Serious injuries of a 3-week-old baby girl in October 2012. Mother admitted shaking and hitting Child D and was subsequently arrested; she was remanded in custody until a Hospital Order was made under Section 37 of the Mental Health Act 1983. Mother had been known to a wide number of agencies since her infancy; she experienced abuse and neglect as a child and entered local authority care four months before her 17th birthday. Mother had a history of mental health problems including anxiety and depression. Identifies themes, missed opportunities and lessons learned, including: inadequate assessment of mother's learning difficulties leading to the withdrawal of support services; lack of agency lead in response to mother's multiple, overlapping needs; agency assumption that father was a protective factor to Child D, despite lack of supporting evidence; and underestimation of mother's support needs as she often presented to agencies as more capable than was the case. Identifies service improvements made by agencies and makes various recommendations focusing on multi-agency working.
      
   Serious Case Review No: 2014/C5019  Published by the NSPCC On behalf of an unnamed local safeguarding children board      This report was written by an independent author and is owned by the commissioning LSCB.  This report is published by the NSPCC with the agreement of the National Panel of Independent Experts.  Publication of this report by the NSPCC does not constitute endorsement of the contents. Copyright of this report remains with the commissioning LSCB.                                                        CHILD D  A SERIOUS CASE REVIEW  Page 1 of 69 TABLE OF CONTENTS   TABLE OF CONTENTS ............................................................................... 2 1. INTRODUCTION ...................................................................................... 4 2. FAMILY COMPOSITION.......................................................................... 4 3. SERIOUS CASE REVIEW PROCESS ..................................................... 5 3.1 Arrangements for the Serious Case Review.......................................... 5 4. METHODOLOGY USED TO DRAW UP THIS REPORT ......................... 6 5. NARRATIVE CHRONOLOGY ................................................................. 8 5.1 Introduction .............................................................................................. 8 5.2 Background .............................................................................................. 8 5.3 Events before the birth of Child D .......................................................... 8 5.4 Events after the birth of Child D ........................................................... 11 6. THE FAMILY .......................................................................................... 12 6.1 Ms E ........................................................................................................ 12 6.2 Mr F ......................................................................................................... 13 7. THE AGENCIES .................................................................................... 14 7.1 Introduction ............................................................................................ 14 7.2 The General Practitioners ..................................................................... 14 7.3 The Community Learning Disability Team........................................... 15 7.4 Maternity Services ................................................................................. 18 7.5 Mental Health Services .......................................................................... 21 7.6 Children and Families Services ............................................................ 25 7.7 Health Visiting Services ........................................................................ 30 7.8 Adults’ Services ..................................................................................... 32 7.9 Dietetic, Accident & Emergency and Acute Paediatric Services ....... 34 7.10 Educational Psychology and Special Educational Needs Services - report for information .................................................................................. 35 7.11  Housing Services – report for information ....................................... 35 7.12 Ambulance Service NHS Trust –report for information. ................... 36 7.13 Specialist child hospital  –report for information ............................. 36 7.14 Police – report for information ............................................................ 36 7.15 Health Overview Report ...................................................................... 37 8. ISSUES SPECIFIED IN THE TERMS OF REFERENCE FOR THIS REVIEW ..................................................................................................... 38 8.1 Introduction ............................................................................................ 38 8.2 During the pregnancy, could more have been done to assess the mother’s needs and provide her with support? ........................................ 38 8.3 Were the mother’s problems appropriately assessed and addressed across agencies, both recently and when she was in care and a care leaver? .......................................................................................................... 39 8.4 How did assessments and interventions seek to understand and address issues of diversity, including those of ethnicity and disability in particular? .................................................................................................... 40 8.5 Did assessments take into account the mother’s relationships, support networks and their impact on her parenting? ............................. 41 8.6 Did the local authority’s triage arrangements have any bearing on how agencies responded to concerns? What form of triage should have been triggered once concerns were notified? .......................................... 41 Page 2 of 69 8.7 Were assessments appropriately child focussed? ............................. 42 8.8 During Child D’s life before the incident, were communication, support and the assessment of risk effective? ......................................... 43 8.9 On the day Child D sustained the injuries, and subsequently, were there any communication problems between agencies? ......................... 43 8.10 How well did all the agencies involved work together - was there good mutual understanding and communication? ................................... 44 8.11 How effective was management oversight both before and after Child D’s birth? Were concerns escalated when that was appropriate? 45 8.12 What issues are there of support relating to learning disability and mental health concerns in this review? ..................................................... 46 8.13 Are local services appropriately using best practice models for safeguarding unborn and very young babies? ......................................... 47 8.14 Were there any organisational difficulties within or between agencies? ..................................................................................................... 48 8.15 What LSCB quality assurance processes could provide timely overview of services to vulnerable children and parents? ...................... 48 8.16 Where can we identify good practice in this case? .......................... 49 8.17 What outcomes are envisaged from the recommendations from this review? ......................................................................................................... 49 8.18 How can the LSCB ensure that recommendations have an impact? Are there implications for training – single agency and multi agency? . 50 9. SERIOUS CASE REVIEW PROCESS ................................................... 50 10. CONCLUSIONS: THEMES, MISSED OPPORTUNITIES AND LESSONS LEARNED ................................................................................ 52 11. SERVICE IMPROVEMENTS MADE BY THE AGENCIES .................. 55 12. RECOMMENDATIONS FROM THIS OVERVIEW REPORT ............... 60 12.1 Introduction .......................................................................................... 60 12.2 Key theme – working together for the child ...................................... 60 12.3 Key theme - Improving the quality of casework and managing risk to the child. ................................................................................................... 61 12.4 Key theme - Developing good systems that keep children safe. ..... 61 APPENDIX A: brief autobiographical details of the author of this report. .......................................................... Error! Bookmark not defined. APPENDIX B: anonymised Terms of Reference for the SCR ............... 64 APPENDIX C: SCR Panel ......................................................................... 68 APPENDIX D: References ........................................................................ 69 Page 3 of 69 1. INTRODUCTION  1.1 Child D, who was just under three weeks old, was admitted to hospital with multiple serious injuries in October 2012. Medical advice was that these injuries had been inflicted. Child D’s mother, Ms E, a woman in her early twenties, was arrested.   1.2 Ms E was known to adults’ and children’s social care services and to a range of health services, before and during her pregnancy and following the birth of Child D.   1.3 On 08.11.12 the Independent Chair of the Local Safeguarding Children Board confirmed that a Serious Case Review (SCR) should be carried out. This decision was based on the following considerations: • Child D had sustained serious, apparently inflicted injuries. • There were indications of weaknesses in the way that agencies had worked together to safeguard Child D.  1.4 The purposes of SCRs are set out in “Working Together to Safeguard Children1” (Para 8.5). They are to • establish what lessons are to be learned from the case about the way in which local professionals and organisations work individually and together to safeguard and promote the welfare of children; • identify clearly what those lessons are both within and between agencies, how and within what timescales they will be acted on, and what is expected to change as a result; and • improve intra- and inter-agency working and better safeguard and promote the welfare of children.  2. FAMILY COMPOSITION  2.1 Ms E lived alone before her baby was born. Her mother and sister lived nearby. The putative father, Mr F, did not live locally but had some contact with Ms E during the pregnancy. 1 Working Together to Safeguard Children (2010) – referred to in this report as “Working Together” – was the government’s statutory guidance on how organisations and individuals should work together to safeguard and promote the welfare of children and young people in accordance with the Children Act 1989 and the Children Act 2004. It has been revised while this review has been in process and replaced by Working Together to Safeguard Children (2013). Agencies drew up their reports before Working Together 2013 was in place. This Overview Report has taken account of changes in the revised guidance.    Page 4 of 69                                              3. SERIOUS CASE REVIEW PROCESS  3.1 Arrangements for the Serious Case Review   3.1.1 Fuller details of the SCR process are set out in Appendix A.  It was determined that the following agencies should contribute to the Review. Those agencies with substantial and / or recent contact were required to submit full Individual Management Reviews (IMR) whereas agencies with less or less recent involvement provided reports for background information.  AGENCY NATURE OF CONTRIBUTION Children & Families Services Individual Management Review (IMR) General Practitioners IMR NHS  IMR / Health Overview Report 2 Maternity Services IMR  Health visiting services IMR Dietetic services, Accident and Emergency Services IMR Mental Health services IMR Learning Disability services3 IMR Adult Social Care services IMR Ambulance Service Information report Housing Services Information report  Police  Information report NHS Foundation Trust Information report Education Services Information report 2 Working Together 2010 (Paragraph 8.30) required that in every SCR the appropriate Primary Care Trust (as was) should draw up a health overview report focusing on how health organisations have interacted together, which will also constitute the IMR for the PCTs as commissioners. This is no longer a requirement. 3 Mental Health Service manages this service now, and has therefore supplied this IMR, but did not do so during the period under review – see Paragraph 7.3.12 below Page 5 of 69                                              3.1.2 The anonymised Terms of Reference for this SCR are attached at Appendix B. When they were drawn up the key issues for consideration specific to this case were judged to be: • difficulties in Ms E’s early life and her family background, as well as current medical and social problems, and the extent to which agencies understood and took account of these issues. • the nature and quality of the services provided during Ms E’s pregnancy and subsequently. • the quality of the specialised learning disability and mental health services provided particularly in relation to safeguarding of children. • the agencies’ response to the requirement to protect unborn and very young babies. • the quality and effectiveness of joint working across the agencies involved.  3.1.3 The review considered in detail the period from just before the conception of Child D to just beyond the date of the injuries. All agencies were also asked to provide a summary of any previous involvement from the point at which the mother came into the care of the local authority when she was a young person.  4. METHODOLOGY USED TO DRAW UP THIS REPORT  4.1 This Overview Report is based principally on the agency IMRs, background information submitted and subsequent Panel discussions and dialogue with IMR authors. Family involvement is discussed at section 6 below.   4.2 The report consists of • A factual context and chronology. • Commentary on the family situation and their input to the SCR. • Analysis of the part played by of each agency, and of their IMR. • Closer analysis of the specific issues identified in the Terms of Reference. • An outline of service improvements made by the agencies in response to these events and more generally. • Conclusions and recommendations.  4.3 The conduct of the review has not been determined by any particular theoretical model but the review has been carried out in a way that is in keeping with the underlying principles of the statutory guidance, set out in Working Together 2013. The review • recognises the complex circumstances in which professionals work together to safeguard children; • seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did; Page 6 of 69 • seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight4;  • is transparent about the way data is collected and analysed; and • makes use of relevant research and case evidence to inform the findings5.  4.3 The government has introduced arrangements for the publication in full of Overview Reports from Serious Case Reviews, unless there are particular reasons why this would be inappropriate. This has implications for the extent to which certain matters, including some sensitive personal information, can be included in this Overview Report. This report is written in the anticipation that it will be published and has been drawn up so as to preserve confidentiality wherever that is necessary. 4 This review does not rely on hindsight, and tries not to use hindsight in a way that is unfair. It does use hindsight where that promotes a fuller understanding of the events and their causation. 5 Working Together (2013) Page 7 of 69                                              5. NARRATIVE CHRONOLOGY  5.1 Introduction  5.1.1 This section of the report briefly describes Ms E’s family circumstances and summarises her contact with the agencies involved in this review. Further factual detail is then provided as necessary throughout the report.  5.2 Background   5.2.1 Ms E was known from her infancy to some of the agencies involved in this review, or their predecessor organisations. There is evidence that her childhood was often unhappy and troubled, and that she was abused and neglected. From her earliest days at school it was identified that she also had a number of educational problems. When she was 11 years old a statutory assessment of her special educational needs found her IQ to be within the “moderate learning difficulties” range.   5.2.2 From that age she attended a special school. She made progress there but her situation deteriorated further during her teenage years. Her behaviour became very “out of control” and risky, and she came into the care of the local authority four months before her 17th birthday.   5.2.3 While living in a semi-independent unit managed by a voluntary organisation Ms E became involved in an inappropriate relationship with a senior member of staff, Mr F. This relationship came to light and Mr F resigned in the course of a disciplinary investigation. Ms E was now over 18 years old and no criminal charges were preferred. Contact between Ms E and Mr F continued and he was to become the father of Child D.  5.2.4 The local authority’s Leaving Care Service continued to support Ms E until she was in her early twenties and was living independently. Contact with the local authority then ceased. No onward referral was made to any other agency.  5.3 Events before the birth of Child D  5.3.1 In October 2011 Ms E was referred by her GP to local Learning Disabilities Psychiatry Team (LDPT). She had approached the GP because she had been experiencing anxiety and panic attacks, and had harmed herself. The referral described her as having a “mild learning disability”. She was seen in late November by a psychiatrist (Dr L) who tentatively diagnosed that she had a generalised anxiety disorder, panic disorder and concurred that she had a “mild learning disability”. She was referred on to psychologists within the LDPT for assessment of her cognitive skills. The referral noted that “Her cognitive abilities need to be assessed properly as she looks more capable of doing many things”.  Page 8 of 69 5.3.2 A nurse, N1, from the LDPT became involved in supporting Ms E and continued to do so until tests were carried out by a psychologist, P1. From these tests P1 concluded that Ms E’s IQ was “low average to average” and that she therefore did not have a learning disability. The tests were not carried out till late April 2012 – some 6 months after she had been referred - and N1 had a good deal of continuing contact with her during that time. However, on the basis of the IQ tests Ms E was found to be ineligible for services from the LDPT and contact with that team was terminated in May 2012.  5.3.3 In February 2012 Ms E had seen her GP who confirmed that she was in the early stages of pregnancy. A swift referral from the GP to ante-natal services gave details of the difficulties in her childhood, referred to her having “learning difficulties” and noted that she was being seen at the LDPT.  The GP and Dr L discussed the situation and decided together that anti-depressant medication (Prozac), which she had taken in the past, should be prescribed for Ms E.   5.3.4 Maternity services responded promptly and continued to provide a high level of direct contact to Ms E throughout her pregnancy. An early referral was made from midwives to their service’s Safeguarding Team. After discussion by the Safeguarding Team, Ms E was categorised by maternity services as “medium risk”.  5.3.5 Ms E contacted the LDPT in April complaining of feeling low. She was seen by N1, who recorded that she was not taking her anti-depressant medication and was “very down”.  At this time Ms E said she was looking after the child of her sister who was having another baby.   5.3.6 In mid May Ms E presented to A&E services at a non-local hospital feeling very low and wanting to talk to someone. She was seen by the Crisis Assessment & Treatment Team who were concerned by her presentation but found her mentally stable. She denied any thoughts of self harm or any delusional beliefs about the baby. She described good social support, contact with a community midwife and her GPs, and continuing contact with the father of the unborn baby. She was discharged with notifications made to a range of health services and children’s social care services local to her address.  5.3.7 This attendance prompted correspondence between a range of professionals and services. Dr L, the GP, the Named Nurse for Safeguarding at the NHS Trust and the Named Midwife had discussions about the concerns arising from this contact. Referrals were made to the local authority, the Community Mental Health Team and the Perinatal Mental Health Service (although the latter was not accepted on the basis that it was too early in the pregnancy).  5.3.8 As part of their response the GPs made a referral to the local authority’s adult social care services.  Adult Services liaised with various agencies and saw Ms E before concluding that she was not eligible for the services they provided.   Page 9 of 69 5.3.9 During May police were contacted by Ms E who reported persistent noise nuisance from neighbours. Appropriate advice about sources of assistance was given.  Police were to have no further significant contact before the injuries to Child D came to light.   5.3.10 A Health Visitor, HV1, from the service that would be supporting Ms E after the birth of her child, had picked up the concerns arising from the presentation at the non-local  hospital in May. In mid-June she called to see Ms E and was concerned about her presentation and her capacity to care for a child. She also contacted C&F (Children’s & Families Services).   5.3.11 In response to these various referrals C&F now carried out a Core Assessment6 led by a social worker, SW1. SW1 visited once in mid-June – a month after receiving the referral from the hospital and apparently prompted by the referral from HV1. The social worker judged that Ms E’s presentation raised no serious concerns and that there was a strong professional network around her. The outcome of the assessment was that no further action was taken by C&F during the pregnancy.  5.3.12 In June Ms E had her first contact with psychiatric services, as a result of her presentation at hospital in May. A psychiatrist, Dr S, assessed her and concluded that she was not mentally ill but, particularly in view of her pregnancy, decided to see her again in three months’ time.    5.3.13 Between July and September Ms E had continuing frequent contact with maternity services and complied fully with ante-natal care. There were no major problems with her pregnancy but she described “unbearable panic attacks”.  It was noted by midwives that she was taking her anti-depressant medication sporadically but there was no contact from maternity services to mental health services or the GPs about this. Throughout the pregnancy Ms D kept in close contact with her GPs.  5.3.14 Ms E was reviewed by Dr S in September. This did not lead to any action other than a further appointment offered in two months’ time.  In October Ms E told a midwife that she had not taken any anti-depressant medication since June. The midwife did not take any action in response to this. A week later Child D was born, a Caesarean delivery. 6 Part of the national framework of guidance, a core assessment should be undertaken when an in-depth multi-agency assessment is necessary to understand a child's developmental or welfare needs and circumstances and the parents' capacity to respond to those needs, including the parents' capacity to ensure that the child is safe from harm now and in the future.   Page 10 of 69                                              5.4 Events after the birth of Child D  5.4.1 Immediately after the birth maternity services made a referral to C&F, expressing concern about Ms E’s ability to care for the child. After liaison between health services HV1 made a similar referral, as did a GP. There were a number of discussions between health services and C&F.   5.4.2 Initially C&F were going to conduct a further assessment but then decided that it was not necessary to do so because their Core Assessment, completed only three months previously, did not raise any safeguarding concerns. They decided that the most appropriate response to the current concerns was to make a referral to their Early Intervention Service (EIS). This service would help Ms E develop parenting skills, and would establish a “Team around the Child” (TAC)7.  5.4.3 Ms E and her baby were discharged from hospital three days after the birth and received standard follow up from the midwifery service. Midwives reported no concerns about the care of the baby who was putting on weight, nor about Ms E’s health or presentation or the condition of the home.   5.4.4 Six days after discharge from hospital Ms E took the baby to the GP (GP3), concerned that the baby was constipated, and was given advice. The GP was concerned about Ms E’s ability to cope with the demands of a young baby and, two days later, wrote to the health visitors to that effect.  5.4.5 Two days after that Ms E again went to the GP stating that the child was not sleeping. The GP (GP4) felt that Ms E was not coping well but was reassured when Ms E said that the child’s father would be staying with them that night.   5.4.6 The following day a New Birth Visit was carried out by a Health Visitor (HV2). The Health Visitor’s assessment was similar to that of the midwives – that Ms E was coping adequately with the care of the child, who appeared well. There was subsequently a discussion between HV2 and GP4, in which HV2 advised that she had no immediate concerns from the New Birth Visit. Nonetheless GP4 contacted C&F, learned that the EIS was visiting in three days time and was satisfied with that.  5.4.7 Meanwhile Ms E and the baby attended a group held at a local Children’s Centre at the suggestion of one of the midwives. Staff at the meeting had no concerns for the presentation of mother or child.  5.4.8 The following day, the Friday of that week, Ms E took the baby to the GPs. They were seen by GP5 who noted that the child had a severe nappy rash. The GP was concerned about Ms E’s ability to care adequately for the 7 A multi-disciplinary team of practitioners established on a case-by-case basis to support a child, young person or family.  Page 11 of 69                                             child and contacted HV2. They discussed the situation and the Health Visitor, decided not to take any action that day but to assess the situation at her next visit, which was scheduled for Monday, her next working day.  5.4.9 On the same day, Friday, C&F were making their first post-natal contact with Ms E, through the EIS service. The allocated member of staff, EIS1, spent a long time with Ms E and the baby. She felt that Ms E appeared to be coping. She was observed to cuddle and sing to her baby, though she told EIS1 that she found night times extremely challenging because of the baby crying. EIS1 made a detailed plan for continuing contact with the family.  5.4.10 GP5 remained concerned after the discussion with HV2 and contacted C&F, at the same time that EIS1 was carrying out her visit. On returning from her visit EIS1 responded to a message left by GP5. EIS1 explained that she felt that Ms E was managing adequately. The GP said that she still had concerns and would make a referral to C&F via their designated referral number8. EIS1 advised her manager of this.  5.4.11 GP5 telephoned the designated referral number and was asked to put her concerns in writing (which she did, later that day, after C&F services had closed for the weekend). There was a discussion between teams within C&F about the fact that the GP had used the designated referral number, when a C&F team – the EIS - was already involved, but no further action was taken by C&F that day.  5.4.12 Two days later – the Sunday - an ambulance attended Ms E’s home in response to a 999 call. Child D was taken immediately to hospital and found to have a number of very serious injuries. Ms E told members of staff that she had shaken and hit the baby on the Friday as she would not stop crying.   5.4.13 Police attended. Ms E repeated her admissions and, in due course, faced criminal charges. She was remanded in custody until her case was concluded when a Hospital Order9 was made. Child D is now the subject of a Care Order to the local authority and has limited contact with each parent.  6. THE FAMILY  6.1 Ms E  6.1.1 The extent of Ms E’s vulnerability is captured in the Health Overview Report: “Ms E was a vulnerable woman in her own right. She had been subject to a difficult childhood where she had suffered (multiple forms of abuse). She had been a looked after child. She had a difficult relationship with her mother and was largely unsupported. She had a number of mental health issues including a history of self-harm, bulimia, anxiety attacks and drug abuse. She had a 8 In early 2012 the local authority introduced one direct number for people to call for advice, support or information on a range of services for children and families, and for professionals to make referrals.  9 Section 37, Mental Health Act, 1983 Page 12 of 69                                             relationship with an older man at a young age… She had some learning disability which left her unable always to understand what people said and with limited reading and writing skills. In every way she was an adult who would need professionals to understand her situation and … help her achieve the best outcome…”.  6.1.2 Ms E presented as a woman who wanted her child and engaged with everybody but agencies did not see the extent of the limitations of her ability to be a parent - each only saw a compartmentalised picture. She was apparently articulate and the extent of her mental health and learning needs was misjudged.     6.1.3 The author of this report and a Panel member visited Ms E in hospital but she refused to see us. Hospital staff reported that she had initially rejected their support and assistance because she believed she should have remained in prison. She was now compliant with medication and recovering. Her mother and sister visited her regularly.  6.2 Mr F  6.2.1 Mr F did not respond to an invitation to meet the author of this report.  Page 13 of 69  7. THE AGENCIES  7.1 Introduction  7.1.1 This section of the report examines the involvement of each of the agencies which have contributed to this review, with reference to their IMR. In doing so it deals with a number of the “headline” issues detailed in the Terms of Reference for the review. The final part of this section also summarises the content of the reports received for information from those agencies which did not have recent or substantial contact. The agencies are considered in the order in which they appear in the brief chronology above.  7.1.2 This review has raised concerns about the practice and performance of some individual professionals. These matters are all being addressed through the relevant organisations’ procedures and are not detailed in this report.  7.2 The General Practitioners  7.2.1 During the period under review Ms E and her baby are recorded as having some contact with fourteen GPs, indicating the size of the large practice with which they were registered. Many of these contacts were not significant for the purposes of this report and usually the practice ensured that she was seen by a small number of doctors –in fact on seventeen of her attendances she saw the same doctor. She had confidence in her GPs and used them appropriately.   7.2.2 The Health Overview Report identifies a lack of productive liaison between the GPs and Maternity Services throughout the pregnancy. Despite the GPs making a very full initial referral, there was no continuing liaison. This is discussed further below, in relation to Maternity Services, but the GPs did not follow up the lack of response to their referral. This was a missed opportunity and the Health Overview Report concludes that “there is not a strong pathway for communication between GP practices and the Midwifery Service”.  7.2.3 No concerns arise from the GPs’ direct involvement with the family. Their liaison with mental health and learning disability services was thorough. GP5 persevered with a referral to C&F on the day that the baby was injured, despite the reassurances in the views of the other professionals directly involved. One of the GPs saw Ms E frequently for counselling. The IMR judges that all of the GPs “followed (GMC) guidance and demonstrated a high standard of professionalism”.  7.2.4 The GPs made an appropriate referral to the perinatal mental health service. That was rejected on the basis that it had been made too early in the pregnancy. The GPs might have diarised the need to re-refer when the appropriate time was reached although the mental health services concede that Page 14 of 69 “The way that (our response) was phrased may not have reassured the GP that they were open to a re-referral”. Nonetheless, one would not expect the GPs to be deterred by that.   7.2.5 GP5’s level of concern, when she spoke with EIS1, was sufficient for her to persevere in calling the designated referral number, which was commendable. However the GPs were well placed to challenge the need for more robust safeguarding input from C&F, and the other agencies, from a much earlier point.  7.2.6 There are some similarities with findings from other SCRs: “Some GPs, who were often one of the first points of contact for families, were uncertain about the levels of concern that should have prompted a referral”10. In this case the uncertainty was more about process and how to deal with an inadequate response to a referral. This is a very common finding in Serious Case Reviews. The Board should satisfy itself both that there are well understood arrangements for escalation of difficulties between services to more senior managers and that agencies are regularly reminded of those arrangements.  7.2.7 It is a reality of child protection work – and many other sorts of multi-agency work – that a degree of determination is needed to ensure that partner agencies “pull their weight” and play an appropriate part in joint arrangements. Procedural agreements often do not automatically swing into action. There were increasing numbers of agencies involved here and a clear need for those agencies to get round a table and talk about this situation. The GPs had the best overview of all the services involved, were best placed to demand a more coherent response and had the professional authority to do so.  7.2.8 Lessons learned from this review have been incorporated into training arrangements in local primary care provision. The IMR author has advised that “GPs will be urged to make their language very clear and realise that they are dealing with professionals who often do not have their understanding of medical issues and who will need to have the exact cause of their concerns spelt out both clearly (and) robustly”. During the past year the Designated Doctor and Named GP have sought “Section 11 audits”11 from GP practices in the borough.  7.3 Community Learning Disability Team  7.3.1 Ms E was first seen by the LDPT in November 2011. She was assessed by a Specialist Registrar in the Psychiatry of Learning Disability, Dr L. Dr L’s assessment was thorough except that it did not go so far as to include any subsequent enquiries with other agencies about Ms E’s childhood experiences. It concluded in a diagnosis of generalised anxiety disorder and 10 Learning lessons from serious case reviews 2009-10 (Ofsted) 11 Section11 of the Children Act 2004 places duties on a range of organisations and individuals to ensure their functions – and any services that they contract out to others – are discharged having regard to the need to safeguard and promote the welfare of children. Page 15 of 69                                             panic disorder, with a request for the service’s psychologists to assess whether Ms E did have a learning disability.    7.3.2 She was next seen by the service for a routine follow up three months later. At this consultation a nurse, N1, was also present as a chaperone. This nurse was to become closely involved in supporting Ms E, seeing her 13 times, supporting her in attending appointments and generally liaising with other professionals. Dr L and N1 demonstrated a continuing commitment and concern for Ms E throughout their involvement.  7.3.3 By now Ms E was pregnant and the GP had as a result ceased to prescribe Prozac. Dr L, in conjunction with the GP, decided to re-start this medication as it was felt that there was a high risk that she might become depressed again. She mentioned that she was receiving counselling from one of the GPs and Dr L ensured that the psychologists were aware of this.  7.3.4 A psychologist, P1, saw Ms E in April, 5 months after Dr L’s referral, and assessed her. The service did not have target timescales but 5 months was clearly an unacceptable delay, compounded by the fact that it then took the psychologists a further six months to produce a written report of that assessment. No explanation for these delays has been provided. The assessment concluded that Ms E did not have a learning disability.   7.3.5 This was fed back verbally to Dr L and subsequently to Ms E herself some days after the assessment. Soon after that Ms E presented at A&E, which led to a number of referrals and communications between services. Among those was the referral by Dr L to mental health services. The LDPT  remained involved, principally through the supportive role of N1, until Ms E had her first contact with the mental health services in June. The service then withdrew.  7.3.6 The first issue arising from this account is the determination of whether Ms E was eligible for services from the LDPT. The review has established that the assessment tool used by P1 had been devised many years ago and that the British Psychological Society has described it as “dubious”. In particular the IMR suggests that it can lead to an inflated assessment of IQ, by as much as 20 points.  “The worldwide accepted tool is the Wechsler Intelligence Scale (WAIS 1V)… The WAIS is seen as the “gold standard” assessment tool and should have been used”.  7.3.7 The consequences of this flawed assessment were very serious. The IMR in respect of the mental health service comments “If she had been diagnosed then a Multi Disciplinary Team approach including, psychology, psychiatry, care manager and allocation of a support worker would have been instigated… they would continue to support Ms E attending antenatal clinic appointments, arrange a visit to the unit with the safeguarding midwife, be present at the birth and consider whether a Mother and Baby Unit may be appropriate to assess her ability to parent”. Page 16 of 69 Ms E lost that support, and the support from other services to which it might have led, on the basis of that assessment.  7.3.8 There is no reference to social care services, either children’s or adults’ services, in the list quoted in the previous paragraph. In fact it seems that the psychologist had proactively advised C&F in May of the outcome of the assessment and had highlighted Ms E’s vulnerabilities. It was appropriate to share the information about a vulnerable and pregnant young woman but it is unclear exactly what the psychologist expected or intended to happen as a result of this notification.  7.3.9 This account raises concern, not just about P1 using the “wrong” test and that this was not identified within the agency (which has confirmed that use of this testing method has been discontinued). More broadly it is of concern that service arrangements are allowed to turn on that one factor. One cannot be reassured from the IMR that this might not happen again – so that if a service user now just failed to meet the required “score”, even using an appropriate assessment model, this could still lead to a withdrawal of services.  7.3.10 In that respect the locality is not unusual and this problem could have arisen in other localities. The Panel was told that the same arrangements apply in all learning disability services across the region. But this is out of line with an underpinning principle of the national arrangements for the provision of health and social care services – that a “person centred” approach should be used in which assessments should be led by the needs of the service user not by the way services are arranged.   7.3.11 Other concerns are raised by another comment in the IMR: “Team dynamics within the LDPT are reported to have been difficult over the last decade; this was described as a power struggle between psychiatry and psychology”.  7.3.12 That discord will not have been diffused by repeated changes in the management arrangements for health services. The LDPT had been initially managed by the local Primary Care Trust. Management was transferred to the  Health Trust  in April 2011. In 2012 (after the injuries to Child D), management was transferred to the mental health service.   “The service went out to tender half way through the financial year 2011-2012 and the Mental Health Service was awarded the contract. The staff were facing their third transfer in less than 18 months with all the associated new reporting and management lines”.  7.3.13 Despite the commitment of the doctor and nurse involved, concerns arise about the overall management and quality of this service. The IMR indicates the need for a more searching and far reaching review of the way this service operates and that is echoed in this report. The work carried out should include arrangements to address the issues arising from this review, namely: Page 17 of 69 • Assessments which do not result in a comprehensive, multi-agency approach, particularly where children may be involved. • A lack of clarity about roles and what “support” really means. • Arrangements for psychological assessment and responding to the outcomes of these assessments. • Overall management of the service with particular reference to how well disciplines work together. The SCR Panel was told that these issues are accepted and addressed in the Action Plan arising from this review.  7.4 Maternity Services  7.4.1  “Throughout her pregnancy Ms E engaged well with maternity services and never missed an appointment”. That comment from this agency’s IMR captures the extent to which maternity services at the local hospital, like many of the services involved in this review, failed to differentiate between engagement and purposeful engagement. This IMR also draws out an absence of professional curiosity by the midwifery service – which recognised Ms E’s vulnerability and increased its own involvement without pressing for the involvement of other services, from both health and social care.   7.4.2 Ms E’s pregnancy was identified at an early stage, and the response of the two agencies involved was good: “She went to her GP at five weeks gestation and was booked at almost 8 weeks gestation. This is an example of good practice as the GP had flagged up that she was vulnerable and the service responded well by providing an early booking appointment to ensure appropriate referrals and support could be put in place”.  7.4.3 Ms E was always entirely open about her involvement with other services. At her first appointment she spoke of having a “Support Nurse” – the Learning Disability Nurse who subsequently accompanied her to maternity appointments until the LD service withdrew – but this did not prompt the midwives to liaise with that service or even enquire as to who they were.  7.4.4 This insularity characterises the input from maternity services. They recognised Ms E’s vulnerability at once and, unusually, decided to see her every week (when a standard level of contact would be 10 visits over 40 weeks for a first time mother). However they did not see the opportunity, or necessity, to involve other services. At this early point the midwives could have used the Common Assessment Framework12 (CAF) as the most 12 The CAF was established by the former Department for Children, Schools and Families. It is described as “a standardised approach to conducting assessments of children's additional needs and deciding how these should be met…The CAF promotes more effective, earlier identification of additional needs, particularly in universal services. It aims to provide a simple process for a holistic assessment of children's needs and strengths; taking account of the roles of parents, carers and environmental factors on their development”.  Page 18 of 69                                             appropriate way of drawing together a multi-agency approach to the situation but this was not apparently considered.  7.4.5 There was a referral by the booking midwife to the service’s “Vulnerable Women and Safeguarding Team”. The review team heard that this meeting can provide a useful screening function, as it considers a large number of potentially vulnerable women. However the referral here led only to a discussion at a poorly attended meeting, reviewing a number of cases.  From that meeting the Safeguarding Midwife was to liaise with mental health services but her liaison was ineffective: “the Safeguarding Lead Midwife reports that she spoke to someone in mental health who knew about Ms E but was unable to clarify the position that Ms E was in”. In fact, at this point Ms E was not yet in contact with mental health services.  7.4.6 In any event this meeting made a fundamental error in deciding that Ms E was not classified as a “high risk” case. By doing so the pattern and content of her ante-natal care was altered. This also gave an inappropriate message of reassurance to the midwives who were supporting her on a weekly basis. The Health Overview Report confirms that weaknesses around the Vulnerable Women’s Team are not restricted to the events under review here: “the … role, referral criteria or membership (of the team)… has not been clarified.  It is uncertain how well this team integrates with the clinical team managing the case and how they access the records particularly if they are working from community bases”.  7.4.7 A picture of confusion in this service is demonstrated in the service’s own analysis of these events: “The Safeguarding Lead Midwife also referred Ms E back to Community Midwifery care with no further actions... The midwives however, were unaware of this referral back to them, although they received a document that suggested they should ask about her mental health at every visit which they were doing and did not understand what this document was or take any further significance from it”.  7.4.8 The midwives displayed a lack of thoroughness in their approach to Ms E’s use of medication throughout the pregnancy. They recognised that she was taking it only sporadically, if at all, but this was not followed up.  “It was an omission on the midwives’ part not to discuss this directly with the GP, the Safeguarding Lead Midwife or the psychiatrist for a more robust multidisciplinary plan of care”.  7.4.9 The IMR identifies a reactive and unimaginative approach, even in response to quite worrying presentations: “when Ms E reports that her panic attacks are unbearable the midwife advised her to speak to her GP as she had an appointment in 2 days’ time … and the GP could assess if she required urgent referral. Ms L had (already) … reported regular liaison with the mental health team. This was a missed opportunity for the midwife to liaise personally …with both the GP and the mental health team (or to liaise directly) with the Named Midwife for Safeguarding”. Page 19 of 69  7.4.10 There are worrying indications of a disorganised approach which lacked management “grip”: “two midwives believe they have imparted information about this case by communicating in a corridor or via the telephone to the Safeguarding Lead Midwife while the recipient of the information was busy with something else”.  7.4.11 The IMR identifies but does not explain what appears to be a fundamental error in the midwives’ routine contact with Ms E. Although they were aware of her contact with mental health services, they failed to ask the “Whooley questions13” at each visit. In fact the dynamic seems to have been that the midwives believed that because a more specialist service was involved they were excused from asking questions and playing their part in a joint approach.  7.4.12 When the baby was born the reality of the problems Ms E was going to experience finally seemed to have been recognised by health agencies. There was considerable liaison between community health and social care services and the Safeguarding Lead Midwife registered her concerns by submitting a CAF form.  7.4.13 Many agencies have recognised that it was not easy to assess Ms E, whose presentation did not fall neatly into any “bracket”, and who certainly did present at times as more coping and capable than may have been the case. The midwives did not register any particular concerns in their post-natal contact: “The midwives reported that Ms E was doing well and caring for her baby appropriately. The home was reported as being relatively clean and tidy, the baby was clean and fresh looking, appropriately dressed for the weather”.  7.4.14 By that time however a fixed view of Ms E’s capacity, and the roles of other agencies, seems to have led the midwives’ approach to the case. This was a significant failure. The midwives had the greatest and most regular contact with Ms E and were best placed to anticipate the problems which would arise. However there is no sense, particularly during the ante-natal period, of the midwifery service understanding that they were operating in a multi-agency system.  7.4.15 It is difficult to gauge from the IMR the extent to which these problems indicate underlying weaknesses in the quality of the service. However there is little to suggest that they are not deep-lying and might not recur. The fact that some of the weaknesses are directly linked to the role of the professional who ought to be best placed to identify them – the safeguarding lead – is a particular cause for concern. Equally however there seems to be an inappropriate expectation that other members of staff are excused from safeguarding responsibilities because this role exists. Moreover it is not clear that this role is adequately resourced and managerially supported.   13 A common method of screening for post-natal depression using standard questions. Page 20 of 69                                             7.4.16 These findings are echoed in the Health Overview Report. They are serious and are said to be entrenched. It is not clear that those problems have been recognised and well understood by the service. They may also be found in the area of a neighbouring local authority which is also covered by this service.  7.4.17 The SCR Panel was particularly concerned about this service. While there were weaknesses in the involvement of all key agencies, the reports from the other agencies responded more purposefully than was the case for maternity services. Panel members reported that they were not aware of any indication of maternity services responding positively to the issues arising from this case. In fact the LSCB Manager and the Designated Nurse for Child Protection specifically reviewed14 maternity services at the local hospital in June 2013, in the light of the emerging lessons from this review, and felt that there was still clear evidence of cause for concern. These concerns have been highlighted to the most senior staff at the hospital and to the relevant Clinical Commissioning Group, and are reflected in the recommendations from this report.  7.5 Mental Health Services  7.5.1 This agency has submitted an incisive IMR which identifies and addresses serious weaknesses in their service to Ms E.   7.5.2 Her first contact was with the Increased Access to Psychological Therapies (IAPT) service as a result of a referral from her GP in August 2011. The IMR explains that this service is “part of the NHS national strategy to improve access to psychological therapies for people with depression and anxiety disorders …and… delivers evidence based interventions defined by the National Institute for Clinical Excellence (NICE) as effective for these conditions, especially cognitive behavioural therapy”.  7.5.3 She was accepted by the IAPT service and placed on the treatment waiting list on 17/10/ 2011. On 21/3/12 it was decided that “Step 3 IAPT” intervention, an intensive service, was appropriate. It is not clear how the service took five months to decide that intensive input was necessary. There were then some unavoidable delays in making contact with her, before she was seen by an experienced psychologist in May 2012.  7.5.4 After that one contact she was discharged from the service because other services, including mental health services, had now become involved. That may have been an appropriate decision although it is not clear what communication there was between services, if any, before the decision was reached, nor what information, if any, was shared with other services such as 14 This was part of a statutory “Section 11 audit” - Section 11 of the Children Act 2004 places a statutory duty on key persons and bodies to make arrangements to ensure that in discharging its functions, they have regard to the need to safeguard and promote the welfare of children.  Page 21 of 69                                             C&F.  Overall the delay in response rendered this an entirely ineffectual intervention.  7.5.5 Ms E was referred to the Community Mental Health Team (CMHT) by the Learning Disability service as an urgent case on 17/5/12 following her presentation at A&E. She was offered an appointment on 21/6/12. This is again an unacceptable delay in response to an urgent referral. A Clinical Director at the Trust has advised that she would have expected the service to respond, at latest, before the end of the working week in which the referral was received.   7.5.6 Ms E did attend that appointment and saw a psychiatrist, Dr S. He took the view that she had no active mental health problems. He was aware of her troubled background but “had no concerns that these contextual issues had a possible negative impact on her mental state or ability to cope with a baby”. No treatment was judged necessary but Dr S offered another appointment in three months time.   7.5.7 Dr S shared this information with his Consultant Psychiatrist, Dr P, but there was no formal supervision in which the decision or the overall response was considered. Ms E attended the next appointment, from which the only outcome was the offer of a third appointment in two months. By that time Ms E was in custody.  7.5.8 The IMR identifies the range of weaknesses in this intervention. There is no indication that the following matters were considered. • Social isolation and its possible impact on her pregnancy and capacity to parent her baby. • Recent presentations to A&E and risk of self harm. • The possible need to involve adult social care services or C&F. • An appropriate medication regime, taking account of her recognised non-compliance.  7.5.9 Furthermore there was no •  in depth history taking as part of the formulation of problems. • risk assessment (on the electronic record or the case file). • overall assessment looking at areas of functioning and social network. • history noted on the electronic record. • evidence that the contact with A&E that led to an urgent referral had been considered.  • evidence of consideration of discussion with maternity services, the Safeguarding Midwife or the Perinatal Mental Health Service.  7.5.10 The IMR notes that the psychiatrist’s mental state examination “does not mention a learning disability. Nor does it identify Ms E as vulnerable in terms of her history of self harm, social isolation in the context of pregnancy. The psycho-social issues were not robustly recorded during the first assessment although he was aware and considered them.  The emphasis Page 22 of 69 and responsibility was placed on Ms E to tell services, when she delivered her baby, that she was known to mental health services”.  7.5.11 The key weakness in this psychiatrist’s assessment was the failure to recognise the complex nature of Ms E’s situation and the consequent need for a multi-disciplinary approach. That would have been provided by the Care Programme Approach (CPA), the national arrangements for responding to complex mental health needs, which provide for a well-structured multi-disciplinary approach. If needs are less complex services are delivered by the Lead Professional Care (LPC) system where a single professional manages the patient’s care.    7.5.12 In this case the clinician judged that the LPC system was appropriate. The failure to implement CPA arrangements is concerning. It seems that the psychiatrist conflated a finding of “no active mental health problems” with a view that no other actions or services were necessary. That was a serious weakness in the doctor’s assessment.  7.5.13 As discussed above Ms E had also been referred by her GP to the Perinatal Mental Health service. That referral was rejected because she was only nineteen weeks pregnant whereas the eligibility criteria for the service require that a pregnancy has at least reached twenty-eight weeks. The response was not unhelpful – it appropriately suggested a pre-birth planning meeting which the Perinatal Mental Health service would attend and was copied to C&F and the Mental Health Service. However it left the onus to re-refer on the GP or those other services. That reactive approach to service delivery could be improved, as the IMR suggests, by arrangements to keep referrals “pending” and regularly review them. The service has already made changes to do so.  7.5.14 The report also refers to problems identified in arrangements for recording, saying that it had been “a challenge to understand how teams worked … The Trust expectation is that all notes: letters, referrals and progress notes are uploaded and written on JADE (electronic recording system). It would appear that, prior to June 2012, the doctors in the service did not regularly update JADE directly. Rather progress notes would be written and scanned or there was a separate case file created”. The Trust’s action plan from this review addresses this issue.  7.5.15 In trying to understand the factors leading to this weak assessment the IMR draws out key issues. Underpinning the overall weakness of the psychiatrist’s assessment and follow up were • an over-reliance on medical diagnosis to guide further action. • a failure to appreciate the need for collaboration with other services. • a failure to think beyond the individual patient and see her in the context of family and community.   7.5.16 Insufficient thought was given, in particular, to the pregnancy, its consequences for the general pressures Ms E felt under and even the Page 23 of 69 potential consequences of the pregnancy for medical diagnosis and treatment:  “In July 2009, Social Care Institute for Excellence (SCIE) published a guide entitled “Think child, think parent, think family: a guide to parental mental health and child welfare” to help services improve their response to parents with mental health problems and their families. This document was updated in 2012. There would be an expectation that clinicians would be able to identify the need for additional support or assessment for parents”.  7.5.17 The IMR puts these difficulties in context, explaining the consequences of yet another major reorganisation of services and their management between 2011 and June 2012. This made significant changes to some employees’ life at work and met with some resistance and unrest. There may have been some consequences for the management of this individual case: “The assessment and feedback meeting had ceased for a period during this change so there was no formal opportunity outside of supervision or informal contact for cases such as this to be discussed. A structure to discuss cases and request a care co-ordinator to support a service user is now part of the way that the Recovery Teams deliver services”.  7.5.18 The report relies on the restructuring and revised management arrangements to tackle the problems which it very clearly identifies, detailing changes to line management and professional supervision, training and communications. The IMR makes appropriate recommendations but the Board will need to be reassured of their effectiveness.  Page 24 of 69  7.6 Children and Families Services  7.6.1 This service was significantly involved with Ms E from infancy. It is hard to imagine a more difficult and unhappy upbringing, which was marred by parental rejection, depression and multiple forms of abuse.   “By the time Ms E was 9 years of age she had stopped eating, had intermittent enuresis, and was described as exhibiting ‘odd’ behaviour although articulate of speech”.   The reference to her being “articulate of speech” is important. It indicates that, from an early age, there were features of Ms E’s presentation which might give a misleading impression of her abilities – and that this information would have been available from a thorough reading of the records.  7.6.2 Throughout her childhood there was substantial but disjointed input from C&F. “Case files make reference to approximately 20 referrals being made to C&F between 1988 and 2001.  During this time the case was open to C&F for long periods”. As she grew older the situation deteriorated: “In 2004 the family situation was in crisis, Ms E refused any support or to engage in any mental health assessment ... She was placing herself at serious risk by running away and establishing damaging relationships where others would abuse her…(she) was aware that people were taking advantage of her (but)… she stated that this was what she wanted”.    7.6.3 When she was in her late teens she came into the care of the local authority by agreement. At first there was a pattern of apparent improvement in the situation, with her seeming more happy and settled, followed by deterioration where she would “abscond, neglect her self-care; speak of suicide and again present as vulnerable”.   However, the stability and support offered by C&F and other services gradually seemed to take effect and, by the time she was 18, it was judged that she was “positive, honest, open, polite, mature and happy”.  7.6.4 She moved at age 18 to live in a semi-independent setting with limited support, commissioned by the local authority from a voluntary agency. That support was led by Mr F who, as described above, had a sexual relationship with her. Case records indicate that Ms E was very upset when this came to light and she spoke of missing Mr F. There was evidence of self-harm. Educational and employment placements failed.   7.6.5 However in 2009 she secured her own tenancy and it was felt that the situation had improved: “The social worker at the time reported that Ms E had settled well into her home and had good independent living skills and the necessary support in place”.   The “support” mentioned appears to have been the support offered by her family and in particular her mother. It is not clear what if anything, professionals knew of her continuing relationship with Mr F.  Page 25 of 69 7.6.6 C&F became involved again eventually as a result of Ms E’s presentation at A&E in May 2012. This was soon after they were sent the letter detailing the outcome of the psychological assessment. This letter had not led to any action within C&F. C&F were notified of the A&E attendance by a direct referral from the hospital on 14/5/12. Also, on 24/5/12, a referral made by GP2 to the council’s adult safeguarding service was copied on to C&F. A social worker, SW1, was allocated to carry out a Core Assessment15. On 13/6/12 a Health Visitor who had proactively responded to notification of the hospital attendance contacted that social worker, who had not yet been to see Ms E.  7.6.7 The very fact that she had made contact immediately after her visit indicates that the Health Visitor had concerns about the situation and we know now that she did indeed have what is described as a “gut concern”. However she may not have communicated that sufficiently clearly. Certainly the eventual assessment by SW1 seems to have focussed on the more encouraging aspects of the contact. The IMR reports from C&F records that “The health visitor reported that she had no concerns about the home environment and Ms E showed no signs of depression during her visit” but does not refer to the lingering concern which had prompted the Health Visitor to initiate the contact.  7.6.8 SW1 visited Ms E the day after being contacted by the Health Visitor. This was a month after the presentation at hospital and subsequent referral to C&F. This was not an urgent matter, in that it was a pre-birth referral, but there is no indication of why there was a delay of a month before any action was taken. There is no indication that the social worker was liaising with other agencies, or exploring the history of the case, in preparation for the visit, and it was not a visit by appointment. It appears that the social worker was prompted to visit by the Health Visitor’s contact – the visit was arranged by telephoning Ms E after the discussion with HV. SW1 based the content of the assessment on that one visit and speaking to GP1 – who knew Ms E particularly well and had been seeing her individually.   7.6.9 Ms E told the social worker about her depression and recent suicidal thoughts. She described noise nuisance and general difficulties she had with her neighbours. The GP expressed concern about her depression and the fact that she was not taking prescribed medication. The analysis in the Core Assessment also reflected what was judged to be a poor relationship between Ms E and her mother.  7.6.10 Nonetheless the assessment concluded that there was no need for continuing involvement by C&F, emphasising that a strong professional network would support Ms E and commenting on her “excitement, commitment and understanding of the skills needed to care for the baby”.   The Panel heard that it was around this time that the Early Intervention Service (EIS) was being established and a referral to that service might have 15 A detailed assessment carried out under the Framework for the Assessment of Children in Need – statutory guidance now superseded by Working Together to Safeguard Children (2013) Page 26 of 69                                             been appropriate at that point. However the case was closed by C&F and there was now no significant involvement from them until the birth of Child D three months later.   7.6.11 After the birth midwives, doctors and health visitors all expressed concerns about Ms E’s capacity to care for the baby and wanted C&F to become involved. C&F initially agreed to assess the situation. Then, taking account of what they regarded as a recent Core Assessment, there was a decision that there was no need for a further social work assessment but that there should be input from the EIS. This service would support Ms E in developing parenting skills. “An email …from C&F to the health visitor outlines that Ms E is likely to need robust support from all agencies and that this would be achieved through a multi agency Team around the Child plan devised by the EIS”.  7.6.12 The IMR is thorough in identifying weaknesses in the way in which C&F dealt with this case and the lessons arising from that. The problems stemmed principally from the inadequacy of the Core Assessment conducted in May / June. The fact that C&F had chosen to carry out a Core Assessment was significant – they could have undertaken a less exhaustive Initial Assessment16, or suggested to referring agencies that an assessment under Common Assessment Framework17 arrangements was appropriate in the first instance. Yet the service chose – appropriately -  to carry out a Core Assessment, theoretically the most “in depth” intervention, indicating that they were alert to the fact that agencies’ concerns were high.  7.6.13 The evidence base for the subsequent assessment was insufficient – one visit, discussions with a Health Visitor who had seen Ms E once, and then a GP – both of whom expressed concerns about the situation. It is not clear what reference, if any, was made to records of previous C&F contact. The social worker appears to have significantly misjudged Ms E’s own capacity and to have under-estimated the difficulties facing any new parent.  7.6.14 The assessment itself was, as summarised in the IMR, “optimistic and did not fully appreciate the significant history and complexities relating to the family dynamics”. This was Ms E’s first pregnancy. She had a personal history which should have raised concerns for any professional. There was recent evidence of mental fragility in Ms E herself and wider problems, including child care concerns in relation to other family members.   16 A brief assessment of a child referred to children’s social care services to determine whether the child is “In Need”, the nature of any services required, and whether a more detailed Core Assessment should be undertaken. 17 The CAF was established by the former Department for Children, Schools and Families. It is described as “a standardised approach to conducting assessments of children's additional needs and deciding how these should be met…The CAF promotes more effective, earlier identification of additional needs, particularly in universal services”.  Page 27 of 69                                             7.6.15 SW1 seems to have given insufficient weight to Ms E’s troubled childhood and the extensive contact with services but to have based the assessment on • a false and unevidenced optimism about her capacity to care for a baby for the first time • an assumption, made without adequate investigation, that other services were significantly involved in supporting Ms E. In sum the assessment failed to meet the fundamental requirements of such an assessment, as described in the local Child Protection Procedures: “The core assessment must provide a rigorous analysis of the child’s needs and the capacity of the child’s parents to meet these needs within their family and environment. Based on this analysis the key questions to be answered are: • What is likely to happen if nothing changes in the child’s current situation?  • What are the likely consequences for the child? ”  7.6.16 An issue emerging repeatedly from SCRs is the failure of services to take adequate account of historical factors. In this case those factors were relatively recent and clear. It is also of concern that such a weak assessment should have been judged adequate by this social worker’s manager. The local Child Protection Procedures require that “A local authority children’s social care manager must approve the outcomes of a core assessment”.  The basis for the unquestioning management decision in this case is not explained.   7.6.17 The significance of this misjudgment is compounded because it became the basis for the decision by C&F not to become involved immediately after Child D was born, despite the concerns expressed by other professionals. Whatever SW1 and his manager may have thought about Ms E’s potential parenting capacity three months previously, this was a new situation and should, without question, have prompted a re-assessment.  7.6.18 It is not clear why C&F managers took this view. They had the discretion to decide to re-assess.  A “common sense” approach would suggest that the easiest thing to do, as well as the most appropriate, would be to go and see the family. Any process of management overview of the decision not to re-assess was clearly ineffective.  7.6.19 The IMR notes organisational factors which provide a context for understanding the dynamics of this decision-making: “in October 2012 there were some organisational issues (including)… an increased work load and it is evident that there was some lack of confidence in decision making.  The EIS was a relatively new service and it appears that during the implementation of this new model there was a lack of clarity in respect of thresholds”.   However there is no evidence that this specific decision was particularly linked to high levels of demand and workload pressures at that time.   Page 28 of 69 7.6.20 The failure to re-assess or to give adequate weight to the concerns of health professionals led C&F in the wrong direction. Assuming that Ms E was going to be able to manage, their response lost urgency. It was not until mother and baby had been at home for two weeks that the EIS saw them. Like many other professionals, most of whom were more experienced and better professionally qualified than she was, EIS1 misjudged Ms E’s capacity to care for the baby. That misjudgement turned partly on Ms E’s presentation – we know that in some ways she presented as more capable than was the case. EIS1 may also have been reassured by the very fact that her service was dealing with the case – as they were not a “high end” child protection service, there may have been a degree of self-fulfilling prophesy; she may not have expected to be faced with a parent who was going to find it unusually difficult to manage a new baby.  7.6.21 This situation might have been avoided if EIS managers had more carefully evaluated the referral from their colleagues. This should have  identified that the level of need indicated that this was not an appropriate referral for them to manage as the primary case holders. It would have been more appropriate for the EIS to work alongside a qualified and experienced colleague, who would be principally responsible for overseeing any child protection concerns.   7.6.22 By its own lights the contact from EIS1 was thorough: “The initial assessment undertaken by the EIS worker …was very child focussed and covered various aspects and factors from practical topics and advice such as the importance of registering the birth, Ms E’s pet being kept away from the baby, discussion about tummy time, face to face talking with baby, how to stimulate a new born and attachment.  The EIS worker also discussed and offered strategies around the sleep difficulties and what different baby cries mean”.    7.6.23 However this assessment and immediate advice, despite its strengths, was being offered in a vacuum, without adequate reference to the history or to the input from other agencies. Two weeks after the birth was too long to wait before Ms E and the baby were seen by C&F although that time had offered an opportunity for agencies to co-ordinate their interventions. It would have been appropriate for C&F to have responded to the concerns of other agencies by taking a lead role and organising a meeting of the various professionals involved but they did not recognise the need to do so.  7.6.24 The final involvement of C&F, prior to the injuries to the baby, was the response to the GP’s contact via the designated referral number. The response itself from the Children’s Access Team (CAT) was inadequate – effectively making a record and asking the GP to submit a written request. Instead, as the local Child Protection Procedures indicate, at the end of the discussion both parties - the referring agency and C&F - should be clear about proposed actions, who will be responsible for those actions and when they will be carried out. C&F services appear to have become sidetracked into an issue about the process of making and receiving referrals and whether or Page 29 of 69 not the designated referral number should be used, rather than analysing sufficiently clearly the content of the referral.  7.6.25 A more proactive approach at an earlier point that day could have avoided these difficulties. EIS1 had made her manager aware of the GP’s concerns and that the GP intended to make contact via the designated referral number. Knowing that the GP had continuing concerns the manager might have contacted a colleague in the CAT to agree how C&F services overall could best respond to the GP’s continuing concerns, and might then have  contacted the GP directly so as to pre-empt a new referral via the designated referral number.  7.6.26 The SCR Panel closely examined the arrangements for the designated referral number. The local authority introduced this system to make the process of referral simpler and swifter. The Panel heard from some agencies that there had been problems of slow response times from the designated referral number. In this case issues relating to the designated referral number were not significant - the key problem was not the “front door” but that agencies did not escalate their continuing concerns to more senior officers in C&F. During the extended period it has taken to complete this review the local authority reports having made substantial improvements to this service. Nonetheless it is right to reflect the concerns raised and the Board will wish to be reassured that the designated referral number arrangements are providing a reliable and efficient “front door” to the service for both public and professionals.  7.7 Health Visiting Services  7.7.1 The Health Visiting service’s first contact was ante-natal when a health visitor, HV1, proactively visited upon receiving notification of Ms E’s presentation at A&E in May. “HV1 reported that on the surface Ms E seemed to have everything under control (but) she had a gut instinct that Ms E was not as capable as she seemed”. HV1 had planned to liaise with the GPs and midwives after her visit but did not do so.  7.7.2 It was good practice by HV1 to make this contact although, as the IMR points out, she should not have needed to rely on “gut instinct” in respect of a young woman who “was known to have depression, to self- harm, suffer from anxiety and learning difficulties… and had been feeling suicidal”.  7.7.3 Moreover, although Ms E spoke about her contact with mental health services, HV1“did not observe any signs of depression when she visited her (so) she did not consider her depressed and therefore appeared to dismiss any concerns in this area”. The concerns raised by this are heightened because we know that Ms E told HV1 that she had not been taking her prescribed anti-depressant medication but HV1 took no action. This was a proactive visit by HV1 but the failure to analyse and respond to her concerns and then to liaise fully with other services undermined its value. Although the subsequent Core Assessment by Page 30 of 69 C&F was inadequate, the referral from HV1 could have been more specific and clear in the concerns raised.  7.7.4 A few days after Child D was born HV1 was informed of the birth by another Health Visitor, HV3. HV3 had been the Health Visitor for Ms E’s family when she, Ms E, was a child and knew the family well. HV3 told HV1 that she was gravely concerned about Ms E having responsibility for a baby. HV3 liaised with C&F and made a referral to them. It is unclear why and how HV3 became aware of the situation. The “proper” route should have been a formal handover from the midwives but the Health Overview Report tells us that: “There is no evidence that the Health Visitor received a comprehensive handover of all the concerns from either the Maternity Service or the GP which should have occurred in all cases but particularly when there are so many vulnerabilities”.  7.7.5 When Child D was two weeks old another Health Visitor, HV2, carried out the New Birth Visit18. The home was clean and tidy. Ms E spoke openly about her involvement with other services. The baby appeared relaxed and calm and Ms E was seen to be smiling and making eye contact. HV2 gave routine advice and confirmed that Ms E knew where to get help if things became difficult at any time.   7.7.6 HV2 did not ask to see the baby undressed. The IMR notes that this was in line with current practice locally where the responsibility for that aspect of the overall assessment lay with the midwives. The IMR suggests that this should be a key part of the Health Visitor’s New Birth Visit: “Seeing the baby naked not only allows the HV to have a base line on the child’s skin condition, it allows them to observe how parents handle their babies and comfort them as they undress and dress them”. This change has already been implemented by the service.  7.7.7 The Health Visiting service therefore had only one direct contact with Ms E and Child D post-natally. However the IMR points out that “There were a series of assumptions made by HV2 during her home visit which resulted in an inaccurate assessment of Ms E’s and her baby’s needs; and an inadequate risk assessment for Child D”. HV2 assumed that • Child D’s father was supportive.  • Ms E was physically well – though she was recovering from a caesarean section. • Ms E was caring for herself and eating regularly – though the HV did not physically check whether there was food in the home. • Ms E was less intellectually disabled than was in fact the case – a common error identified in this review. • Ms E had other family supports. • Ms E was well organised and managing a demanding set of arrangements for contact with a range of services. 18 A universal service to all newly born children in the UK, where advice is provided on, for example, feeding, weaning and general care. Page 31 of 69                                             The IMR points out the lack of evidence on which to base these assumptions and makes the point that there was no “assessment of Ms E’s emotional resilience and how she would cope with a newborn baby whose cry could be piercing and relentless”.  7.7.8 This reflects a continuing theme of professionals taking an over-optimistic view of Ms E’s abilities in the face of compelling evidence to the contrary. HV2 acknowledges that she should have ensured that she was more fully informed about Ms E’s background and vulnerabilities, although it is clear that she had been briefed on this by HV1.   7.8 Adults’ Services  7.8.1 This report deals initially with Ms E’s contact in 2006/7 with the man who was to become the father of Child D. That exploitative relationship further confirms the vulnerability of Ms E.  7.8.2 For the purposes of this review Adult Services’ involvement started from a written referral from her GP in May 2012. That referral arose from her presentation at the non-local A&E earlier in the month, which led to a flurry of activity across all agencies. The GP’s referral was addressed to “Safeguarding Adults” and describes her as a vulnerable pregnant woman in  need of additional support. The response to the referral came from the Adult Services Reablement Team.   7.8.3 The Reablement Service “provides planned, short term, intensive help. The service is designed to help a person restore their independence, to help them to do as much as you can for themselves, rather than someone doing things for them. Reablement workers spend anything between one and six weeks supporting each individual to re-learn lost skills following a period of illness, disability or a time when a person may have lost some confidence”. In this authority, the Reablement Team serves as the first point of assessment for all Adult Social Care Services with the exception of mental health.  7.8.4 The service did not contact the GP but initially treated the referral, effectively, as a request for practical, household support – one of the principal functions of the Reablement Service. The following day the officer dealing with this was contacted by the psychiatrist from the Learning Disability service, who said that he was concerned about Ms E having suicidal thoughts and an eating disorder. The IMR reports that “He was seeking a Safeguarding Adults’ referral, again in the context of self neglect / harming behaviours”.  7.8.5 After further consideration the Reablement Service decided to copy the GP’s referral to C&F and pass the substantive referral to the Adult Services “Long Term” team. Here it was considered by a manager who decided that this was not a safeguarding referral and passed the referral to a colleague “to undertake a Section 47 NHS and Community Care Act Assessment as both doctors were requesting practical support for Ms E”.  Page 32 of 69 7.8.6 That assessment was carried out very swiftly and concluded that Ms E was sufficiently independent that she did not meet the criteria for the provision of services and that no further action should be taken. The assessing officer had recorded that the two “main risk areas” were “deliberate self harm” (“medium”) and “suicidal thoughts” (“high”).  There was no feedback to the GP or psychiatrist, and no direct liaison with C&F. The assessment appears to have been based on the immediate situation. What might happen in future and particularly any risk to the baby do not appear to have been considered.  7.8.7 The IMR notes that the lack of direct liaison with other agencies was a weakness but judges that the overall service response was otherwise appropriate because Ms E’s “described behaviours fell outside adult safeguarding arrangements and that she did not appear to be eligible under the Fair Access to Care Services (FACS19) criteria for support under community care provision”.  7.8.8 This account raises a number of issues. The most straightforward, which it recognises, is the lack of any direct liaison from Adult Services with any other professional, either to clarify what was wanted or to feed back on what had or had not been provided. This illustrates the lack of alertness to the fact that Ms E was pregnant and to the needs of her baby. There was an assumption that these matters had been addressed by copying a referral to C&F.  7.8.9 The account illustrates the way in which needs and demands can get re-interpreted to meet what a service provides rather than what is requested or required. The Reablement Service provides practical help and concluded that “She only wanted practical assistance with household tasks”. The Community Care assessment “concluded that Ms E was independent in all aspects of personal care and domestic chores with some support from her mother who visited weekly. She had no physical disabilities, was able to go out, use public transport independently, managed her own finances… and was negotiating a house move with a Housing Officer”.  7.8.10 The report explains why this was “not an adults’ safeguarding matter”  because • no other party was causing Ms A significant harm. • matters of self neglect and self harm fall outside the remit of the most relevant guidance, the  adult safeguarding procedures20.  Those procedures state that “Self-neglect does not come under the scope of these procedures – which relate to circumstances where there is a person or agent, other than the adult at risk, who is causing significant harm. 19 FACs (Fair Access to Care services) is as system for deciding how much support  people with social care needs can expect, to help them cope and keep them fit and  well. It applies to all the local authorities in England. Its aim is to help social care  workers make fair and consistent decisions about the level of support needed, and  whether the local council should pay for this. 20 Adult Safeguarding Procedures Page 33 of 69                                             Practitioners should refer to other procedures relating to handling self-neglect”.  7.8.11 Research by SCIE21 sets out the complexities of reaching a definition of self-neglect, and the wide variance, internationally, in how this is defined and understood. A key distinction is exemplified in the difference between the approach to self-neglect in the USA and the approach in this country. In the USA self-neglect is “officially” categorised as a form of abuse, while in the UK this is not the case and there is no statutory requirement to report and respond to self-neglect.   7.8.12 In any case there was, as the Community Care assessment demonstrated, now no indication that Ms E was neglecting or harming herself. The real concerns were that she was unwell, pregnant, vulnerable and might not be adequately supported.   7.8.13 The overall response from Adults’ Services lacked professional curiosity. The assessment was prompt and, within its limits, thorough. But, like the learning disability assessment, it was a service led assessment, not one led by the needs of the service user. It was not sufficiently alert to the need for a multi-disciplinary approach to the provision of services to vulnerable families.  7.8.14 This SCR has already led to some improvements in communications and liaison between the two services, including involvement in the Multi Agency Safeguarding Hub (MASH), “shadowing” arrangements for staff and further consideration of how historic information in children’s records can be made more easily accessible to Adult Services if necessary. This Overview Report suggests that there should be further specified arrangements within the local authority which enable Adults’ and Children’s Services to work together more effectively when vulnerable people become parents. That approach should not be restricted by an approach to service provision which is led purely by nationally defined eligibility criteria.   7.9 Dietetic, Accident & Emergency and Acute Paediatric Services  7.9.1 Acute paediatric services at this hospital were only involved from the point when Child D was brought to hospital with inflicted injuries. At that time Child D received appropriate treatment before transfer to a specialist child hospital.   7.9.2 During her pregnancy Ms E received dietetic advice, which appears to have been appropriate: “The dietician obtained a good history from Ms E and shared this information appropriately with the GP and midwife”.  7.9.3 Ms E attended A&E at this hospital on one occasion during her pregnancy, in April. On that occasion the service did not demonstrate alertness to safeguarding issues. Despite knowing that she was pregnant and 21 Self neglect and adult safeguarding: findings from research (SCIE September 2011) Page 34 of 69                                             diagnosed with depression A&E staff did not investigate more fully or carry out any assessment of risk. No notification was made to midwifery / health visiting services. Ms E “should have been referred to the local Liaison Health Visiting Service who would have facilitated communication and information sharing with GP, HV and midwife”.    7.9.4 The IMR does not explore this further or indicate whether this is a familiar weakness in the service. There is an implication that this may be a continuing problem, in the report’s comment that “Identifying vulnerable adults with children or vulnerable pregnant women in A&E remains a challenge”. Moreover notifications following the injuries to Child D did not follow local protocols and there was some delay in information being shared with designated and community health lead professionals.  7.10 Educational Psychology and Special Educational Needs Services - report for information  7.10.1 This brief report confirms that Ms E was known to specialist education services throughout her time at school. A Statement of Special Educational Needs was issued when she was eleven years old and she attended a special school. “Her word reading and spelling skills were two years behind her age, her reading comprehension was three years behind her age and she showed significant learning difficulties in mathematics”.    7.10.2 The report’s summary is telling: “Ms E was a young person with moderate learning difficulties, with a tendency towards anxiety, who had difficulties with social communication and in forming social relationships … She had experienced being bullied.  Although she developed some independence skills she was emotionally vulnerable and became less secure when she moved away from … a small group teaching and learning environment...”  7.11 Housing Services – report for information  7.11.1 This report sets out details of the contact between Ms E and her landlords, the local authority. The report confirms that there were a number of problems arising from the conduct of neighbours – noise nuisance and anti-social behaviour. It is clear that these matters were at times very unsettling for Ms E and will have contributed to the pressures she was attempting to manage. The difficulties were eventually dealt with, to Ms E’s satisfaction, by a specialist Anti- Social Behaviour officer.   7.11.2 Otherwise the report is in keeping with a number of other submissions to this review, which have commented on Ms E’s open and “chatty” presentation and the difficulties that may have concealed:  “the Housing Officer offered the opinion that Ms E could be described as a model tenant”.       Page 35 of 69 7.12 Ambulance Service – report for information.  7.12.1 The only involvement of the Ambulance Service was their response when alerted to Child D’s injuries. This was prompt and appropriate and no matters arise.  7.13 Specialist child hospital –report for information  7.13.1 This agency was only involved after the injuries to Child D. They have submitted a report describing the very serious injuries sustained and their treatment. Child D has responded well to that treatment but the injuries have had life-changing consequences.  7.14 Police – report for information  7.14.1 The Police had no significant contact with this family and have submitted a brief report to that effect. Page 36 of 69  7.15 Health Overview Report  7.15.1 The purpose of the Health Overview Report (HOR) is to provide a particular focus on how health organisations have worked together. It also serves as the report which draws together issues relating to the commissioning of health services.   7.15.2 The HOR identifies “many missed opportunities” to work with Ms E, and the ways in which her presentation as an open, pleasant young woman led agencies to misunderstand and under-estimate how needy she was: “The fact that services such as Maternity left Ms E to liaise with the GP about her anxiety attacks highlights a complete lack of empathy for her position and no understanding of her vulnerability”.  7.15.3 The report’s concerns about safeguarding arrangements in the maternity service are prominent. This service had the greatest continuing contact with Ms E throughout the pregnancy but failed to respond to the evidence of cause for concern.   7.15.4 Apart from the fact that children are central to their work, maternity services are also unusual in that they can plan more accurately than many other health services when their involvement should start and finish. In that context the report appropriately questions “why a referral (was made to C&F) after the birth of baby D … by the Midwifery Service when she had been under their care for several months”.  7.15.5 These were not individual errors. The report highlights the failure of the service to take appropriate corporate responsibility for safeguarding.  “Safeguarding is everyone’s business and the Safeguarding Midwife is there to provide support and supervision but it is unsafe to believe that one person can carry sole responsibility for safeguarding”.  7.15.6 This report also confirms the serious concerns about Ms E’s contact with mental health services “failure to complete a comprehensive assessment, failure to take into account social isolation, failure to understand the recent presentation at [     ] Hospital, the need to refer to Social Care and the Safeguarding Midwife and the need for follow up with [the Perinatal Mental Health Service]. There is failure to mention any learning disability or identify vulnerability. There was no exploration of non-compliance with her anti-depressants or her anxiety about her pregnancy”.   7.15.7 Overall, the HOR picks up the same concerns identified throughout this report – poor use of medical and social histories, a lack of liaison and communication between agencies and professionals, an absence of any overall lead in planning and providing services. In sum “different areas of the health services continued to work in isolation, did not share pertinent information and keep each other updated, and made assumptions about each other’s roles and responsibilities, often failing to clarify very basic facts and trusting a very vulnerable young woman to provide a full history”. Page 37 of 69  8. ISSUES SPECIFIED IN THE TERMS OF REFERENCE FOR THIS REVIEW  8.1 Introduction  8.1.1 Many of the issues raised under these specific terms of reference have been considered in previous sections of this report and, where appropriate, are summarised and cross-referenced here.  8.2 During the pregnancy, could more have been done to assess the mother’s needs and provide her with support?   8.2.1 Maternity services recognised Ms E’s vulnerabilities and gave her additional support. However they largely did so without reference to any other agency. They appropriately made an early referral to their Safeguarding Team but, when that did not lead to any further intervention, their concerns appear to have lapsed. The midwives were in the best position to form a view about Ms E’s capacity for parenting and one would have expected that they would keep the need for safeguarding input under review.  8.2.2 The Core Assessment conducted by C&F was of a poor standard and led to an inappropriate management decision to close the case, without reference to all key agencies. The assessment assumed that the services with which Ms E was in touch were having a beneficial effect, when that may not have been the case. It would have been most appropriate for C&F to have maintained some contact with Ms E through the pregnancy or, at least, to ensure that key agencies were ready to re-refer as necessary. SW1 failed to liaise directly with mental health services, noting only that she was engaged in “counselling” and did not make any contact with maternity services. Then the response of C&F when the case was referred after the birth was inadequate - but those making the decision not to re-assess would have been misled by the content of the Core Assessment.  8.2.3 As set out above, the psychological assessment carried out by the Learning Disability service was seriously flawed. This led to the withdrawal of the Learning Disability service from the case, so that Ms E lost the support of the Learning Disability Nurse and the psychiatrist.   8.2.4 Adult Services’ assessments were service led rather than needs led. They were sound by their own lights but did not demonstrate a sufficient alertness to the complexity of the situation and the ways in which individual needs challenge the structures of services and relationships between services.  8.2.5 The rejection of the referral by the perinatal mental health service was a significant development. That was the best opportunity during the ante-natal period for a well-informed, multi-agency assessment which had a real focus on Ms E’s parenting capacity and the safety of the child. The overwhelming case for the involvement of that service is set out in the IMR: Page 38 of 69 “A young person who has been a Looked After Child is at higher risk of mental health problems, Ms E had a clear history of self harm and substance misuse.  She lived alone and the support networks were not checked out at the point of assessment. A young woman who is pregnant is going through a change physically and psychologically that can be difficult to cope with; these contextual issues would have made pregnancy an additional consideration to her mental state”.  8.2.6 The psychiatric assessment was weak in many ways. It did not lead to a robust set of arrangements to support this very fragile and vulnerable young woman through her pregnancy and beyond.  8.2.7 The only professionals, whose pre-birth involvement was significant but does not in itself give rise to any direct cause for concern, were the GPs. As suggested above they too have some responsibility for the corporate failure of all the agencies to talk to each other in an effective way.  8.2.8 A common thread running through all the agencies’ involvement was the failure to take adequate account of Ms E’s history and family background. Some of the agencies did not make themselves aware of it. Others did not research it fully. An explicit, shared chronology would have helped the agencies to respond in a more informed way.  8.3 Were the mother’s problems appropriately assessed and addressed across agencies, both recently and when she was in care and a care leaver?  8.3.1 The agencies’ responses to Ms E’s mental health problems and learning difficulties, during her pregnancy and subsequently, have been covered above in sections 7.3 and 7.5.  8.3.2 We do not have a detailed account of all the services provided and the work carried out with Ms E while in care and when she was a care leaver. In any case the more important consideration is that she was in her late teens by the time she came into care. She had already experienced significant harm throughout her childhood.  8.3.3 The only agency in a position to comment on her experiences in care and as a care leaver is C&F. Her time in care was not easy: “Ms E’s behaviour would greatly improve and she would report being happy and settled in placement, education placements would be identified and commenced.  By the next review a regression would be reported where she would abscond, neglect her self-care; speak of suicide and again present as vulnerable”.  8.3.4 In May 2005, in response to attempted suicides, “a mental health assessment was undertaken the outcome being that there were no mental health issues”. Page 39 of 69 So, several years before the birth of Child D, Ms E’s presentation was causing significant alarm but she was failing to fit neatly into the ways in which services were organised.   8.3.5 It is not clear if any support was offered and / or accepted by Ms E when it came to light that she was being sexually exploited by a person in a position of trust.   8.4 How did assessments and interventions seek to understand and address issues of diversity, including those of ethnicity and disability in particular?   8.4.1 Agencies struggled to understand Ms E’s disability and this is a key issue in understanding their responses to her. Even if they had not been misled by the flawed psychological assessment, it is clear that Ms E’s presentation was not straightforward and a number of professionals concluded that she might be more competent than was the case. There are references to her “engaging” personality and to some extent this may have disarmed those professionals who were concerned. However every professional with whom she had contact did recognise a degree of vulnerability.   8.4.2 The Health Visitors’ IMR appropriately identifies a significant additional pressure for Ms E – her own health and well-being following the birth of Child D: “the experience of the delivery of her baby would have been a more painful one than most. She then had the aftermath of a caesarean section to cope with”.  8.4.3 Ms E’s ethnicity is described in one of the IMRs as “mixed British, Irish, Indian heritage”. The local authority area is an extremely diverse locality. Public data tells us that the ethnicity of fewer than half the population is White British. None of the IMRs finds any evidence that there are any significant issues of identity / heritage to be taken into account in this case.    8.4.4 The SCR Panel expressed some concerns about the extent to which ethnicity had been considered in the delivery of services to Ms E but also in the IMRs themselves. The Panel felt that this indicated a failure to give adequate weight to issues of diversity and to understand that such issues can have a significant impact on how people engage with and make use of services. Page 40 of 69  8.5 Did assessments take into account the mother’s relationships, support networks and their impact on her parenting?  8.5.1 The input from all agencies seems to have lacked any real effort to understand the nature of Ms E’s relationships with her baby’s father, or with her own family. They were all seen as supportive when there was no evidence that this was the case, or that any support offered was useful to Ms E. No professional spoke to her mother, her sister or Mr F at any time during the period under review. The evidence, some of which was known to all professionals, that she had been abused in her own family and exploited by Mr F, seems to have been given little weight.   8.5.2 The reality was that Ms E was very much alone. The accounts she has given of the circumstances in which the injuries were caused clearly indicate that she felt isolated and unsupported at that time – a Friday evening with what must have felt like a long and difficult weekend ahead of her.  8.6 Did the local authority’s triage arrangements have any bearing on how agencies responded to concerns? What form of triage should have been triggered once concerns were notified?   8.6.1 “Triage”, usually used in medical settings, refers to a process of prioritising responses against need. For the local authority this had to be done twice – in response to the referral following Ms E’s attendance at A&E in May, and then in response to the referrals received when Child D was born and subsequently.  8.6.2 The C&F IMR describes a methodical process which, in June, initially led to an evaluation of the urgency of the referral as medium. That was appropriate at the time for C&F, whose principal priority would be the unborn child. However there was then a weak follow-up to that assessment. It does not seem that the “history” of the case – the previous involvement of Ms E with C&F services – was adequately researched. So, although SW1 had some knowledge of the background, it is not clear that the assessment was fully informed. The IMR states that “there was a missed opportunity at this point as considering the history and any likely impact on Ms E’s ability to care for her child would inform planning, future intervention and (would have) provided a more robust Core Assessment”.  8.6.3 In September 2012 the LSCB launched a local protocol providing guidance to staff involved in pre-birth assessments such as this. The Board will need to evaluate how far and how effectively that protocol continues to be embedded in the agencies’ practice.  8.6.4 When the case was re-referred following the birth of Child D the response by C&F was not methodical. Initially C&F agreed to carry out a further assessment. Then that decision was overturned, on the basis of the previous Core Assessment – an inappropriate decision which was not based on a clear evaluation of the situation. It seems patently unwise to decide not Page 41 of 69 to re-assess a new mother, with all the problems Ms E had experienced, in the face of re-referrals from several medical and nursing professionals.   8.6.5 The IMR from C&F refers to the establishment of the Multi Agency Safeguarding Hub (MASH) – a service development being implemented in many localities, where professionals from the key agencies – C&F, police, health and adult social care – are co-located and jointly evaluate and prioritise referrals. These arrangements might have ensured more effective communications between all the agencies in dealing with the presentation in May -  although health services, and adult social care services were not at that time part of the MASH in the council.  8.7 Were assessments appropriately child focussed?   8.7.1 Following the birth maternity services give a good account of monitoring the child’s physical well-being: “The baby was closely assessed. The baby was weighed three times. The mother demonstrated clear understanding of feeding and the baby was putting on weight. When the baby had a Guthrie test the mother showed concern by comforting (the baby) … (The) midwife had very clearly documented this. The baby had been seen three times naked while being weighed. There were no untoward markings noted on the baby and mild nappy rash reported at the last visit. Ms E was advised to treat with sudo-cream and if no improvement to go to GP for further advice”.  8.7.2 The Core Assessment carried out by SW1 did not drill down into the detail of how Ms E would be able to manage the demands of looking after a new baby. An over-optimistic view was taken, a factor frequently identified in SCRs: “The rule of optimism rationalises evidence that contradicts progress - so even where the facts show that risk is ongoing or increasing, professionals tell themselves that the opposite is true”22. As discussed above the decision not to carry out a re-assessment by social workers once the child was born suggests a lack of focus on the new baby. The one face to face contact between the EIS service and the family was thorough and reflects the strength of that service, and of the individual officer involved.   8.7.3 The assessments by mental health services lacked any focus on the child. The IMR describes how “there is no evidence of ‘Think Family23’ in the context of her potential for self harm, access to support in the community or her past history. There was no liaison between the psychiatrist with the ante natal services or with Children’s Social Care”.   8.7.4 The involvement of health visiting services is a more mixed picture.  “Once Baby D was born, HV3’s statement clearly highlighted her concern for the newborn and HV1’s CAF referral was similarly focussed on the child”.   However “HV2 who undertook the first visit did not adequately assess the risk to the baby and was more focussed on support for mother”. 22 Haringey LSCB – Key Messages 23 Think child, think parent, think family – SCIE, March 2012 Page 42 of 69                                              8.7.5 These accounts again illustrate the difficulty posed to agencies by Ms E’s presentation. The most serious failure was that agencies did not collaborate in a joint assessment to form the fullest, best-informed picture of her capabilities, and the degree of support she would need. This is particularly worrying given that she was compliant and receptive to help and support.    8.8 During Child D’s life before the incident, were communication, support and the assessment of risk effective?  8.8.1 As described in the previous section of this report the assessment of risk by all agencies was not sufficiently well-informed or thorough. The issue of inter-agency communications is considered below. Some of the support provided and the interventions of some individual professionals were of a good standard but, based as they were on an inadequate understanding of the overall situation, could only have a limited effect.    8.9 On the day Child D sustained the injuries, and subsequently, were there any communication problems between agencies?   8.9.1 Child D was injured on a Friday. During that day: • Ms E took the child to the GP because of severe nappy rash. • The GP prescribed cream to treat the nappy rash and asked that the baby be brought back on Monday. • The GP and HV2 discussed the situation: HV2 was already planning to visit on the Monday and felt that it was not necessary to bring that visit forward. • EIS1 carried out her scheduled initial assessment. Ms E confirmed that she had not been taking her prescribed anti-depressant medication. • The GP and EIS1 shared information about their contacts with the family that day. The GP decided to make a referral via the designated referral number. EIS1 said she would make her manager aware of the GP’s continuing concerns. • EIS1 spoke to her manager. The manager has not made a note of any advice given to EIS1. • The GP contacted C&F via the designated referral number and was asked to submit her concerns in writing. • There was a conversation between the manager for EIS1 and the manager for the C&F designated referral number service. That manager advised that EIS1 should have taken the information from the GP and shared it with colleagues within C&F, rather than suggesting the GP should contact the designated referral number. • No further action was taken that day within C&F. • After “office hours” the GP submitted a written note of the information she had already passed on. • Some time later that day Ms E inflicted the injuries which have led to this SCR  Page 43 of 69 8.9.2 Despite its tragic conclusion, in many ways the communications on that day were better than at other times during the period under review. The GP, HV and EIS1 shared information promptly and appropriately. On the basis of how the case had been handled thus far they reached a reasonable set of agreements about how the matter should be taken forward. EIS1 shared the GP’s concerns appropriately with a manager.  8.9.3 I would not have expected any agency to take further action directly with the family that day. Although Child D now had a severe nappy rash, and the GP’s concerns were appropriately growing, there was no indication that an “emergency” response was needed. The key errors had been made months previously, when agencies commenced their involvement in Ms E’s pregnancy, failed to assess the reality of the risks to mother and child and failed to put in place arrangements to communicate and work together to manage those risks.  8.9.4 There is some room for improvement in the agencies’ actions that day. The manager for EIS1, in what was a high risk situation, should certainly have made a written record of her involvement and advice. The GP should have been given a clear message about what C&F would do in response to her referral.  8.9.5 There were weaknesses in communications after the injuries came to light. The Health Visitors note that they were not contacted by the hospital to which the baby had initially been admitted and only discovered what had happened as a result of a routine police 24 notification. The Named Midwife was not informed by the hospital or by the Named Professionals in the hospital. It is not clear why communications were insufficient after a serious incident but the Board is asked to clarify its guidance to and expectations of key professionals in such circumstances.  8.10 How well did all the agencies involved work together - was there good mutual understanding and communication?   8.10.1 This was largely not a situation where agencies were in dispute. As discussed in the next section of this report the absence of dispute and challenge between agencies is a more concerning feature. However it cannot be said that there was “good mutual understanding and communication”.  8.10.2 C&F misjudged the situation and did not identify that there was a need for more structured liaison and planning. That might have been evident almost without seeing Ms E, purely on the basis of her history and the nature of the agencies already involved. Instead there was an assumption, based on insufficient evidence, that the involvement of other agencies excused C&F from drawing those agencies together. As the lead child protection agency that is what they should have done.  24 These are the routine notifications to social care and health by the Police Service of children coming to their notice  Page 44 of 69                                             8.10.3 Some good work was undermined by the lack of liaison with other agencies. HV1 proactively visited Ms E during the pregnancy and spoke to SW1 but did not liaise with midwives or the GP. “Good practice would have dictated that the HV liaised with her own health colleagues to ensure they were updated on the latest developments rather than to allow a third party (especially one that was not a health practitioner) to do it for her. If she had done this, she would have discovered that the midwives were not visiting her and she may have elicited a more meaningful history about Ms E from the GPs”.  8.10.4 Some liaison was rendered less effective because of a lack of process.  “N1 provided support to Ms E and accompanied her to numerous appointments and follow-ups. N1 liaised with Children and Families, the CMHT and the Safeguarding Leads for Health Visiting and Midwifery.  However, it is not clear what information was shared and …N1 had made an assumption that the Mental Health Team would be taking over the case when they closed it”.  8.10.5 The mental health services’ IMR makes a similar point: “The assessment and support plan for Ms E should have highlighted that this was a case involving the level of complexity requiring it to be initially managed under the Care Programme Approach. Ms E clearly needed social support and a pre-birth planning meeting would have explored this with other agencies”.   8.10.6 Adult Services note that communications might have been improved had they been more direct and sustained: “As with the involvement of the Reablement team, there may have been different outcomes, in respect of contacting Children’s Services again, if discussions had been undertaken with the GP and with Dr L following the conclusions of the assessment”.  8.10.7 Communication between agencies and individuals is fundamental to all effective safeguarding. The need for professionals to be talking to each other here was evident if only because of the number of agencies involved. One would expect the cause for concern to be recognised by all the agencies which had a continuing involvement – perhaps particularly by the GPs and maternity services, where there was very regular contact and therefore a regular reminder that a child was involved.  Instead there was little evidence of any inter-agency liaison.  8.11 How effective was management oversight both before and after Child D’s birth? Were concerns escalated when that was appropriate?  8.11.1 The weakness of the Core Assessment by C&F was not picked up by management processes within C&F. It appears to have been signed off by a manager without any question or challenge, despite being fundamentally flawed in not tackling key issues and the fact that not all of the other agencies involved had been contacted. That is of particular concern when the decision by C&F to take no further action relied on input from those other agencies. Page 45 of 69  8.11.2 That input was principally to be provided by mental health services but there were also problems of management oversight within that service. As set out above the mental health assessment carried out was weak and there was no adequate process for quality assuring the work of the psychiatrists.  8.11.3 Similarly, in the Learning Disability service, “During the time that the case was with the LD service there is no evidence to suggest that there was any management oversight”.    8.11.4 The lack of purpose and direction in the maternity services’ involvement is amply evidenced and was not questioned by any other service.  8.11.5 Professional escalation processes – that is, the arrangements for involving more senior officers when professionals cannot reach agreement – let Ms E down mainly after the birth of Child D. Before that the greatest systemic weakness was the overall absence of communications and the consequent failure by professionals to identify that there were weaknesses in the response of other agencies.  8.11.6 After Child D was born health visitors and the GPs were dissatisfied with the decision by C&F not to become involved but did not challenge that by talking to managers. The GPs’ contact with the designated referral number  was well-intentioned but a more appropriate response, given the previous history, would have been for the GP to speak directly to a more senior officer within C&F.  8.11.7 There are escalation processes in place locally and the local  Child Protection Procedures also provide guidance on this. Nonetheless it is an operational reality that professionals need to be routinely and regularly reminded that these arrangements are in place and should be used.  8.12 What issues are there of support relating to learning disability and mental health concerns in this review?   8.12.1 These matters have been addressed principally in the sections above, 7.3 and 7.5, which deal with the lead agencies for those services. Generally there seems to have been little well-informed understanding across other services of the diverse nature of learning disability and mental ill health. The extent to which agencies operate without reference to each other, and view aspects of need narrowly from the viewpoint of their own discipline is a common feature in Serious Case Reviews, and is manifest throughout the events under review here. Page 46 of 69  8.13 Are local services appropriately using best practice models for safeguarding unborn and very young babies?   8.13.1 The simple answer to this question is, from the evidence of this case, that they are not. Unlike many safeguarding situations the antenatal period gives an opportunity for professionals (and families) to work together to plan how the parent(s) and new baby can be best supported. Agencies can assess the situation, identify risks, evaluate the capacity of parent(s) to safeguard the baby, work together and share information so as to ensure the best planned and co-ordinated arrangements for supporting the new situation. This was a very significant missed opportunity in this case, particularly as this was not a non-compliant parent, but someone who demonstrated a willingness to be involved with agencies.  8.13.2 Research by Ofsted25, evaluating over 400 Serious Case Reviews, found that babies less than one year old had been the subject of a high proportion (35%) of those reviews. Each one of the headline findings of that research has a correspondence with this case: • “there were shortcomings in the timeliness and quality of pre-birth assessments • the risks resulting from the parents’ own needs were underestimated, particularly given the vulnerability of babies • there had been insufficient support for young parents • the role of the fathers had been marginalised • there was a need for improved assessment of, and support for, parenting capacity • there were particular lessons for both commissioning and provider health agencies, whose practitioners are often the main, or the only, agencies involved with the family in the early months • practitioners underestimated the fragility of the baby”.  8.13.3 It is particularly disappointing to learn that the local authority does have some targeted arrangements for these vulnerable children: “(A) model of best practice is provided through a comprehensive “Parenting Programme when working with mothers of unborn and very young babies”.   It appears that no professional considered that this service could have been of benefit during Ms E’s pregnancy.  8.13.4 Although there was no local protocol in place at the relevant time the local Child Protection Procedures very clearly set out arrangements for protecting unborn children. They stress the need for early intervention, which could certainly have happened here: “concerns should be addressed as early as possible before the birth” These procedures are straightforward and helpful. They were clearly relevant in this situation. It is of concern that no agency appears even to have considered their implementation. As suggested above awareness and use of the local protocol and this guidance will now need to be tested. 25 Ages of concern: learning lessons from Serious Case Reviews Page 47 of 69                                              8.14 Were there any organisational difficulties within or between agencies?   8.14.1 The review has identified that: • There had been significant large-scale reorganisations which have affected some of the health services involved in this case. • There had been a large-scale reorganisation in the C&F service which was continuing to affect services during the period under review. • There is an apparently unresolved history of discord between professional groups within the Learning Disability service. • The psychologists in the Learning Disability service took far too long to assess Ms E’s IQ and even longer to make a record of that assessment, without any target timescales. • Supervision arrangements in a number of services were unsatisfactory. • There was uncertainty among services about the role and functioning of the designated referral number arrangement. • The perinatal service was operating an inflexible arrangement for dealing with “early” referrals.  8.15 What LSCB quality assurance processes could provide timely overview of services to vulnerable children and parents?   8.15.1 The Board will want to avoid “re-inventing the wheel”. There is a huge amount of research and guidance already developed in this area. The guidance is increasingly focussed on real “well-being outcomes” – whether and how children are actually safer as a result of what the Board and its constituent agencies do. Ways of gathering evidence about the quality and quantity of services and the outcomes of those services are being continuously improved.  8.15.2 Agencies are developing ways of breaking down the overall task into categories, perhaps using this approach which draws on the work of the local Safeguarding Children Board: • Practice - issues such as priority services, specific risk issues or vulnerable groups • Practitioner - issues such as relationships, workforce development, supervision and organisational culture. • Environment / Context - issues such as poverty, housing and social deprivation  8.15.3 Within those areas various combinations of techniques and methods – external peer review, “deep dive” analysis of identified priority areas, staff audits, service user feedback arrangements – can be programmed to provide diverse and well-informed information. The LSCB’s Business Plan will already have identified local priorities to be taken into account.  Page 48 of 69 8.15.4 Serious Case Reviews will obviously form an important part of these arrangements – and Boards are now26 encouraged to apply similar approaches to cases which have not met the statutory criteria for a SCR. While acknowledging that SCRs are usually only about one case, they do allow for a very intensive examination of multi-agency professional practice within that case. They are exercises which require significant resources and the best use needs to be made of what they produce.  8.15.5 SCRs have been criticised for repeatedly identifying the same lessons to be learned. Clearly we should not be complacent about that, and this report does not in any way seek to excuse basic failures in professional practice and organisational rigour. But it is a reality that safeguarding children and vulnerable adults is complex and challenging, and there are many ways in which things can go wrong. It would be a significant error to assume that the “same old mistakes” will not recur. The challenge lies in devising the most robust and reliable arrangements for anticipating and identifying those weaknesses within and between local services. The dissemination to local agencies and their key staff of the “lessons learned” from this SCR should serve as a reminder of how basic some of those service weaknesses can be.  8.16 Where can we identify good practice in this case?   8.16.1 Under previous arrangements for evaluating SCRs Ofsted27 suggested that the “best” reviews would identify “Good practice… with… potential for wider implementation”. Some agencies and individuals – principally GPs and the Learning Disability professionals - demonstrated a continuing commitment to Ms E. Some agencies have responded promptly and vigorously to issues arising from the review – Health Visitors are ensuring that they always see a baby undressed at visits, the perinatal mental health service has adopted a more proactive approach to early referrals. However the review has not identified any examples of innovative practice which could be flagged up for implementation elsewhere.  8.17 What outcomes are envisaged from the recommendations from this review?   8.17.1 The key outcomes are probably those which SCRs repeatedly seek to promote: • Early support arrangements for children and families which respond flexibly to their needs and which focus on the child. • A better understanding of the enduring effects of abuse and neglect in childhood and their consequences for parenting. • Assessments which recognise the complexity of family situations, including the position of “absent” fathers. • Agencies taking a more open approach to their responsibilities and displaying a real commitment to working together. 26 Working Together 2013  27 OFSTED SCR Descriptors January 2009 Page 49 of 69                                             • More thorough and reliable work by individual professionals. • More consistent and productive communications between agencies and professionals, and a better understanding of other agencies’ responsibilities, especially between adults’ and children’s services. • An understanding of when and how to escalate concerns about other agencies’ practice.  8.18 How can the LSCB ensure that recommendations have an impact? Are there implications for training – single agency and multi agency?   8.18.1 The national biennial report28 on SCRs considers the issue of recommendations in depth, reflecting mixed opinions: “Some respondents indicated that the analysis of outcomes of recommendations and action plans is the only way of knowing the impact on practice; others were concerned that emphasising recommendations and action plans was too simplistic, casting doubt on the fact that the impact on practice was necessarily measurable”.  8.18.2 The biennial report recognises the stultifying effect of a proliferation of recommendations, while accepting that there will, by the very nature of this process, be situations where recommendations are necessary and inevitable. Nonetheless it concludes that  “LSCBs should be less reliant on recommendations being the central plank of the learning process in serious case reviews”.  8.18.3 Some recommendations from this review are unavoidable: it would be inappropriate for the Board not to require some changes in aspects of practice demonstrated here. Where recommendations are made they should be supported by a continuing and robust process of monitoring, measuring and responding, supported by targeted training, staff development initiatives and user feedback.  9. SERIOUS CASE REVIEW PROCESS  9.1 Some of the agencies involved in this review failed to meet timescale targets during the review process. The Review was initiated in December 2012 and it was not possible to bring a report to Board until January 2014. Although a relatively large number of agencies had been involved, across both children’s and adult’s services, for most of those agencies their involvement had been limited and their final reports were not lengthy documents.   9.2 Working Together requires that SCRs should normally be completed in six months unless they are particularly complex. That complexity often arises when several localities are involved, or the review needs to consider more than one child. There were no such factors in this case. There were no delays in producing this Overview Report other than those caused by the agencies. The SCR Panel reviewed the compliance with timescales of all agencies and found a number of explanatory factors. These included pressures on 28 Building on the learning from SCRs 2007-2009 Page 50 of 69                                             resources and capacity, illness of key members of staff, failure to follow the Terms of Reference or, for some health services, to consult appropriately with the Designated Professional, so that reports had to be re-drafted - and a simple failure to give the exercise an adequate priority.   9.3 Agencies have not awaited the conclusion of this review before addressing the issues which arise from it. Their action plans demonstrate work already in progress and completed. Nonetheless it is important that reviews and similar exercises are completed without undue delay and there is consequently a recommendation to the Safeguarding Board. Page 51 of 69 10. CONCLUSIONS: THEMES, MISSED OPPORTUNITIES AND LESSONS LEARNED  10.1 The review has identified a range of individual, agency and inter-agency weaknesses in the overall response to Ms E during her pregnancy and subsequently. Many of those weaknesses are often identified as causative factors in Serious Case Reviews. The Board will need to be reassured that agencies have accepted that the findings of this review indicate a need for significant improvements in the way they work with pregnant and vulnerable women.  10.2 Agencies had a great deal of information about Ms E. There were numerous indications that she would find it difficult to cope with the responsibilities of being a new parent. Those signs can be found in her childhood, when she had been abused and exploited, her mental health, her learning disability and her continuing isolation and lack of reliable support. Her presentation could be deceptive, so that she sometimes appeared more capable than was the case – but even that presentational issue had been identified and documented when she was a child. Despite this background agencies missed or under-estimated the consequent need to safeguard Child D.  10.3 Ms E did not always take the medication prescribed for her depression because, we believe, she experienced difficult side-effects. Otherwise she did not seek to conceal her contact with the various agencies and was entirely compliant with what those agencies required of her. She was not someone who was “hard to reach”. It is likely that a continuing supportive and educational relationship with an appropriate professional during the pregnancy – as was provided by the Early Intervention Service after the baby was born – would have enabled agencies to form a clear and early view of her parenting capacity, and the support she would need post-natally.   10.4 There was little professional interest in the father of Child D – who he was and how he might be able to support Ms E and the baby. He was seen as a protective factor without any attempt to understand the nature of the relationship between him and Ms E, and in the face of evidence that the roots of their relationship lay in the exploitation of a vulnerable young woman.  10.5 The fundamental failing was that agencies did not work together. Despite the number of services involved there was never any inter-agency meeting. Such a meeting could have been set up under a number of working arrangements – CAF, CPA or child protection procedures – but opportunities to do so were repeatedly missed. Any of the agencies could have initiated such a meeting but there was no attempt to do so. No agency used escalation arrangements to challenge the response of another agency.   10.6 The Panel has tried to understand how there could have been such a disconnected response to someone who clearly had multiple, overlapping problems. Key factors identified were that Page 52 of 69 • Ms E had so many difficulties that it was too easy to conclude that somebody else must be taking a lead. • Some services – particularly maternity and mental health – generally operated without adequate reference to other agencies. • Relationships between children’s and adults’ services were not well developed. • The Panel advised that local agencies historically and in general had not given sufficient priority to safeguarding.  10.7 Some key agencies – maternity, children’s and mental health services – seriously misjudged the situation in their assessments. These were failings of individual practitioners and their managers or supervisors as well as failures in working practices and systems within those agencies. Some of those mistakes were elementary – such as failing to consult adequately or at all with colleagues in other agencies. All the assessments relied on an unevidenced optimism about Ms E’s capacity to care for a baby.  10.8 Maternity services had the greatest amount of direct contact with Ms E but made little positive use of that contact. During the pregnancy there was no proactive liaison with other services. It is extraordinary that the maternity services should make safeguarding referrals to the local authority once the child was born when they had seen the mother frequently throughout the pregnancy. There was nothing unusual or unpredictable about the child to prompt a referral at that stage. The Review found insufficient evidence of alertness to safeguarding issues in this service. Local members of the SCR Panel described these problems in the service as “entrenched” and the review provided little reassurance that they might not recur.   10.9 The local authority needs to ensure that its arrangements for supervision and review are more reliable than is evidenced in this case. Although the Core Assessment was weak in its process and conclusions, it was still agreed without challenge or comment by a manager. After the child was born, although a manager had taken a counter-intuitive decision not to re-evaluate an assessment, that decision was not challenged or questioned.  10.10 Some agencies feel that the designated referral number arrangements were not working well at the time of these events. That is highlighted here, not because it was significant in this case, but because it should be a keystone of local safeguarding arrangements. The agencies need to be confident that the service is adequately resourced and that its purpose is clear.  10.11 The issue of whether or not Ms E had a learning disability was given too much weight in the agencies’ overall response to her. The consequences of her IQ assessment being of poor quality and reaching the wrong conclusion were far-reaching. But an even greater concern is the priority given to this part of the overall assessment. It symbolises the way in which Ms E was seen as a passive recipient of services rather than an individual user of services. Then, because she did not fit neatly into the way that services are configured and delivered, no service “owned” her and no agency gave adequate weight to the implications of her pregnancy. The consequences of this in this case were Page 53 of 69 extreme but it will not be unusual that vulnerable young people fall between various sets of eligibility criteria. This needs to be factored in to the commissioning of services generally.  10.12 In recent years a number of key services in this review have been through one or more major reorganisation and / or transfer of responsibility between “parent” agencies. Some of the agencies have specifically identified lack of organisational stability as a factor in these events. Issues of conflict between teams and services have been identified.   10.13 The review has tried hard not to allow judgments to be over-informed by hindsight. The Panel felt that there were clear indications throughout the period under consideration of a need for a robust, collaborative approach to protecting Child D and supporting Ms E, and of the potential risks in not taking such an approach.   Page 54 of 69 11. SERVICE IMPROVEMENTS MADE BY THE AGENCIES  11.1 All agencies have accepted the major concerns arising from this review. Because it is being finalised over a year after the injuries to Child D agencies have already taken many steps to improve their services in response to the matters identified in this report. More than 200 staff have attended training sessions based around the lessons to be learned from this review.   11.2 Those agencies most significantly involved in the case were asked to provide a summary of the major service improvements made and planned, and they have provided the information set out below. The Action Plan in response to the specific recommendations from this Review is provided separately.  LOCAL SAFEGUARDING CHILDREN BOARD  Multi agency feedback seminars on learning from this SCR began during the summer and continue. There was a seminar for all staff on working with fathers in December 2013. Networking meetings have been further developed by the LSCB to include health and education staff meeting with social care workers. In October 2013 there was a networking event for those who work with adults and those across the partnership who work with children, to look at joint protocols. The LSCB published multi agency guidance on thresholds for intervention in January 2013 and there are regular LSCB multi agency audits which review this.  GENERAL PRACTICE  Training is taking place for all GPs on key issues arising from the Review. Delivered by the Named GP for Safeguarding and the Designated Health Professionals, that training addresses information sharing, quality of referrals to Children’s and Adults’ Services, and understanding of roles and responsibilities. All surgeries are being encouraged to identify lead GPs for vulnerable families and for case files to be flagged.    NHS FOUNDATION TRUST    Mental Health The perinatal service now works to a new NHS England specification for Mother and Baby Units. The service now admits women much earlier in their pregnancies and proactively follows up women who are referred before admission is appropriate. The service is working on an action plan that will allow for them to be registered through the Royal College of Psychiatry. A system of shadowing between mental health services and children’s social care staff is now in place.  A review of systems in place in the county has taken place to ensure clinicians are making full entries into electronic records and that paper records cease; this will be audited. An audit of safeguarding training attended by psychiatrists is planned.  Page 55 of 69  Learning Disability   The practices of the local Learning Disability Team have been reviewed and will be audited. The LD team now has a weekly documented professionals / clinical meeting to discuss new cases, consider how a lead professional is identified and a coordinated approach for the client is best provided. Consideration has been given to the team moving to one site. Training is being reviewed this autumn and gaps identified and filled.   The team is now using an evidence-based assessment tool (the WAIS Assessment Tool) when undertaking eligibility assessments. Those cases assessed with the previous inaccurate tool have been audited and liaison with Children’s Services has been initiated as necessary.   Eligibility assessments are completed within two weeks of referral. Feedback on the assessment can be given within 48 hours and a written report is provided within 4 weeks. This has been audited on 20 assessments. The team has reviewed how the voice of the person is addressed and captured in assessments so that records can demonstrate this. Patient satisfaction surveys have been completed. All senior professionals now have formal peer support or supervision in place. An audit has taken place of the supervision schedules since April 2013.   HEALTH VISITING SERVICE  Health visitors ensure they are seeing new babies undressed in new birth visits and babies are being weighed unclothed. Work is ongoing to review pathways of communication at intra and inter-agency level. Health visiting links with GPs are now in place to improve the flow of information.   Record keeping training was delivered to health visitors and school nurses on 18/3/13 to ensure only one set of electronic records is being kept, family members’ records are linked, relevant male adults are registered and linked to families, and all correspondence and CAFs are uploaded onto the electronic file. Guidance has been given that all alerts on Rio (an electronic patient record system) are turned on appropriately and removed when no longer relevant, and that all liaisons with other practitioners are followed up in writing in a secure manner. The Named Nurse for Safeguarding has written a template of prompts for reports for writing records, which has been circulated to staff.   A Safeguarding Supervision Policy has come into immediate effect, so that all practitioners bring concerns about any vulnerable children to supervision, not only those subject to child protection plans. Safeguarding children is to be an item on the Senior Management Team agenda, and representatives from Adult Services attend Safeguarding Children Meetings at least quarterly.  Page 56 of 69  NHS TRUST  Paediatrics  A safeguarding problem list and action plan is to be incorporated in existing discharge templates for the paediatric ward and postnatal unit.  Work is ongoing to strengthen the information sharing pathway between hospital and community, ensuring comprehensive discharge summary letters to GPs, appropriate use of the Liaison Health Visiting Service, and efficient and timely communication between acute and community Named Professionals.  The child protection medical assessment and report template should be used for every child protection case to ensure adequate assessment / documentation, and distribution of report to relevant professionals within health, social care, police and named professionals in the community. Child protection reports should be typed and send out by the Child Protection Office. There is an ongoing implementation of the safeguarding protocol in A&E to identify and safeguard vulnerable adults with children via on going staff training and awareness.  Maternity Services  Midwifery training has been reviewed and will be audited in January 2014 in regard to roles and responsibilities, multi agency escalations, and communication.  Whooley’s questions (a tool for screening for depression) are now incorporated into notes for completion at every visit and ante-natal appointment; this will be reviewed in September 2013 and audited in January 2014.   CAF training and awareness has been given to all midwives. Guidance is in place for shared documentation to encourage inter-professional documentation so that all agencies write in the maternity hand held notes or place a photocopy of their record in the notes to facilitate communication.  An internal review has begun into the role of the Vulnerable Women’s Team seeking to strengthen the role of the safeguarding lead midwife and team, and implement the SCR’s recommendations, overseen by the Director of Nursing.   Risk assessments have been strengthened to include hospital records to be available at bookings, documents of fathers, and family support networks, and ensuring all professional details are included in files. Psychosocial meetings have been strengthened, with cases being brought for discussion. Psychosocial meetings now have an action log to be reviewed at the next meeting, minutes are disseminated and discussed, and multi agency attendance has been strengthened. Midwives have committed to undertaking joint home visits with social workers.   Page 57 of 69 Regular quarterly midwives’ safeguarding supervision is in place, including group supervision; this will be audited in January 2014.  Accident and Emergency Services  A safeguarding problem list and action plan is incorporated into existing discharge templates on the paediatric ward and postnatal unit. The information sharing pathways between the hospital and the community are being strengthened, ensuring comprehensive discharge summary letters to the GP and use of the Liaison Health Visiting Service. The child protection medical assessment and report template should be used for every child protection case. Child protection reports should be typed and sent out by the child protection office. A safeguarding protocol in A&E to identify vulnerable adults with children is being implemented. All these initiatives are to be audited in January 2014.  LOCAL AUTHORITY  Children’s Services  Arrangements between agencies for working together on concerns arising before a child is born have been clarified and improved. A pre-birth “tool kit” has been circulated to enhance the LSCB pre-birth protocol. One of the Child Protection Chairs29 is the nominated pre-birth lead for the children’s workforce, providing advice to social workers undertaking pre-birth assessments and liaising with midwifery services. Children’s Services now attend psychosocial meetings at hospitals for pre-birth referrals and weekly meetings at the children’s ward.  There has been a very significant investment in staffing with an increase of 24 extra social workers.  The “front door”, the first point of contact with the public and other agencies, has been redesigned so as to involve professionals from other disciplines – teaching, health visiting and early years provision. Multi Agency Safeguarding Hub (MASH) screening meetings have been further developed involving an increasing number of local agencies. The functioning of the designated telephone number into Children’s Social Care is under review and there is an improvement in the management of calls.   There has been significant investment in improved arrangements to deliver better informed assessments, including a specific focus on the management skills needed to drive up the quality of those assessments. Assessments are allocated to social workers who will then keep the case where it requires longer term work, providing better consistency.   Work is ongoing in Children’s Services to recruit and retain a skilled workforce and support has been given to encourage good quality core assessments, 29 An officer with specialist expertise in child protection Page 58 of 69                                             including analysis, understanding of risk factors, understanding the role of fathers and men in families and households, and planning. The supervision of staff has been a key service improvement target with enhanced arrangements for individual staff, including managers, and across whole teams.   Working arrangements between agencies have been further improved by a programme of staff secondments and regular inter-agency meetings of managers and specialist staff. Joint work with adult services is being progressed following a positive workshop between Probation and Children’s Services and the development of working protocols.  The role of the EIS and the links between the EIS and other services have been enhanced so that this service is better integrated with other children’s services. EIS now have an escalation protocol and a nominated Child Protection Chair to help develop their risk assessment and safeguarding awareness. The service is being supported by a specialist consultancy and staff have undertaken training in a range of key areas.  The local authority is beginning to draw together performance data arising from these new arrangements and has evidenced improvements across the service, particularly in relation to revised inter-agency arrangements for thresholds for intervention. The number of assessments has increased by over 50% from 2011-12 to 2012-13, and applications for court orders also increased by 50%. This combined with a decrease in re-referral rate and numbers of children subject to a child protection plan for more than 2 years demonstrates a change in the approach to thresholds for intervention.   Adults’ Social Care   An agreement regarding information access has been reached between Children’s Services and Adults’ Services.  Amendments have been made to the electronic record system and guidance on information sharing has been issued to relevant staff. Shadowing arrangements for staff between Adults Services and Children’s Services are being promoted.  A guidance note was issued to all relevant staff and managers in Adult Social Care to ensure that staff provide feedback to referrers, and referrers are then clear about any actions to be taken.   The LSCB “Escalation and Resolution of Concerns” protocol has been issued to all relevant managers and staff and discussed at team meetings. The file audit process now ensures that at least one case in every round of independent file audits includes a household known to Children’s Services.  A “Think Family” best practice forum was held for 60 Adult Services’ staff  members and managers in September 2013, including training on joint protocols relating to disability, mental health problems or substance misuse  concerns, and learning from this SCR.  Page 59 of 69 12. RECOMMENDATIONS FROM THIS OVERVIEW REPORT  12.1 Introduction  12.1.1 These recommendations arise from this Overview Report which reflects the views of the SCR Panel and the independent Overview Report author. They are all directed to the Local Safeguarding Children Board and have been endorsed by that Board.   12.1.2 In her reviews of child protection arrangements Professor Eileen Munro has referred to “the child’s journey30” – the journey from needing help to being protected. The LSCB and local agencies have adopted key themes from that work to drive forward service improvement and these recommendations are grouped around relevant themes.   12.2 Key theme – working together for the child  Recommendation1  The Board should require those agencies which have provided IMRs to this review to demonstrate that • The need to work with other agencies is routinely considered when providing services to families and individuals, and staff are familiar with the relevant arrangements for doing so. • Referrals between agencies are specific and adequately evidenced. • Arrangements for escalating problems to more senior officers are understood and appropriately used.  Background to this recommendation: this review has found evidence of fundamental failures in agencies’ understanding and application of routine arrangements for working with partner agencies. Referrals between agencies were not always made or were not clear enough in the concerns they sought to express.   Recommendation 2  The Board should develop multi-agency guidance to promote ways of helping vulnerable young people who may not meet the eligibility criteria of individual agencies and services.  Background to this recommendation:  There are young people whose vulnerabilities will not “match” the standard ways in which needs are assessed and the criteria for providing services. A flexible and integrated approach to this is needed.    30 Munro review of child protection: interim report  - The Child’s Journey Page 60 of 69                                              12.3 Key theme - Improving the quality of casework and managing risk to the child.  Recommendation 3 The Board should require those agencies which have provided IMRs to this review to demonstrate that their assessments are robust, well evidenced (including appropriate use of historical information and liaison with other agencies), carried out without delay and routinely reviewed. Assessments should be structured so as to respond to individual needs rather than to overarching eligibility criteria or to the way in which services are configured.  Background to this recommendation: the weaknesses in the overall approach to this case were clearly linked to assessments which were based on insufficient evidence, lacked analytical rigour or were not in keeping with current professional standards.  Recommendation 4 The Board should require the local Clinical Commissioning Group and the local NHS Trust to develop and agree a detailed and measurable action plan, (which will also be monitored by this Board), in response to the concerns about maternity services arising from this review. This may also have implications for other localities and the Board should bring this Serious Case Review to the notice of a neighbouring Local Safeguarding Children Board.  Background to this recommendation: the Review Panel was particularly concerned about the weaknesses evidenced in the involvement of maternity services in this case. There was a fundamental lack of alertness to safeguarding concerns and safeguarding arrangements.   12.4 Key theme - Developing good systems that keep children safe.   Recommendation 5 The Board should require the local authority to review the designated referral number service to ensure that it provides a swift and reliable way of registering concerns about children who may be in need of protection.  Background to this recommendation: the review was informed of concerns about the effectiveness of the local authority’s designated referral service, which provides the “front door” to safeguarding services.  Recommendation 6 The Board should ensure that this Serious Case Review is brought to the attention of the “Chief Executives’ Group”, a regular meeting of senior local decision makers. The Chief Executives’ Group should be made particularly aware of the consequences for the safeguarding of children of recent service reorganisations, and how these might be identified and mitigated.   Page 61 of 69 Background to this recommendation: the Review heard reports of concerns from a number of agencies about the destabilising effects of serial reorganisations and changes to management arrangements in some local services. There was no direct evidence that this was a significant factor in this case, and agencies generally reported that new service management arrangements were now settling in. Nonetheless the Board will wish to remain watchful.  Recommendation 7 The Board should, by dissemination to agencies of the findings of this review, emphasise the need to complete case reviews and similar exercises thoroughly and within target timescales. The Board should encourage agencies to develop further understanding of issues of diversity and equality.  Background to this recommendation: this has been the first Serious Case Review conducted in the borough for some years and there were some difficulties in the process of the review. Some agency reports did not meet deadlines. Most agency reports failed to address issues of diversity despite being asked specifically to do so.  Recommendation 8 The Board should ensure that there are reliable arrangements between agencies for sharing information after serious incidents.  Background to this recommendation: the Health Visitors were not made aware of Child D’s injuries by any other agency.Page 62 of 69 Page 63 of 69 APPENDIX B: anonymised Terms of Reference for the SCR     These Terms of Reference have been modified and anonymised so that they can be published as an appendix to the Overview Report.  Decision to conduct the SCR Child D, aged 3 weeks, was admitted to hospital with head injuries, suffered seemingly through shaking. Child D’s mother was known to adults and children’s services and health services before and during the pregnancy and following the birth.   It was decided that a SCR was necessary because: The child has sustained a potentially life threatening injury and serious and permanent impairment of physical health and development through abuse; (8.11 Working Together 2010) The child was seriously harmed following a violent assault perpetrated by an adult, and her chances of surviving without long term impairment are low; (8.11 WT) One of more agency felt that concerns about a child’s welfare were not taken sufficiently seriously, or acted upon appropriately by another agency. (8.12 WT)  Notifications of this decision were made to the Department for Education and to Ofsted in November 2012.  Existing Learning In October 2011, Ofsted published a report31 considering 482 serious case reviews carried out between April 2007 and March 2011. A large proportion of cases concerned babies less than one year. The key findings were:  Shortcomings in the timeliness and quality of pre-birth assessments; Risks resulting from the parents’ own needs were underestimated; Insufficient support for young parents; Role of fathers had been marginalised; There was a need for improved assessment of, and support for, parenting capacity; There were particular lessons for commissioning and provider health agencies, whose practitioners are often the main, or the only, agencies involved with the family in the early months; Practitioners underestimated the fragility of the baby.  National lessons from previous SCRs point to babies under a year being especially vulnerable. However, many of these reviews point to prevention having been possible.   The LSCB would wish this review to move beyond the findings which are found commonly in these SCRs, and suggest achievable best practice models 31 Ofsted  - Ages of Concern October 2011 Page 64 of 69                                             for safeguarding babies and unborn babies in the borough and would wish to challenge those agencies working with these most vulnerable children and their parents to adopt those best practices, if they are not already using them.    Key issues and questions this case raises The purpose of this SCR is to understand this case and consider whether professionals could have taken any other steps to support the mother and avoid the injury to the child. The purpose of this review is to establish what lessons can be learned from the case in which local professionals worked individually and together to safeguard and promote the welfare of children. It is essential to maximise learning that the child’s daily life experiences and welfare are at the centre of the review.     The SCR will identify how the learning will be acted upon by agencies and within which timescales, in order to improve safeguarding practice locally and provide learning particularly for work with vulnerable babies and parents.  The following questions are pertinent:  1. During the pregnancy, could more have been done to assess the mother’s needs and provide her with support?  2. Were the mother’s problems appropriately assessed and addressed across agencies, both recently and when she was in care and a care leaver? 3. How did assessments and interventions seek to understand and address issues of diversity, including those of ethnicity and disability in particular?  4. Did assessments take into account the mother’s relationships, support networks and their impact on her parenting? 5. Did the local authority’s triage arrangements have any bearing on how agencies responded to concerns? What form of triage should have been triggered once the referral concerns regarding the mother were received?  6. Were assessments appropriately child focussed?  7. During Child D’s life before the incident, were communication, support and the assessment of risk effective?  8. On the day Child D sustained her injuries, and subsequently, were there any communication issues between agencies?  9. How well did all the agencies involved work together – was there good mutual understanding and communication?  10. How effective was management oversight both before and after Child D’s birth? Were concerns escalated when that was appropriate? 11. What issues are there of support relating to learning disability and mental health concerns in this review?  12. Are local services appropriately using best practice models for safeguarding unborn and very young babies?  13. Were there any organisational difficulties being experienced within or between agencies?  14. What LSCB quality assurance processes could provide timely overview of services to vulnerable children and parents?  15. Where can we identify good practice in this case?  Page 65 of 69 16. What outcomes are envisaged from the recommendations from this review? 17. How can the LSCB ensure that recommendations have an impact? Are there implications for training – single agency and multi agency?  Period under review Enquiries and chronologies will cover the period from approximate conception to just beyond the key incident. This ensures focus on the baby and preparations for the birth and initial parenting, as well as interventions following the birth and communication between agencies following the key incident.   However, all agencies will construct a narrative summary from 2004, when the mother became looked after, to the period of the detailed SCR chronology, highlighting any salient issues which should be addressed under the SCR Terms of Reference.  Organisations to be involved in the SCR  Health Services Learning Disability Services,  Mental Health Trust.  Hospital – Maternity Services Hospital - Paediatrics, Acute Team and Accident and Emergency  General Practitioners Ambulance  Health Visiting services   Other services Children’s Services (Targeted Services, Early Intervention Services and Children’s Centre) Adults Services and Housing Services Police  Conduct of the review Agencies will construct a comprehensive chronology of involvement by their organisation and an analysis of involvement. Agencies will consider the events which occurred and which were omitted, to understand the decisions and judgements made. This will be from an individual practitioner’s perspective as well as the organisation they represent and the community of professionals they were involved with.  Interviews with staff members can be undertaken. The overview report will be written with a view to publication of the open document without redactions.   The independent Overview Report author, assisted as appropriate by a member of the SCR Panel will be directly involved in any contact with the family.   Parallel processes Page 66 of 69 The Police Service (Child Abuse Investigation Team) will liaise with the Coroner’s Office and Crown Prosecution Service as required.   Media interest The Police Service will take the media lead until criminal proceedings are determined. LSCB will then assume lead responsibility for any media issues.   Independent Chair and Author The Independent Chair of the SCR Panel will be LSCB Independent Chair.  The Independent Overview Author has considerable experience in conducting Serious Case Reviews.   The LSCB Board Manager will be the link person for the Independent Chair and Author and will coordinate this review.   Page 67 of 69     APPENDIX C: SCR Panel   Name / Designation Organisation Role  Independent Independent Chair Designated Nurse Clinical Commissioning Group Panel member Designated Doctor Clinical Commissioning Group Panel member School Governor Board Member LSCB Panel member Divisional Director, Early Intervention Services Children’s Services Panel member Divisional Director, Targeted Services Children’s Services Panel member Service Manager, Quality Assurance Children’s Services Panel member Assistant Chief Executive NHS Foundation Trust Panel member Head of Service  Adult Services Panel member Senior Lawyer Legal Services, Social Care and Education Panel Member  Independent Overview Report author In attendance Board Manager LSCB In attendance Administration Assistant LSCB  In attendance     Page 68 of 69 APPENDIX D: References  Footnotes have been used to indicate specific quotations from or references to research, practice guidance and other documentation. This Overview Report has been generally informed by the following publications  • Working Together  to Safeguard Children,(HM Government  2010) • The Victoria Climbie Inquiry (Lord Laming 2003) • The Protection of Children in England: A Progress Report  ( Lord Laming 2009) • Improving safeguarding practice, Study of Serious Case Reviews, 2001-2003 Wendy Rose & Julia Barnes DCSF 2008  • Analysing child deaths and serious injury through abuse and neglect: what can we learn – A biennial analysis of serious case reviews 2003-2005 • Understanding Serious Case Reviews and their Impact - a Biennial Analysis of Serious Case Reviews 2005-07 DCSF 2009 • Local Safeguarding Children Board – SCR Toolkit (2010) • Review of the involvement and action taken by Health Bodies in relation to the case of Baby P ( Care Quality Commission (2009).   • Learning together to safeguard children: developing a multiagency systems approach for case reviews. ( SCIE 2009) • The Munro Review of Child Protection: Final Report (HMSO May 2011) • The Munro Review of Child Protection: Interim Report (HMSO February 2011) • Publication of Serious Case Review Overview Reports: Letter from Parliamentary Under Secretary of State for Children and Families 10th June 2010 • Working Together to Safeguard Children (2010) • Working Together to Safeguard Children (2013) • Adult Protection Procedures • Self neglect and adult safeguarding (SCIE 2011) • Multi agency working and information sharing project (Home Office 2013)     Page 69 of 69 