from Serious Case Reviews particularly in respect of the screening of new referrals.  Over the last two years BSCB has met that challenge by developing a Multi-Agency Safeguarding Hub (MASH) which was launched on 24th July 2014.  The MASH is a multi-agency team which integrates and co-locates key safeguarding agencies with a view to better identifying risks to children and improving decision making, interventions and outcomes.  The MASH enables the multi-agency team to appropriately review their information systems, share all appropriate information in a secure environment, and ensure that the most appropriate response is provided to effectively safeguard and protect the child.    8.16. Current plans for this service are that the Birmingham MASH will continue to evolve and see agencies across all sectors represented by over 60 professionals from Social Care, Police, Health, Education and the Voluntary Sector co-located at Birmingham City Council offices.  The proposed involvement of the Mental Health Trust in MASH will greatly help in the assessment of risk where parents of vulnerable children are known to practitioners from that Trust.    8.17. The MASH will be the first port of call for anyone with a child safeguarding concern and is seen as a significant development in addressing what had been a perennial problem i.e. inadequate or superficial screening of such referrals within Children’s Social Care.  As with any new development on this scale it will need time to bed in but the Serious Case Review Panel shares BSCB’s confidence that it will successfully address the concerns identified in this and previous Serious Case Reviews.    Final Overview Report  BSCB 2011-12/1   58  Mental Health Trust  8.18. The IMR for this Trust has robustly considered their involvement with Louise Barley and concluded that there was ‘excellent liaison between services and other agencies around the general management of Louise Barley’s case’.    8.19. However, the author of the IMR has also identified that there had been a failure to follow the Trust’s policy on safeguarding children, as well as a failure to implement the BSCB inter-agency procedures and best practice guidance.  The key learning points from the IMR are:  • a need to ensure that all relevant practitioners have undertaken training on safeguarding children issues in line with the Trust’s mandatory policy on this subject; and • the need to improve record management in the Perinatal Psychiatric Service.    8.20. In the course of their enquiries, the Serious Case Review Panel has identified at least six previous Serious Case Reviews where the mental health of the parent was a factor in the death of a child, and where the recommendations called upon the Mental Health Trust to improve training and practice in respect of safeguarding the children of their patients.  The most high profile of these cases was presented to the BSCB in April 2010 (then known as Case 14) which, due to the unusual and horrific nature of the child’s death, received significant attention from national media.    8.21. Birmingham and Solihull Mental Health NHS Foundation Trust submitted an IMR to that Review which contained the recommendation:  ‘to take account of the learning identified from the IMR for all Trust clinical staff’.    Final Overview Report  BSCB 2011-12/1   59  In the Action Plan attached to the Review, the Trust has added the words ‘action completed’ to this recommendation.  8.22. Given that, in the twelve months following this Serious Case Review, practitioners within the Trust failed on six occasions to identify and address safeguarding concerns in respect of Kieron, the Serious Case Review Panel has to challenge the effectiveness of the Trust’s follow up to this recommendation.    8.23. On the evidence of this case, safeguarding practice within the Trust has not improved despite the learning derived from the previous Serious Case Reviews, and there is an urgent need for Senior Managers within the Trust to ascertain why their public commitment in this area has not been translated into effective practice at the frontline.   The IMR author has been robust in his identification of the issues and the Trust now needs to see that the lessons learnt really are the catalyst for change and improvement.    8.24. It has been drawn to the attention of the Serious Case Review Panel that the Mental Health Trust is commissioned to offer secondary mental health care and that much of the primary mental health care provided in the community is diagnosed, recognised and treated by GPs.  The use of the generic term ‘mental health’ in this report needs to be read in that context.  None of this however diminishes the Panel’s concerns about the role of the Trust where their patients are also parents of vulnerable children, and the proposed audit is still seen as a valid intervention.    8.25. In July 2012 the GMC published new guidance for all Doctors who provide care for adults who are also parents.  This was implemented on 3rd September 2012, and this comprehensive document could be used by the Mental Health Team as a catalyst for education and change.    8.26. For BSCB the issue is one of great importance.  The mental health of parents has long been identified as a significant factor in child protection work Final Overview Report  BSCB 2011-12/1   60  particularly in cases where children have died or suffered serious injury.  Reviews of Serious Case Reviews undertaken by Ofsted in recent years confirm that in 2003/05 past or present mental health issues for either parent was a factor in 61% of the 161 cases considered while the corresponding figure for 2005/07 was 63% of 189 cases.  8.27. It should be of concern to BSCB that one of their partner agencies appears unable to implement and sustain necessary changes to their practice despite the sometimes disastrous impact that this is having upon the lives of children.    8.28. The Serious Case Review Panel is recommending that BSCB undertake direct work with the Trust, preferably informed by a thematic audit of current cases in the safeguarding system, to identify the barriers to achieving full compliance with safeguarding procedures.  Such an audit should identify children subject to safeguarding enquiries and/or Child Protection Plans where one of  their parents is receiving a service from the Trust, and then analyse the Trust’s contribution to that work e.g. the quality and frequency of information sharing, attendance at Child Protection Conferences and Core Group Meetings, provision of written reports to Conference, etc.  8.29. Anecdotally the Panel has received information suggesting that practice has improved since 2011 so the suggested audit should give added weight to that perception.   Community Healthcare Trust  8.30. The IMR written on behalf of this Trust identifies the learning points as:  • a need to ensure that staff make appropriate contacts/referrals if they see a vulnerable adult with unmet needs within the household of a family with young children; Final Overview Report  BSCB 2011-12/1   61  • a need to develop analytical case recording skills to ensure that issues of developmental delay can be recognised through consistent observation and recording; and • the use of the Common Assessment Framework by Health Visitors can give a structure to work with children who have complex health problems or developmental delay, and a way of addressing the child’s needs holistically.   8.31. The Panel considers these points to be well evidenced in the IMR but feels there is further learning to be derived from the Health Visitor’s failure to clarify the nature of Louise Barley’s contact with Mental Health Services.  It should be acknowledged at this point that, as described earlier in the report, practitioners and clinicians from the Mental Health Trust did not share information appropriately with various agencies including the Health Visitor.  However, Louise Barley’s contact with the Trust was known to the Health Visitor in March 2011 if not earlier but she chose not to make further enquiries, which would have helped her understand whether Louise Barley’s mental health issues could be having a detrimental impact upon her capacity to provide safe and nurturing care for Kieron.    8.32. Such an enquiry might also have had the effect of alerting the Mental Health Trust of the need to consider Kieron’s safety and welfare in the light of Louise Barley’s mental health.    8.33. In her referral to Children's Social Care in March 2011, the Health Visitor described Louise Barley as having a ‘tragic past’ and the Serious Case Review Panel believes that contact with the Mental Health Trust at this time would have enabled the Health Visitor to better understand the impact of her earlier experiences on her present life, her ability to form appropriate adult relationships and, of course, her attachment to Kieron.    8.34. Notwithstanding the above point, the Serious Case Review Panel considers that the Health Visiting Service provided a good standard of care to Kieron Final Overview Report  BSCB 2011-12/1   62  and strong support to Louise Barley, but it will make a recommendation to the Trust concerning the need to liaise with the Mental Health Trust in cases where targeted intervention is required or, as the Health Visitor believed in March 2011, the threshold for a Child Protection Plan was met.    Birmingham Women’s Hospital   8.35. The IMR for this Trust considers that the learning points arising from the Review are all linked to issues of domestic abuse i.e. the awareness of staff about the issue and the consistency in patients being routinely questioned on the subject when presenting for ante-natal appointments.    8.36. Two recommendations are made by IMR author i.e.:  • all Midwives to attend mandatory training on domestic abuse issues; and • routine enquiries to be made of patients, and documented in case records (or the reasons why the questions were not asked).  8.37. Both these recommendations are supported by robust arrangements for monitoring their effective implementation but again the Serious Case Review Panel believes there is further learning to be derived from the failure of Midwives to assess Louise Barley’s vulnerability during pregnancy in the context of her involvement with Mental Health Services and her recent overdoses.  8.38. It is of some concern to the Panel that despite a range of concerning information being available to the Midwifery Service, no-one apparently thought to ask the obvious question i.e. in view of Louise Barley’s history, is it safe for her to take a baby back to this family home where the other adults resident there had a range of personal problems of their own?  Final Overview Report  BSCB 2011-12/1   63  8.39. The answer may well have been in the affirmative but the issue remains that a risk assessment was not even considered let alone a safeguarding referral to Children's Social Care.    8.40. This report will contain a recommendation that the Trust reviews its policies and guidance in this area to satisfy BSCB that staff are alert to the circumstances where risk assessments are required and that they are competent to carry them out or to refer them to other agencies as necessary.    Update: September 2014  8.41. The current Serious Case Review Panel recognises that the above concerns date back to 2009 and is reassured by the updated IMR submitted to the reactivated Review earlier this year.  This report describes improved screening of newly pregnant women (i.e. attention to any report of domestic violence, substances misuse, mental health issues, etc) to ensure any vulnerability is identified and acted upon, as well as improved training on safeguarding children issues for a wide range of staff according to their assessed need.  Other than robust oversight of the impact of these measures, the Serious Case Review Panel is satisfied that their concerns have been addressed.    Birmingham Women’s Hospital   8.42. This Trust had limited contact with Louise Barley in the period set for this Review – she was last seen in September 2009 when she was in the care of the joint Obstetric and Epilepsy Clinic.  There was no contact between the Trust staff and Kieron.    8.43. The IMR author believes that Louise Barley received appropriate care and follow up support when she attended the Trust and has identified no specific learning points.  Staff did identify Louise Barley’s vulnerability, particularly in the light of her earlier overdoses, but considered that her relationship with her Mother was a protective factor. Final Overview Report  BSCB 2011-12/1   64   8.44. The Serious Case Review Panel has not identified any other issues in relation to this Trust.  NHS South Birmingham (GP)  8.45. The IMR author for this Trust has identified that Louise Barley’s GP failed to consider a number of risk factors that compromised her capacity to safely parent Kieron and also failed to liaise with the Health Visitor who was having regular contact with the family.    8.46. This learning is addressed by a recommendation that ‘when a parent is identified with mental health problems the GP should always discuss with the Health Visitor in order to ascertain the likely effect on parenting capacity…’  8.47. It is pointed out in the IMR that a recommendation was made in a recent Serious Case Review conducted by BSCB (2011/12-2) that ‘encourages’ GPs to have regular scheduled meetings with Health Visitors to enable discussion about families of concern.  The Serious Case Review Panel was pleased to note that a recent (2014) audit undertaken on behalf of BSCB demonstrated improved practice in this area.  There is confidence within BSCB that this area of work is now embedded in ongoing audit work/staff training and policy development and, as a direct consequence, these actions will make a positive difference to the safety and welfare of children in Birmingham.    8.48. Of concern to the original Serious Case Review Panel was the IMR author’s finding that the GP missed a number of opportunities to identify potential safeguarding issues for Kieron and does not appear to have ‘considered at all the impact of Louise Barley’s mental health upon her ability to parent Kieron’.  In mitigation it has been suggested to the Serious Case Review Panel that:  • the GP would see many parents with low level mental health issues and neither Mother or her partner would stand out as a risk to children; and Final Overview Report  BSCB 2011-12/1   65  • he may well have assumed that specialist services involved with Louise Barley would have made appropriate safeguarding referrals as and when necessary.  8.49. However it is the view of the Serious Case Review Panel that making assumptions in child protection matters can never be defended, and this raises concerns about the quality of safeguarding training accessed by the GP.  8.50. The IMR author has confirmed that safeguarding training in the practice was up to date but this appears to have had only a limited impact upon practice.  Scrutiny of previous Serious Case Reviews conducted by BSCB confirmed that this is not a new issue.  In addition to the Serious Case Review mentioned above, the issue of GPs failing to identify and report safeguarding concerns, and their compliance with safeguarding training, has been mentioned in at least five other Reviews between 2007 and 2009.  8.51. BSCB needs to understand why so much work and so many well intentioned recommendations appear not to be having the desired impact.  The Serious Case Review Panel also recommends that BSCB take advantage of the timely publication of the GMC Guidance ‘Protecting Children And Young People – A Guide For Doctors Who Treat Adult Patients’ (published July 2012) in order to promote sustainable change in this area.  8.52. Some of the key messages from this guidance are:  • when Doctors care for an adult patient, that patient must be their first concern but they should also consider whether the patient poses a risk to children or young people; • Doctors must be aware of the risk factors that have been linked to abuse and neglect and look out for signs that the child or young person may be at risk; Final Overview Report  BSCB 2011-12/1   66  • Doctors should have a working knowledge of local procedures for protecting children in their area; and • Doctors must develop and maintain the knowledge and skills to protect children and young people at a level that is appropriate to their role.  8.53. The guidance document is comprehensive (64 pages) and contains a wealth of practical guidance with extensive links to research.  The GMC had set an implementation date of the 3rd September 2012 and it was a strong recommendation from the original Review report that BSCB engaged with the Birmingham and Solihull PCT Cluster to ensure that it receives an appropriate high profile launch in Birmingham.  More recently (July 2014) the NSPCC, in collaboration with the Royal College of General Practitioners, has published an overview of policy, practice and research, which local practitioners and managers would benefit from studying.    8.54. It was the opinion of the original Serious Case Review Panel that only through a commitment to robust implementation and ongoing monitoring of GPs’ compliance could BSCB hope to finally resolve this perennial flaw in local services for safeguarding children.    Update: September 2014  8.55. The new Serious Case Review Panel has been given updated information which suggests that, over the last three years, there have been a number of new developments which give greater confidence about the engagement of GPs in the child protection process i.e.  • all GP practices now have arrangements to meet and regularly liaise with Health Visitors to consider cases where children may be at risk; • the CCG has safeguarding champions who can support and give advice to GPs on safeguarding issues;  • GP training in respect of safeguarding children (extended now to all practice staff) is of greatly improved quality; and Final Overview Report  BSCB 2011-12/1   67  • there has been significant improvement in the engagement of GPs in the Child Protection Conference process following meetings with Children’s Social Care staff at which the ‘strengthening families’ model was explored.    Children’s Centre  8.56. Although the Children’s Centre was only involved with Kieron and his family for the last twelve weeks of his life, the IMR author has taken full advantage of this Serious Case Review to identify a number of learning points that will inform their future work.  8.57. The IMR confirms that practice will be strengthened in the following areas:  • induction and training on safeguarding issues will be reviewed and further developed for staff; • information sharing and case recording issues will be enhanced to ensure a consistent approach to identify developmental delay or safeguarding concerns; • the use of the Common Assessment Framework will be embedded into service delivery; and • supervision processes for staff will be improved to reflect the need for objectivity and challenge.  8.58. The Serious Case Review Panel considers this IMR to be robust and its learning has been reflected in the recommendations.  West Midlands Police  8.59. Until the evening that Kieron was admitted to Hospital with fatal injuries, West Midlands Police had only two contacts with the family in the period set for this Review.  Final Overview Report  BSCB 2011-12/1   68  8.60. Neither of these contacts raised any concerns about the practice of individual officers or about force policy and protocol.  The report makes only one recommendation and that is in relation to how West Midlands Police contribute to future Serious Case Reviews.  This recommendation, which the Serious Case Review Panel fully endorses, arose from the failure of West Midlands Police (for reasons that cannot be identified) to share information with partner agencies about Kieron’s fractured vertebrae when first identified. That information would have influenced judgements about the safety of Craig Lewis’s two children from his previous marriage during their regular contact sessions.    Birmingham Children’s Hospital  8.61. Birmingham Children’s Hospital had contact with Kieron ten times in his life of which five contacts were in the six week period preceding his death.    8.62. The significant contacts prior to Kieron’s admission with fatal injuries on 19th June 2011 were:  • 17.05.11 – when a junior member of the medical team failed to consider bruising noted on Kieron under the Hospital’s child protection procedures; and • 28th, 29th and 30th May 2011 – when medical staff treated Kieron for injuries following an alleged fall but failed to identify that Kieron had suffered a number of fractured vertebrae.    8.63. Birmingham Children’s Hospital have considered both these events most carefully and recognise that, in respect of the attendance on 17.05.11 the junior member of the medical team failed to follow appropriate safeguarding procedures.  As a consequence there was no adequate scrutiny of the bruises (the explanation that it was caused by straps in a high chair lacked credibility) and an opportunity to intervene under safeguarding procedures was missed.    Final Overview Report  BSCB 2011-12/1   69  8.64. The IMR goes on to consider why an otherwise competent doctor (who had undergone child protection training) failed to even seek advice from senior colleagues on this occasion but, other than workload issues leading to personal error could identify no other specific reason.  As with the later Hospital attendance on 28th May 2011, the response of the Doctor was likely to have been very different if Kieron’s safety was being monitored by a Child Protection Plan in the wake of the Health Visitor’s referral in March.  The doctor in question has subsequently been given further guidance and instruction in respect of his performance on safeguarding children matters.    8.65. Whether a safeguarding referral at this stage would have made any difference to the final outcome is of course speculative.  A safeguarding referral from Birmingham Children’s Hospital less than two months after one from the Health Visitor could have prompted a child protection enquiry which in turn may have led to safeguarding action that could have prevented the fatal injuries suffered by Kieron later that month.  However, the Serious Case Review Panel cannot be certain that this would have been the sequence of events and the outcome of any referral at that time.    8.66. Kieron’s attendance at Birmingham Children’s Hospital on 28th, 29th and 30th May raises two issues:  • should Hospital staff have been alert to the deceit of Louise Barley when she fabricated a story in order to facilitate Kieron’s early discharge home; and • were Hospital staff negligent in failing to recognise that he had been the victim of a serious assault in which he suffered a number of fractured vertebrae?  8.67. In respect of the first bullet point, it is not thought that any Hospital protocols were breached.  At that stage there were no suspicious circumstances in respect of Kieron’s condition and the story told (a sibling being cared for by a neighbour and Craig Lewis needing to go to work) was entirely plausible.  Final Overview Report  BSCB 2011-12/1   70  While Hospital staff would have preferred Kieron to remain for two hours more, the decision to allow Louise Barley to take him home (with clear guidance on observing his progress) appears entirely reasonable.  It is also noted that Louise Barley returned Kieron to Hospital within a few hours in response to his continued vomiting and in line with the guidance on head injuries provided to her.    8.68. The author and the Serious Case Review Panel have paid particular attention to the second bullet point having been made aware of comments attributed to family members that have appeared in the media e.g. a newspaper article dated 14.07.14 quotes Kieron’s birth father as saying ‘Every part of Kieron should have been checked that day, not just his shoulder’.    8.69. Kieron was taken by ambulance to Birmingham Children’s Hospital on the evening of 28th May 2011 when his Louise Barley reported that he had fallen while trying to walk, struck his head and shoulder and then had a ‘floppy’ episode.  Medical staff noted an abrasion to his shoulder and a swelling to the bridge of his nose.  The shoulder was x-rayed but no injuries were observed.    8.70. As described above, Kieron was discharged earlier than medical staff would have wished but was returned by his Louise Barley later that evening and again on 30th May with symptoms of vomiting and general distress.    8.71. The IMR is clear that the practice of medical staff on all three occasions was in line with Hospital policy in respect of the management of minor head injuries in children. Indeed the practice of the doctor who saw Kieron on his first admission was described as ‘above the minimum expected standard of practice’ as he undertook a full top to toe examination which included checking the spine manually.  The examination of the spine revealed no tenderness and gave the doctor no reason to request a further x-ray.    8.72. If it is accepted that the medical staff involved acted appropriately and within the Hospital’s guidelines for such situations then the next question is whether Final Overview Report  BSCB 2011-12/1   71  those guidelines are ‘fit for purpose’, in particular should all children who visit the Emergency Department at Birmingham Children’s Hospital with minor injuries (or those in certain age groups or with certain conditions) automatically be subject to top to toe examinations including full skeletal surveys.    8.73. This point was put to the Named Doctor for Safeguarding at Birmingham Children’s Hospital by the Chair of the Serious Case Review Panel and elicited the following responses:  • mandating that all young children presenting with minor injuries have a full head to toe examination has ‘huge implications for the treatment time of these children and also for all other children attending the emergency department’;  • the existing guidance to doctors prompts them to consider non-accidental injury at many stages in their assessment of the child, particularly in the range of injuries associated with child abuse (which includes head injuries); and  • any indication or impression that the history is ‘inconsistent, implausible or indicates a lack of appropriate care of supervision’ would prompt a response under safeguarding procedures.       8.74. The letter also points out that Kieron did have a top to toe examination and this gave rise to no concerns that suggested a need for a full skeletal survey, and it concludes by saying that the Hospital cannot support a recommendation making such examinations mandatory for all children seen in the Emergency Department.    8.75. The Serious Case Review Panel has clarified with the Hospital that had Kieron been subject to a Child Protection Plan at the time of his attendance there on that occasion (and on 17th May 2011 also) there would have been greater focus upon the safeguarding concerns but not necessarily a full skeletal Final Overview Report  BSCB 2011-12/1   72  survey.  The Serious Case Review was advised by Birmingham Children’s Hospital that whether or not he was subject to such a survey would be a clinical decision and not influenced by his child protection status.         8.76. Given that formal safeguarding arrangements were not in place did Hospital staff have any reason for singling out Kieron from the many other children presented there with minor injuries, and implementing child protection procedures?  Certainly Louise Barley and Craig Lewis did not give them any particular cause for concern and, other than three Hospital presentations in three days, there was nothing sinister or worrying about this case based on the knowledge of those members of staff involved in his care.      8.77. The Serious Case Review Panel has taken separate medical advice in reaching the following conclusions about the performance of medical staff on the four occasions that Kieron attended Birmingham Children’s Hospital in May 2011 i.e.  • the bruising noted by a junior doctor on 17th May 2011 should have been considered as non-accidental in line with the available evidence and discussed with a senior colleague or safeguarding professional to decide upon the need for action under safeguarding children procedures; • no blame can be attached to staff members on 28th May 2011 for failing to realise that Louise Barley had lied to them in order to facilitate Kieron’s early discharge home;    • all medical staff involved in Kieron’s attendances on 28th, 29th and 30th May 2011 acted appropriately and within Hospital guidelines when treating him and there was no negligence in the failure to identify his fractured vertebrae; and • a recommendation to make top to toe examinations compulsory in respect of all minor injuries is considered to be disproportionate and unworkable.    8.78. The Serious Case Review Panel supports the recommendation contained in the IMR of Birmingham Children’s Hospital i.e. to revise the guidance for Final Overview Report  BSCB 2011-12/1   73  managing children who present at Hospital frequently (including improved liaison with community based health staff) and to incorporate the lessons of this Serious Case Review into future training, particularly for junior staff.    8.79. It is likely that the family of Kieron will find it difficult to accept that any child can be presented at Hospital with fractured vertebrae and not have this problem identified but, in the context described above (and where the child is non-verbal and has already been diagnosed with developmental delay) the Serious Case Review Panel considers that no blame can be applied to the staff involved.         8.80. As stated at the very beginning of this report the task of the reactivated Serious Case Review Panel in 2014 was twofold i.e.   • a review of how the recommendations of the interim report presented to BSCB on 16th November 2012 had been implemented; and • consideration of whether further lessons can be learnt by partner agencies of BSCB from the additional information that could now be released by the Police (primarily related to the last five/six weeks of Kieron’s life).    8.81. The first bullet point has been addressed throughout the preceding paragraphs of this section of the report, and overall the Serious Case Review Panel is satisfied that partner agencies of BSCB have responded robustly to the concerns raised in the interim report.  The development of the Multi-Agency Safeguarding Hub is viewed with particular interest as it suggests an innovative, and hopefully effective response to a perennial problem i.e. superficial and inadequate screening of safeguarding referrals within Children’s Social Care.    8.82. In addressing the second bullet point above (and recognising that there is inevitably some overlap between the two) the Serious Case Review notes that Kieron was seen on eight separate occasions in the period 16.05.11 to Final Overview Report  BSCB 2011-12/1   74  19.06.11 and, with one exception, all these contacts were with health personnel i.e.   •••• once at clinic by a Community Nursery Nurse; •••• once with a Family Support Worker from the local Children’s Centre;       •••• twice at the Child Development Centre (physiotherapist and neuro-development clinic); •••• four times at Birmingham Children’s Hospital (once for an MRI scan as part of the CDC assessment and three times in the emergency department following his alleged fall on 28th May 2011)                      8.83. In addition the Health Visitor made a visit to the new family home (good practice in circumstances where there are concerns for the development of a child) but did not see Kieron who said to be asleep at the time.    8.84. No contact was made by Children’s Social Care who were unaware of the family’s change of address, having closed their case after addressing the Health Visitor’s referral in March 2011.    8.85. In conducting his analysis and identifying the key issues from this period, the Author has used the revised terms of reference (see section 4) as the framework for this work and the following paragraphs should be read in conjunction with that section.    Kieron’s Life Experiences  8.86. Considering Kieron’s daily life experiences needs to be addressed in two parts i.e. his life while living with Louise Barley in the home of Maternal Grandmother, and the final six weeks of that life when Louise Barley obtained her own tenancy.  Regrettably very little can be ascertained in respect of that life in those final weeks as the only person who saw him at home was the Family Support Worker, and she was simply there to collect Kieron and Louise Barley for an introductory visit to a toy library.  The Health Visitor however had Final Overview Report  BSCB 2011-12/1   75  considerable knowledge of his life experiences while living in the home of Maternal Grandmother and, despite clear evidence that Kieron was a much loved child by all the family, concerns were regularly expressed in respect of the home environment and the impact upon Kieron’s development i.e.  •••• the home was frequently noted to be ‘cluttered and untidy’ restricting the amount of safe play space available to Kieron; •••• hygiene conditions were regularly unacceptable thereby posing risks to his health; •••• on occasion the atmosphere was described as ‘smoky’ and there was a persistent smell of cigarette smoke in the home; •••• Kieron was noted to spend inappropriately long periods in a baby bouncer or a pushchair rather than being free to develop age appropriate gross motor skills;  •••• there was a lack of age appropriate toys to stimulate Kieron’s learning and development; and •••• although Maternal Uncle was cared for ‘lovingly’ by the family his regular outbursts, some violent were a constant source of stress for the family (and in fact one was the trigger for Louise Barley seeking her own accommodation).  Craig Lewis  8.87. Very little was known by partner agencies about Craig Lewis during the relevant period.  Craig Lewis was seen by health professionals on a number of occasions but his presentation and behaviour caused no concern at this time. He did visit his GP on 3rd May 2011 and during the consultation acknowledged using cocaine twice a week that he was finding difficult to reduce.  Appropriate advice was given by the GP who, at that time, had no knowledge of his relationship with Louise Barley and Kieron.  No other agency involved with the family was aware of this habit and he was not engaged with any drugs agency.  Craig Lewis advised the Author in interview that his occasional use of cocaine and alcohol was not a factor in Kieron’s death and, in the absence of Final Overview Report  BSCB 2011-12/1   76  evidence to the contrary, the Serious Case Review Panel can draw no conclusions from this.  No agency involved with Kieron was aware that Craig Lewis had children from a previous relationship.  Early Help  8.88. The IMR from the Community Health Care Trust describes in detail the range of early help made available to Louise Barley and Kieron throughout his life.  From the very beginning the Health Visiting Team maintained ‘a constant level of targeted intervention’ which included a referral to the local Children’s Centre (at ten weeks old), and the ‘Flying Start’ programme (a home visiting service) but this latter service was not taken up by Louise Barley.  In addition it was the Health Visitor who, in noting Kieron’s developmental delay, referred him to the Child Development Centre for assessment.  Louise Barley did not take up all the support offered but the Serious Case Review Panel do not consider that her failure to do so should have prompted any safeguarding action by the Health Visitor.  The IMR does suggest that better co-ordination of services to Louise Barley and Kieron in those early days could have been improved if a CAF assessment had taken place.  There is confidence that the response to a similar referral in 2014 would be more robust but it is recognised also that still more could be achieved with the allocation of additional resources.    Organisational Culture and Behaviour  8.89. None of the IMRs submitted in this Serious Case Review suggested that organisational culture played any role in their agency’s performance while providing services to Kieron and the Serious Case Review Panel have not identified any evidence to suggest otherwise.  Where performance fell below the required or optimum standards it is attributed more to individual error than organisational issues.      Final Overview Report  BSCB 2011-12/1   77  Context/Multi-Agency Response  8.90. It is clear from the available information that there was never any ‘multi-agency consideration of appropriate intervention’ in respect of any risks to Kieron’s safety and welfare.  There were a number of points at which such consideration might have been undertaken had individual practitioners demonstrated greater professional curiosity and made enquiries among partner agencies of BSCB e.g:  • prior to Kieron’s birth, when midwifery staff failed to assess Louise Barley’s vulnerability in the context of her history and mental health problems;  • shortly after Kieron’s birth when Louise Barley reveals concerning information about his biological Father;  • on 15th October 2009 when the G.P. received a letter of concern from the Nurse Practitioner (Epilepsy): • in October 2010 when Louise Barley was not responding to the Health Visitor’s advice about home conditions and Maternal Uncle was displaying aggressive behaviour;  • in March 2011 when Children’s Social Care closed a safeguarding referral from the Health Visitor after making two telephone calls;  • on 17th May 2011 when a junior doctor at Birmingham Children’s Hospital noted bruising on Kieron’s back (the explanation for the bruising was later described as ‘not credible’); and • on 30th May 2011 when Kieron was presented at Birmingham Children’s Hospital for the third day running which (the IMR suggests) should have prompted a review of the parents’ capacity to promote Kieron’s safety and welfare and an attempt to ascertain why the Hospital appeared unable to meet his health needs.  8.91. All these events are discussed earlier in this section of the report, as is their potential impact upon the tragic outcome for Kieron.  The Author and the Serious Case Review Panel have made it clear that they consider formal child Final Overview Report  BSCB 2011-12/1   78  protection procedures should have been commenced on at least three of those occasions which would have led to multi-agency consideration of Kieron’s safety, probably via a Child Protection Conference.    8.92. The reasons why they did not progress in that way is also considered earlier in this report and can be summarised as a lack of professional curiosity and individual errors of judgement.  There are no obvious weaknesses in safeguarding procedures but in the above circumstances no-one considered the need to implement them (other than the Health Visitor in March 2011 whose referral was promptly closed down by Children’s Social Care).    Assessment of Cerebral Palsy  8.93. It is clear that the Child Development Centre undertook some enquiries into Kieron’s home circumstances (social, economic and environmental) but there is insufficient information available for the Serious Case Review Panel to draw conclusions about any impact upon the reasons for this Serious Case Review.  There is nothing to suggest that the assessment process was anything other than robust.    Identification of Risk Factors  8.94. Only the Health Visitor considered the accumulation of risk factors in Kieron’s life (to the extent that in March 2011 she felt the threshold was met for a Child Protection Plan) while other professionals either failed to recognise the significant of information before them (errors of judgement) or failed to make appropriate checks of partner agency records (poor practice).  Last Six Weeks of Kieron’s Life  8.95. As stated earlier in this report the only professionals involved with Kieron in the last six weeks of his life were from health disciplines i.e. the Child Development Centre, the Health Visitor and Birmingham Children’s Hospital, Final Overview Report  BSCB 2011-12/1   79  plus one contact from the Children’s Centre.  While all these professionals were working individually to promote Kieron’s life chances, there is no evidence of their working together in this short period to achieve that outcome.    8.96. An example of where inter-disciplinary liaison may have made a difference was raised in the IMR written by Birmingham Children’s Hospital i.e. the decision of the Paediatric Liaison Health Visitor not to contact Kieron’s community based Health Visitor on the occasion of his three attendances there on 28th, 29th and 30th May 2011.  In the first instance such a referral would have ensured that Kieron’s progress and recovery was monitored by the local Health Visitor (and she would certainly have insisted on seeing him at her home visit on 9th June if she had been aware of his recent Hospital attendance) but a secondary benefit would have been that Birmingham Children’s Hospital had access to the range of concerning factors that had led the Health Visitor to make a safeguarding referral only two months earlier.  That additional information, when shared with medical practitioners, may have occasioned a more detailed examination of Kieron.  Whether it would have prompted a full skeletal survey (the only way that the vertebral fractures would have been discovered) is less clear.    Deceit of Louise Barley and Craig Lewis  8.97. There are only two proven incidents where Louise Barley and Craig Lewis deceived professionals although it can reasonably be presumed that there were others, particularly in the last six weeks of Kieron’s life e.g. was he really asleep when the Health Visitor visited on 9th June or was Louise Barley hiding him because of obvious signs of assault/abuse.    8.98. The first known incident of deceit was at Birmingham Children’s Hospital on 28th May 2011 when, in order to facilitate Kieron’s earlier discharge, Louise Barley told staff that a neighbour was caring for his sibling.  This issue is considered earlier in this section of the report and no blame has been apportioned to any Hospital staff for failing to spot such an innocuous lie.   Final Overview Report  BSCB 2011-12/1   80   8.99. The IMR submitted to this Review by West Midlands Police clearly demonstrated that, from the moment that the Police first made contact with the family following Kieron’s death, both Louise Barley and Craig Lewis began to manipulate and deceive officers and this continued right up to the trial in 2014’.  Clearly their motivation for doing so was to try and prevent their arrest, conviction and imprisonment for serious offences against Kieron, but thanks to the persistence of the investigation, supported by forensic evidence, their plans were ultimately unsuccessful.   8.100. While it is likely that there was further deception by both Louise Barley and Craig Lewis, there is no evidence to suggest that any individual professional failed to identify and address obvious inconsistencies in any information provided by Kieron’s carers.    Final Overview Report  BSCB 2011-12/1   81  9. CONCLUSIONS, KEY LEARNING POINTS AND COMMENTS  9.1. Kieron was clearly a much loved child within his family and, despite increasingly obvious evidence of developmental delay, was described as happy, contented and ‘bubbly’.    9.2. It is likely that this delay in development was partly as a consequence of being born at 33 weeks’ gestation, but there is also ample evidence within the Health Visiting records that his home environment was a contributory factor e.g.  • cramped and cluttered conditions that inhibited his ability to explore his environment and learn new skills (e.g. pulling himself up, walking, etc); • he spent long periods of time strapped in a buggy; • a lack of opportunity for stimulating play with age appropriate toys; and • limited opportunities to mix with other children whereby he could learn to socialise etc.    9.3. These issues were identified and raised with the family who, in fairness, did try to respond to the advice offered by the Health Visitor although sustaining that compliance proved difficult and this eventually led to the Health Visitor advising Louise Barley that she would have to refer Kieron to Children’s Social Care if things did not improve.    9.4. The previous sections of this report have clearly set out the problems that beset Kieron’s development while living in the home of maternal grandmother and how these problems were influenced by issues of disability, parental mental health, poverty and the numerous father figures that came and went in his life.  However, nothing that the Serious Case Review Panel has read or heard in the course of this Review suggests that his life was at risk prior to his Louise Barley moving into her own tenancy in early May 2011.    Final Overview Report  BSCB 2011-12/1   82  9.5. It is at this point that Louise Barley’s partner becomes a significant feature in Kieron’s life, a role which clearly involved some level of direct care for him.  The relationship between Louise Barley and Craig Lewis had begun in January of that year but now intensified.  Both advised the Author that he had not fully moved into the flat to co-habit with Louise Barley but was spending significant periods of time there (the Health Visitor noted male clothing around the home).    9.6. What is clear retrospectively is that Kieron was subject to physical abuse within days of Louise Barley moving into her new home i.e. bruising was noted during a Hospital appointment on 17th May 2011 and the parents’ explanation is, with hindsight, accepted as ‘lacking credibility’.  In the first 21 months of his life Kieron’s development was increasingly a matter of concern but at no point until now had indicators of physical harm been noted.  9.7.  The violence towards him increased significantly in the days following that incident to the point that, when seen at Hospital on 28th May 2011 (allegedly having suffered a fall while trying to walk), he had actually suffered vertebral fractures, injuries that were highly unlikely to have been caused accidentally.  The circumstances surrounding the failure of medical staff to identify those fractures is considered at length in the preceding section of this report and concludes that no blame can be apportioned to those staff.    9.8. Much attention has been paid to Louise Barley’s deceit on the occasion of this Hospital attendance i.e. she lied to staff in order to facilitate Kieron’s discharge home earlier than staff wished, the implication being that she wished to avoid further investigation that might have revealed the true extent of his injuries.  However, this suspicion is undermined by the fact that Kieron was returned to Hospital by Louise Barley on 29th and again on 30th May as he continued to present as unwell.  Overall the Serious Case Review Panel thinks that no great significance can be attached to Louise Barley’s behaviour in this respect on 28th May.    Final Overview Report  BSCB 2011-12/1   83  9.9. The IMR prepared on behalf of Birmingham Children’s Hospital suggests that two courses of action were indicated following Kieron’s attendance there on those three successive days i.e.  • action by medical staff under the ‘frequent attendee’ protocol to identify how the Hospital were failing to meet the child and family’s needs; and  • liaison between the Paediatric Liaison Health Visitor and the community based Health Visitor to share information about Kieron’s treatment and to ensure appropriate follow up.    9.10. Action under the second bullet point would have been particularly helpful as the Health Visitor knew nothing of this Hospital attendance when she made a home visit on 9th June 2011.  At this visit she was denied contact with Kieron who was said to be sleeping, but there was little doubt that she would have insisted upon seeing him had she been aware of his recent visit to the Hospital.  Whether she would have seen anything of significance that required safeguarding action is now only known to Louise Barley and Craig Lewis.  What is known is that this was the last occasion he might have been seen by any professional prior to his admission to Birmingham Children’s Hospital with fatal injuries on 19th June 2011.    9.11. The Serious Case Review Panel was greatly shocked to note the speed at which Kieron moved from a child whose developmental delay was the subject of concern (and concerted action) by professionals, to a child whose very life was threatened and ultimately ended.  It can only have been a matter of days after Louise Barley moved out of the comparative safety of Maternal Grandmother’s home before Kieron was subject to physical abuse, abuse which escalated over the coming days/weeks leading to his death approximately six weeks later.  9.12. Given that Kieron’s situation deteriorated so quickly in this period, the Serious Case Review Panel has considered carefully whether any professional missed Final Overview Report  BSCB 2011-12/1   84  an opportunity to safeguard him and have concluded that there were two occasions when liaison between Birmingham Children’s Hospital and partner agencies of BSCB (notably the Health Visitor and Children’s Social Care) might have prompted a more robust response i.e.  • on 17th May 2011 when a junior doctor did not discuss bruising noted on Kieron with senior colleagues; and • on 28th May 2011 and the two following days when a failure to liaise with community based  personnel meant that a history of concerning information about Kieron and his family (which had led the Health Visitor to make a safeguarding referral only two months earlier) was not obtained and taken into account.    9.13. While such enquiries may have prompted a more robust examination, the previous sections of this report document the Serious Case Review Panel’s view that the response of Birmingham Children’s Hospital, and indeed of all the agencies involved with Kieron at this time, would almost certainly have been very different if he had been the subject of a Child Protection Plan following the Health Visitor’s referral in March 2011 i.e. their questioning would have been more rigorous, their investigation of the presenting symptoms more robust and their overall intervention would have been equally focused upon safeguarding as upon attention to the reported injuries.    9.14. In such circumstances there is considerable confidence that the true nature of Kieron’s injuries would have been identified which in turn would have led to immediate safeguarding action.    9.15. However, Kieron was not subject to such a plan and the failure of Children’s Social Care to progress the Health Visitor’s referral into a child protection enquiry under Section 47 of the Children Act 1989 is considered earlier in this report.  It is impossible for the Serious Case Review Panel to say with certainty that any such enquiry would have led to a Child Protection Conference and to Kieron being made the subject of a Child Protection Plan, Final Overview Report  BSCB 2011-12/1   85  but a comprehensive assessment picking up on all the concerns identified in the course of this Serious Case Review make it a strong possibility.    9.16.  The Serious Case Review Panel was asked to consider whether there was a prevailing culture in Children’s Social Care at that time involving a reluctance to use the formal child protection process as  means of managing caseloads (children subject to Child Protection Plans have a range of statutory responsibilities attached to their cases e.g. home visits at specified intervals, core group meetings, etc.) but no evidence was found to support this.  9.17. The numbers of children subject to Child Protection Plans in Birmingham in 2010/11 is detailed earlier in this report and gives rise to no concern about practice in that period i.e. as would be expected the numbers are higher than both Birmingham’s statistical neighbours (similar authorities) and the England average, and there are no unusual variations (i.e. significant drops) in this period.    9.18. It is the opinion of the Serious Case Review Panel, that the decision not to instigate a child protection enquiry following the Health Visitor’s referral was not influenced by any prevailing culture but was as a result of poor practice by the Senior Practitioner and poor decision making by the Team Manager.    9.19. Given that Louise Barley’s partner had been convicted of the manslaughter of Kieron (following a guilty plea) the updated terms of reference for this Serious Case Review required the Panel to consider Craig Lewis’s role in the family, particularly the impact of his cocaine and alcohol use.    9.20. Again this is fully explored in the preceding sections of this report and the conclusion of the Serious Case Review Panel is that there was no evidence to suggest that any professional who had contact with Louise Barley’s partner in the last six weeks of Kieron’s life should have viewed the partner as a threat to his safety or welfare.  He was seen several times by health professionals when attending appointments with Louise Barley and Kieron, and never gave Final Overview Report  BSCB 2011-12/1   86  any cause for concern in respect of his behaviour or presentation.  Craig Lewis was not engaged with any drugs agency and the only reference to his use of cocaine was at a GP consultation on 2nd May 2011 when he acknowledged using it twice a week and said he was finding it difficult to cut down.  The GP had no knowledge of his involvement in Kieron’s life and, quite appropriately, signposted him to a drugs agency (guidance which he chose not to follow).    9.21. Louise Barley and Maternal Grandmother both describe Craig Lewis as a kind and caring man who interacted well with Kieron and seemed genuinely fond of him.  Both claim to be thoroughly shocked at the assaults upon Kieron, never suspecting for a second that he was capable of such behaviour.  Certainly the IMR from West Midlands Police confirms that he has no history of violent behaviour.    9.22. In interview with the Author, Craig Lewis either could not or would not give any explanation as to why this apparently ‘kind and caring’ man should commit such terrible offences but whatever his motivation the Serious Case Review Panel is confident that this behaviour could not have been predicted based upon his previous presentation.    9.23. As in most enquiries of this nature it has been relatively straight forward to establish what actions and decisions were taken by the professionals involved and to understand their impact upon the life of Kieron.  More difficult is to try and understand why those actions and decisions were taken.  The following paragraphs will consider what the Serious Case Review Panel believes to be the key moments in this case i.e. the moments that might have changed the course of events, and will briefly give the Panel’s observation on the ‘why’ question.   9.24. At the very beginning of this chronology the midwives and obstetricians involved with Louise Barley when she was pregnant with Kieron failed to identify her vulnerability and to factor this into her ante-natal care.  The Final Overview Report  BSCB 2011-12/1   87  author of the IMR for that Trust suggests that this happened because in 2009 local procedures in respect of safeguarding children were not robust and there was no culture of awareness in this area that would have supported the practitioners involved to take appropriate action.  The Serious Case Review Panel has received assurances and some evidence that practice (and procedures) are very different now, significantly reducing the risk of such a similar situation developing today.    9.25. Once Kieron was born, why did staff from the Mental Health Trust fail on several occasions to consider Louise Barley’s capacity to provide safe and nurturing care for Kieron in the light of her mental health problems the ‘Think Family’ message?  In the view of the Serious Case Review Panel the answer lies in the failure of the organisation (over many years and through a number of Serious Case Reviews) to give adequate priority to safeguarding children whose parents were accessing their services.  This is reflected in procedures, front line practice (lack of engagement with the child protection process) and training.  The Panel received anecdotal information that there has been a significant improvement since 2010/11 but still considers that this should be evidenced via a themed audit of practice.    9.26. Why did Louise Barley’s GP Practice not consider the safety and welfare of Kieron in the light of the concerning (and sometimes contradictory) information that was shared with them in respect of Louise Barley’s engagement with mental health services?  It has been suggested to the Serious Case Review Panel that GPs have many patients with symptoms similar to Louise Barley and that, in the context of their heavy workloads, there was nothing exceptional about this case that should have caught his attention from a safeguarding perspective.  The Author is not satisfied with this explanation, particularly in the light of comments about the practice of GPs in previous Serious Case Reviews and the many recommendations that have accompanied those Reviews.  However, the Author and the Serious Case Review Panel were reassured by developments over the last three years in which significant improvements in training, protocol and improved liaison with Final Overview Report  BSCB 2011-12/1   88  Health Visitors feature highly.  This improvement was facilitated by a ‘task and finish group’ within BSCB on GP engagement issues.    9.27. Why, in response to the Health Visitor referral in March 2011, did the Senior Practitioner fail to make robust enquiries of partner agencies (or interrogate her own agency records) before closing this referral after making only two phone calls and without seeing Kieron?  This action cannot be explained in terms of culture or procedure and can only be considered to be poor practice by an individual, possibly under significant workload pressure.    9.28. A similar question has to be posed in respect of the Team Manager’s decision to counter-sign this recommendation and approve closure of the referral.  No explanation is offered in the IMR presented by Children’s Social Care and the Serious Case Review Panel has again concluded that this was poor decision making by an individual made in the face of prevailing workloads.  However, the Serious Case Review Panel was pleased to note positive developments in respect of the screening of safeguarding referrals i.e. the launch in July 2014 of the Multi-Agency Safeguarding Hub, and sincerely hopes that this will be the answer to a problem identified in numerous Serious Case Reviews over recent years.    9.29. One further question has to be posed in respect of this safeguarding referral.  Why did the Health Visitor (who said in her referral that she believed the level of concern for Kieron now met the threshold for a Child Protection Plan) fail to implement local ‘escalation’ procedures when the referral was closed so abruptly after only two telephone calls?  No clear answer is available in the IMR presented on behalf of the Community Health Care Trust but the Serious Case Review considers that the Health Visitor (whose work with this family was otherwise excellent) either lacked knowledge of those procedures or, more likely, lacked the confidence to implement them.    Final Overview Report  BSCB 2011-12/1   89  9.30. The Serious Case Review Panel also considers that the Health Visitor should have liaised with the Mental Health Trust to obtain information about Louise Barley’s health, information that would have informed judgements about her capacity to promote Kieron’s safety and welfare, and has considered why this did not happen until March 2011.  While acknowledging that there was a reciprocal responsibility upon the Mental Health Trust, the Panel believes that, as concerns rose in respect of Kieron’s developmental delay and the impact of environmental factors upon that became a significant factor, then the Health Visitor’s assessment was incomplete without the knowledge of Louise Barley’s diagnosis and treatment by the Mental Health Trust.  Again no explanation is offered by the IMR author for the Community Health Care Trust so Panel has reached the conclusion that this was a practice/training issue for the individual concerned and has recommended wide circulation of further guidance in this area.   Update: August 2015 It has subsequently been brought to the Author’s attention that the Health Visitor believed that Louise Barley was receiving counselling in respect of an alleged historical sexual assault which she considered to be different from someone receiving intervention or support in respect of a diagnosable mental health condition e.g. depression.  The Manager providing this information also considers that the Health Visitor would have made appropriate enquiries of the Mental Health Trust had she had any evidence of a mental health disorder that may have impacted on her parenting capacity.  The SCR Panel is happy to acknowledge this but considers that there is still value in the recommendation for action by the Community Healthcare Trust (see also paragraph 8.31 regarding the need for practitioners to clarify the role of the Mental Health Trust with vulnerable parents).  9.31. The next question raised by the Serious Case Review Panel was why, on 17th May 2011 the examining doctor at Birmingham Children’s Hospital failed to discuss bruising noted on Kieron with senior colleagues.  This issue Final Overview Report  BSCB 2011-12/1   90  was considered at length at Section 8 of this report and the Panel agree with the IMR’s conclusion that this was an error of judgement by an otherwise competent junior doctor who has since been given further guidance in respect of future practice. In considering how this Doctor, and others faced with similarly difficult judgements, could be helped to reach better conclusions, the Serious Case Review Panel was deeply influenced by an article published by Doctor S. Maguire in April 2011 (Which Injuries May Indicate Child Abuse?).  The article includes a chart with summary guidance and body maps that the Serious Case Review Panel believes would be advantageous to hard pressed practitioners if they could be laminated and placed strategically within the Hospital’s examination rooms.  A recommendation to that effect will be made in this report.    9.32. Kieron attended Birmingham Children’s Hospital again on 28th May 2011 (and followed this with two further attendances on 29th and 30th as he continued to present as unwell) and a significant question posed in this Serious Case Review is should the medical staff responsible for his care have identified fractured vertebrae that a subsequent forensic examination confirmed were present at the time.   Again this was debated at length by the Serious Case Review Panel and their deliberations are detailed in the preceding sections of this report.  The conclusion of the Panel is that the staff involved acted within the agreed guidance for minor head injuries and their examination of Kieron gave them no grounds for undertaking a full skeletal survey.  The Serious Case Review accepts entirely that a full ‘top to toe’ examination of all children attending the Emergency Department at Birmingham Children’s Hospital is a disproportionate response to this issue.      9.33. A recent research study on the methods of learning lessons from Serious Case Reviews (Sidebottom 2010) suggests a number of problems regarding their effectiveness, including:  • an overwhelming sense that there is too much emphasis on getting the process right than improving outcomes for children; and Final Overview Report  BSCB 2011-12/1   91  • shallowness and sustainability of learning.  9.34. Others will judge how well the balance implicit in the first bullet point has been achieved in this Review, it has certainly been Serious Case Review Panel’s intention to keep Kieron at the heart of our deliberations while at the same time working to local and national guidelines in respect of Serious Case Reviews.    9.35. However, the findings of this Serious Case Review fully support the second bullet point in relation to sustainability of learning.  There are three major issues arising from this Review that have cropped up repeatedly in Serious Case Reviews undertaken by BSCB i.e.:  • the failure of GPs to consider safeguarding issues when, in the course of treating the parents of vulnerable children, they receive information that suggests either immediate referral to Children's Social Care or discussion with a designated safeguarding professional in respect of thresholds; • superficial, sometimes inadequate, screening of referrals of concern to Children's Social Care i.e. decisions made on presenting information only rather than a scrutiny of internal case records for evidence of previous concerns and obtaining information from partner agencies about their current and past involvement; and  • the failure of Mental Health Trust staff to ‘think family’, in particular their failure to consider the capacity of those patients who are also parents to provide safe and nurturing care to their children and to what extent their poor mental health inhibits that capacity.  9.36. These earlier Serious Case Reviews make compelling reading and were well evidenced.  The reports presented in those Reviews concluded with comprehensive and pertinent recommendations that were intended to enhance training, improve procedure and practice and make children safer.  Despite this another child has died and these same three issues are identified yet again as significant factors in that death.   Final Overview Report  BSCB 2011-12/1   92   9.37. The Social Care Institute for Excellence (SCIE) in its 2009 publication ‘Learning Together To Safeguard Children – Developing A Multi-Agency Systems Approach For Case Reviews’, suggests that the findings of Serious Case Reviews tend to be familiar and repetitive, raising questions about their value for improving practice.  Such a criticism could be levelled at this Review as, in addition to the three issues highlighted above, some other familiar issues were identified i.e.  • failures to communicate and share information across agencies and, in some cases, between different departments of the same agency; • poor record keeping, making it difficult to understand or evaluate intervention by practitioners; and • inconsistent/inadequate training for professionals who come into contact with children and young people.  9.38. Good practice in each of these domains is essential for the provision of an effective service for safeguarding children, but this Review found weaknesses at different points in Kieron’s story.  However, evidence was also received that these issues are now robustly and routinely monitored by BSCB and current quality assurance measures so the Serious Case Review Panel will make no further recommendation in this respect.    9.39. There have been many difficulties in undertaking a Serious Case Review that, for perfectly understandable and acceptable reasons, has been spread across three years however one significant benefit is that the Author and the Serious Case Review Panel have been able to consider how the partner agencies of BSCB responded to the Interim Overview Report presented to them on 16th November 2012.  9.40. Overwhelmingly the Panel has noted this response to be positive as evidenced throughout this report, with the improvements to GP engagement in the child protection process and the development of the Multi-Agency Final Overview Report  BSCB 2011-12/1   93  Safeguarding Hub being the stand out achievements.  Guidance on thresholds for intervention under child protection procedures (another issue that crops up regularly in Serious Case Reviews including this one) has been updated, and the BSCB publication ‘Right Services Right Time’ launched in May 2013 is a valuable new working tool for practitioners in all partner agencies.    9.41. While the impact of the Multi-Agency Safeguarding Hub (which only commenced operations in July 2014) has still to be evaluated, the early signs are positive.  Combining the resources of partner agencies to ensure effective screening of safeguarding referrals is, in the opinion of the Author, the most significant single development in this area for many years and will make children in Birmingham safer.  9.42. At the conclusion of this report the Author and the Serious Case Review Panel are required to reach a judgement about whether the death of Kieron was predictable and/or preventable.  The judgement in respect of predictability is much easier to make and the Panel is clear that, although there were ongoing concerns about his developmental delay (exacerbated by home conditions) no-one could have predicted that within six weeks of Kieron and Louise Barley moving into their own home he would be dead.    9.43. The question of preventability is slightly more difficult and is clouded by speculation i.e:  • staff at Birmingham Children’s Hospital would have been more focused upon safeguarding issues when Kieron attended there on 28th May 2011 if he had been subject to a Child Protection Plan;  • Kieron may have been the subject of such a plan if staff at Children’s Social Care had processed the Health Visitor’s referral of March 2011 through the child protection system; and  Final Overview Report  BSCB 2011-12/1   94  • the failure to progress the referral through the child protection system may have been reversed if the Health Visitor had implemented the escalation policy, etc.    9.44. However, no certainty can be applied to any of these points and the Serious Case Review Panel has concluded that Kieron’s death was neither predictable nor preventable.  9.45. A recent review of Serious Case Reviews undertaken in Northern Ireland comments:  ‘The majority of cases subject to a case management review are very similar to lots of other cases known to GPs, Health Visitors, Teachers and Social Workers.  Therefore trying to predict which children are at greater risk of dying or suffering serious injury is ultimately a futile exercise.  However, providing families with early, sustained and co-ordinated support does reduce the likelihood of children suffering unnecessarily’.  9.46. Ironically in Kieron’s case that support was in the process of being put into place following the diagnosis of cerebral palsy but sadly, given his sudden and violent death, it never had the opportunity to improve his life chances.    Final Overview Report  BSCB 2011-12/1   95  10. RECOMMENDATIONS   10.1. The Interim Overview Report to be BSCB on 16th November 2012 made six recommendations i.e:  • That BSCB exercise its monitoring and evaluation function (paragraph 3.28 to 3.29 Working Together to Safeguard Children 2010) to routinely evaluate measures taken by Children's Social Care to improve the screening of referrals of concern about children.  • That Birmingham Women’s Hospital NHS Foundation Trust take actions to satisfy itself and BSCB that its staff are adequately skilled and knowledgeable about safeguarding children procedures and that those procedures are sufficiently robust to ensure that all pregnant vulnerable women are identified and appropriate assessments undertaken in respect of any risks to their unborn children, and that safeguarding referrals are made when necessary.    • That BSCB carry out a thematic audit of The Mental Health Trust’s compliance with internal and multi-agency safeguarding children procedures and their commitment to local child protection systems.    • That The Mental Health Trust robustly promote the recent GMC guidance (July 2012) ‘Protecting Children and Young People – A Guide for Doctors Who Treat Adult Patients’ to their staff and establish an ongoing quality assurance process to monitor its implementation and effectiveness.    • That BSCB and NHS South Birmingham robustly launch and promote the above GMC Guidance to all GPs in their locality and, while engaged in this activity, identify and address the barriers to co-operation with child protection procedures that are identified so often in Serious Case Reviews locally.   Final Overview Report  BSCB 2011-12/1   96   • That the Community Health Care Trust issues a practice directive to Health Visitors on the need to liaise with the Mental Health Trust about the parents of vulnerable children in order to inform assessments of need for them.  Such guidance to include information on issues related to consent/confidentiality.    10.2. The preceding sections of this final Overview Report confirm that significant progress has been made in implementing these recommendations and the Serious Case Review Panel is satisfied that services for safeguarding children in Birmingham are better as a consequence.    10.3. The Serious Case Review Panel makes only one further recommendation i.e.   • that Birmingham Children’s Hospital place laminated copies of the chart headed ‘Patterns of Bruising in Accidental and Non-Accidental Injury’ (Doctor S. Maguire 2011) in strategic locations within the Hospital.       Alan Ferguson Independent Author  