Serious injury of a 7-month-old baby. Child W was taken into care on an emergency order following the incident and mother's partner was arrested on suspicion of assault. Before Child W was taken into care, family had made frequent visits to both GP and Accident and Emergency with concerns about Child W's health. Maternal history of: domestic abuse, depression, non-attendance at appointments for herself and her children and providing inconsistent information to professionals. Mother's partner had a history of: alcohol misuse and anxiety related illnesses. Identifies learning, including: agencies need to be more proactive to fulfil their safeguarding role; professionals need a wider understanding of the significance of injuries in young babies; agencies working with families should routinely enquire about and challenge adults where risks emerge about living arrangements, relationships and care; management and recording of strategy meetings needs to be consistent; communication within and between NHS agencies needs to be clearer; and there needs to be a way for agencies to flag known risks posed by adults without convictions.
      
 Title:  Overview report of the serious case review in respect of Child W. LSCB: Manchester Safeguarding Children Board Author: Hester Ormiston Date of publication: 2013  This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC.  This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above.                                    Overview Report of the Serious Case Review in Respect of Child W    MSCB Independent Chair: Ian Rush      This report has been commissioned and prepared on behalf of Manchester Safeguarding Children Board and is available for publication on the 30th September 2013.  i   Contents                 Page No.   Introduction ...................................................................     1    Overview of What Was Known.................................................  8    Single Agency Involvement ......................................................  10   Analysis ...................................................................  25   Summary ...................................................................  37   Challenges ...................................................................  44            ii  Glossary       A & E Accident and Emergency CCNT Children’s Community Nursing Team CCS Children’s Community  CHS Community Health Services CMFT Central Manchester University Hospitals NHS Foundation Trust CPS Crown Prosecution Service CSC Children’s Social Care DfE Department for Education DNA Did Not Attend FRT First Response Team (part of CSC) FWIN Force Wide Incident Number GMC General Medical Council  GMP Greater Manchester Police GP General Practitioner HV Health Visitor IMR Individual Management Review LSCB Local Safeguarding Children Board MNHS COR Manchester NHS Commissioning Overview Report MSCB Manchester Safeguarding Children Board NHS National Health Service OCD Obsessive Compulsive Disorder OOH Out Of Hours OPUS Operational Policing Unit System PAHT Pennine Acute Hospital Trust PPIU Public Protection Investigation Unit (Police) SCR Serious Case Review SCRSG Serious Case Review Subgroup TOR Terms of Reference WT Working Together to Safeguard Children          Page 1 of 46 1. Introduction  a. Circumstances that led to this Review  1.1 On 12th July 2012 MW (Child W’s mother) took Child W to Hospital 1 as the child had a swollen right foot. The foot was X-rayed and as no sign of a fracture was found Child W was discharged home. The X-ray was reviewed on 13th July 2012 when a number of healing fractures were identified.  1.2 DR16 (a radiologist) also checked a previous X-ray taken on 29th June 2012 at Hospital 2 when none of the current healing fractures were identified.   1.3 The recent history of medical intervention was that MW had taken Child W to Hospital 1 on 3rd June 2012 reporting that the child had sustained a bruise when the child’s seven year old half sibling (SS2) had let the child fall from the sibling’s knee onto a hard surface floor. Child W had vomited once but not lost consciousness. On examination there was a 2 x2 cm bruise right tempero-occipital region (right lower side and back part of the head) but there was no swelling. After four hours observation, Child W was discharged.  1.4 The next day MW returned to Hospital 1 (4th June 2012) and reported that Child W had vomited and she had seen blood in the baby’s mouth. A CT scan was normal and Child W discharged on 5th June 2012.  1.5 On 7th June 2012 MW returned to Hospital 1 with Child W reporting that the child was lethargic, irritable and not feeding. Child W was observed to be well but blood tests revealed a possible bacterial infection which was treated intravenously. Child W was discharged home on 10th June 2012, with daily administration of intravenous drugs for a further five days by the Children’s Community Nursing team (CCNT).  1.6 On 26th June following a consultation with GP3, MW took Child W to Hospital 1 for a paediatric assessment of a non-blanching rash to the leg and a swollen foot. A further course of intravenous antibiotics was prescribed to be administered by CCNT.   1.7 On 27th June 2012 SN4 from the Health Visiting team visited Child W at home as follow up to the visit to Hospital 1. MW gave SN4 a full description of the hospital visits and outcomes but said she was still concerned that there was no clear diagnosis. In view of the tenderness of Child W’s feet and the non-blanching spots, SN4 advised MW to take Child W to Hospital 2 for assessment.   1.8 On examination Child W was found to have a bruise on the right lower back and a swollen and tender left foot. The unexplained bruise and some of the history (reported bruise on Child W’s thigh three months earlier) led to referral for skeletal survey, ophthalmology assessment, medical photographs, urgent social service referral, safeguarding nursing referral, as well as medical examination for Child W’s half siblings. The skeletal survey was completed on 29th June 2012. It identified Page 2 of 46 compressed fractures to Child W’s left tibia two to four weeks old, and a possible chip to the bone of the left foot. A strategy meeting was held on 28th June 2012, but because of the absence of key staff a second strategy meeting was held on 29th June 2012. The outcome of the meeting was ‘no further action’ as MW had been consistent and appropriate and the bruise was considered as accidental. However it was also noted on the strategy minutes that Childrens Social Care (CSC) would complete a core assessment.   1.9 The review of the 29th June X-ray carried out on 13th July 2012 revealed a healing fracture on the first metatarsal and healing fractures on the 2nd to 5th long bones in the foot.  SW1 took MW and Child W back to hospital for a further examination by DR13. This identified that the child had a red mark to the side of the lip, a torn fraenum and a laceration in the genital area.   This was recorded to be an acute injury which was found to have fresh blood indicating a possible assault that had ‘happened today.’    1.10 At the strategy meeting it was agreed that the children, Child W, SS1 and SS2 (Child W’s half siblings) should be made subjects to police protection and that MW and MPW (her current partner) should be arrested on suspicion of assault.  1.11 A further strategy meeting on 20th July identified a further fracture to the left forearm bone.  1.12 The circumstances of the incident were considered by the Manchester Safeguarding Children Board (MSCB) Serious Case Review Sub Group (SCRSG) on 3rd August 2012 when it was recommended that an SCR panel should be convened. The Independent Chair of Manchester Safeguarding Children Board, Ian Rush ratified the recommendation on 4th August 2012.   b. Terms of Reference  1.13  Working Together to Safeguard Children (WT) 2010 states that any Serious Case Review (SCR) must do the following: • establish whether there are lessons to be learned from the case about the  way in which local professionals and agencies work together to safeguard children; • identify clearly what those lessons are, how they will be acted upon and what is expected to change as a result and as a consequence; • improve inter-agency working and better safeguard children.  1.14 The SCRSG agreed a number of key lines of enquiry which incorporate the expectations of Working Together 2010 as Terms of Reference (TOR). These were considered at a preliminary meeting of the Independent Chair of the SCR, the Independent Author of the Overview Report, the SCR Business Support Officer, the Chair of Manchester Safeguarding Children Board, a Consultant Paediatrician who was a representative from the SCRSG and the MSCB Media and Communications Manager on 13th September 2012.  Page 3 of 46  1.15 The TORs were amended slightly and it was agreed that MSCB would write to four neighbouring Local Safeguarding Children Boards (LSCBs) where previous partners of MW and MPW live to inform them of the SCR and to invite them to consider whether their area had any information that would be relevant to the TOR.  1.16 The agreed TOR are: 1. Review the decision making relative to Child W's marks and injuries observed between 30th April 2012 and the 13th July 2012. This to include marks or injuries observed during home visits and attendance at GP's surgeries and hospitals. 2. Review the apparent opportunities for challenging decision making and why this did not happen. 3. Evaluate the planning, recording and decision making at the strategy discussions on the 28th June 2012, 29th June 2012 and the 13th July 2012. 4. To what extent did agencies and services take account of issues such as: race and culture, language, age, disability, faith, gender, sexuality and economic status and how did this impact upon agencies assessment and service delivery? 5. To what extent, if any, did agencies communicate effectively and work together to safeguard and promote the continued well-being of Child W? 6. Establish whether there are lessons to be learned from the case about the way in which local professionals and agencies work together to safeguard children. 7.  Identify clearly what those lessons are, how they will be acted upon and what is expected to change as a result and as a consequence.  8.  Improve inter-agency working and better safeguard children.   1.17 Before any agency was asked to provide an Individual Management Review (IMR) a number of Manchester agencies were asked if their records held any relevant information about the children or adults considered in the review, within the timescale of the review. Neighbouring LSCBs were also contacted for information about the family (see paragraphs 1.33 to 1.36).  1.18 Those contacted includes all NHS providers in the Manchester area and NHS Direct, as well as: • Manchester Housing Department; • Sure Start and Early Years; • Manchester Education Department; • NSPCC; • MARAC;  • CAFCASS; • Greater Manchester Probation Service; and • Manchester Adult Social Care.  1.19 Correspondence was received from:  • Manchester Education Department; • NSPCC; • Christie Hospital;  • Greater Manchester West Mental Health NHS Foundation Trust; Page 4 of 46 • Manchester Mental Health and Social Care Trust.  Only Manchester Education Department provided some information which is included in Section 2 of this report.    c. Timescale for the Review  1.20 Events were reviewed from Child W’s date of birth until 13th July 2012 (date Child W and the half siblings were taken into police protection).   d. Membership of the Review Panel  1.21 The Serious Case Review Panel was made up of: • Detective Sergeant, Greater Manchester Police (GMP); • Deputy Designated Nurse, NHS Manchester; • Consultant Paediatrician,  Designated Doctor, NHS Manchester; • Interim Head of Safeguarding, MCC Children’s Social Care; • Project Team Manager, NSPCC; and • Independent SCR Chair.  1.22 The Independent SCR Chair was Mike Tarver and each meeting has been attended by the Independent SCR Author, Hester Ormiston, who wrote the Overview Report and Executive Summary. Mike Tarver is a registered Social Worker (Health & Care Professions Council) with experience of senior management of a wide range of local authority services spanning over 30 years predominantly in the fields of Safeguarding and Looked After Children. During this period he was Head of Child Protection in two inner city local authorities for 11 years where he had extensive experience of coordinating the work of Area Child Protection Committees including numerous ‘Part 8 Reviews’ for which he was the overview writer. Since 2006, he has worked independently as a project and Interim Manager and Consultant covering a broad spectrum of work in both Children’s and Adult Services across the North West. He has recent experience of chairing several serious case reviews and authoring Individual Management Reviews. He has been the appointed Independent Chair for a North West Safeguarding Children Board since January 2010.   1.23 Hester Ormiston is an Independent Consultant who completes work across the range of social care services. Miss Ormiston was a qualified Social Worker who previously worked in social work and social work senior management posts as well as the (previous) Social Services Inspectorate for 30 years. Miss Ormiston has previous experience of chairing an Area Child Protection Committee (as was), chairing Serious Case Review panels and as author of overview reports.   Page 5 of 46 1.24 Both Mr Tarver and Miss Ormiston are independent of all the agencies concerned and neither the Independent SCR Chair nor the SCR Author is employed by any local authority or agency, only undertaking commissioned pieces of independent work.  The panel has been supported by the MSCB Business and Performance Manager and the MSCB SCR Business Support Officer.   1.25 The Panel received IMRs for the following agencies:  • Children’s Social Care (CSC); • NHS Manchester (NHS); • Greater Manchester Police (GMP); • Central Manchester University Hospitals NHS Foundation Trust (CMFT);  • The Pennine Acute Hospitals NHS Trust (PAHT).   Each author of the agency Individual Management Review reports was asked to focus on Child W but also to take account of any historical, critical safeguarding concerns in relation to other children in the family and any known partners of Child W’s Mother.  1.26 A preparation session was held for the IMR Authors and the agency manager responsible for quality assurance on 4th October 2012. All IMRs have been prepared by staff or managers who have not had direct or line management contact with the families. Each one has been countersigned by heads of service or equivalent. The panel has considered each IMR, offered comments and following some revisions found them to meet the expectations of Working Together 2010.  1.27 The Serious Case Review Panel met on the following dates: • 12th September 2012; • 13th November 2012; • 6th December 2012; • 17th December 2012; • 8th January 2013; • 20th February 2013; and  • 12th March. Each meeting lasted between three and four hours.   1.28 The SCR was completed in more than six months from the notification to Department for Education (DFE) as one of the IMR authors became ill and it took some time to find a replacement author. DFE was notified of the delay on 14th January 2013 when it became clear the timescale could not be met. The draft SCR overview report was presented to MSCB on 11th April 2013 for consideration of how to respond to the challenges presented instead of recommendations. Following the Board it was agreed that the Overview Report would include the Board’s responses to the challenges within the report with a further delay until the end of July.   Page 6 of 46 e. Genogram   Each IMR contains the details of the family that were known to that Agency.  The complete genogram for the family is included below.                KEY:    Red Line      Maternal Line    Blue Line   Paternal Line    Black Line Subject    Green Line Subjects Step Siblings    Dashed Line     Separated  Child W Father to Child W (FW)  Father to Step Siblings (FSS) Mother’s Partner (at time of incident) (MPW)  Mother to Child W (MW)    Step Sibling (SS1)   Step Sibling (SS2)   Page 7 of 46 f. Family Involvement  1.29 At the commissioning meeting held on 13th September 2012 it was agreed that it would be appropriate to offer some involvement to family members. However it was recognised that there was the potential for criminal proceedings and that making contact might interfere with evidence. As the GMP investigation continued it was considered likely that MW would be a prosecution witness and so while the SCR Chair wrote to notify her that the review was taking place, no invitation to meet could be offered until either a trial had been completed or the CPS had recommended no further action.  1.30 Just as the review was near completion the Local Authority was given the formal record of a Finding of Fact hearing, held in March 2013, which arose from the Care Proceedings in relation to Child W and siblings. The panel Chair had been advised by the police representative that a final decision about any possible prosecutions in this case would not be made until the outcome of this hearing.     1.31 As a result of the Finding of Fact, CPS recommended no further action, all three children returned to MW on 28th May and so arrangements were made for the Chair to visit MW on 5th July 2013, accompanied by the MSCB Business and Performance Manager.  1.32 The meeting was distressing for MW as she had realised with hindsight that MPW could have injured Child W, to the extent that her children were in care for 11 months. She also now realises that staff in the two hospitals should have managed Child W's care differently and that the injuries to her child ought to have been identified sooner. MW conceded during interview that the children were regularly left in MPW's care but she never suspected him of harming them during this period.     Page 8 of 46 2. Overview of What was Known  2.1 Paragraphs 2.2 to 2.5 give information about the family members that was in agency records but was not known to the key professional staff who examined or made decisions about Child W in the timescale of this SCR. Paragraphs 2.6 to 2.13 give information about the family circumstances recorded during the timescale of the SCR.  2.2 MW had lived with three partners before her relationship with MPW began. One (FSS) is the father of SS1 and SS2 who lives with another partner and her two children in a Greater Manchester LSCB area. The housing records suggest that the new partner was pregnant in July 2012 but there is no other relevant information on the household. FSS has had no contact with SS1 and SS2 for several years (last known contact September 2008). A second partner was ExPMW but agencies have not recorded any significant details about him and the dates of him living with MW are not known.  2.3 The other ex-partner of MW is FW, the father of Child W.  Records indicate that after some significant domestic abuse from him, MW left FW and has not returned. He is not named on the birth certificate. FW has two children by a previous partner (born 2006 and 2009). He currently lives with PFW, her two children and two children from the partnership (born 2008 and 2011). From the dates of birth of FW’s children it seems that FW lived with MW for only a short while and his long term partner is PFW. The family has been known to Children’s Services in the LSCB area and there are three recent episodes of domestic abuse recorded by GMP in 2012.   2.4 MPW used to live with his partner (ExMPW) and their child (CExMPW) in another LSCB area. CExMPW has regular contact with MPW. ExMPW had reported one incident of domestic abuse from MPW and that he misuses alcohol. MPW had attended Accident and Emergency (A&E) in the LSCB area on 1st May 2012 with chest pains.  2.5 There are more detailed records of MPW in another LSCB area where his mother lives.  He is well known at the GP practice where he has been supported to manage his long term problems with anxiety, obsessive thoughts and alcohol use. He has completed a course of cognitive behavioural therapy to help him manage his Obsessive Compulsive Disorder (OCD) in 2011. He was allocated a high intensity mental health service in April 2012 but did not attend. The practice did not know there was a baby in the home of his current partner, but did know about CExMPW.  2.6 The medical history of SS1 and SS2 was recorded when the family changed GP practice in April 2012. The notes show that SS1 had visited the GP practice 11 times for immunisations, developmental checks and self-resolving illnesses (plus three Did Not Attends (DNAs) for immunisations) and had been taken to A&E eight times with two admissions for short term illnesses and two assessments by the Out Of Hours (OOH) service.  2.7 SS2 had been taken to the GP practice 15 times for immunisations or self-resolving illnesses (plus one DNA for immunisation). One contact resulted in the referral to the Eye hospital. The GP records did not show if SS2 attended the Eye hospital but had Page 9 of 46 noted four missed appointments with the Orthoptist. Additionally SS2 had two hospital admissions, one for the extraction of six teeth, the other for a non-specific illness and two presentations to A&E.  2.8 The number of NHS attendances is normal for children of these ages, but SS2’s teeth extraction is commented on in TOR 4.  2.9 The second GP practice knew that MW had a history of non-attendance, as that was the reason she had been asked to cease her registration with them in October 2010.  2.10 The Health Visiting (HV) service (CMFT Community Health Services (CHS)) had provided primary care services to MW for SS1 and SS2. On the first visit for Child W full records were made about FW, the reason for lack of contact with MW and her relationship with MPW. The records include that MW’s parents live nearby and support her. There is little information on the home with the only relevant comment being that the ‘home is noted to be clean and comfortably furnished, baby equipment seen in the living room’. Child W was noted to be clean and well dressed.  2.11 Manchester Education Department was the only ‘trawled’ agency with information about the family. The department passed on information from the school of SS1 and SS2. The summary noted that at times the children were absent or late to arrive. Both are achieving below the expected standard for their age, but are well behaved and both try hard. The information given about school attendance and parental involvement indicated there was no need for the agency to provide an IMR.  2.12 Within the timescale of the review MW, MPW and Child W were seen by a high number of staff from NHS agencies. This included two GPs, PN1 and the OOH service from NHS Manchester, as well as many staff from CMFT acute services, CMFT CHS services, and PAHT.    2.13 The IMR for the HV service is the only one giving the recorded family history of MW, and Child W. Other NHS agencies will have asked for recorded information about the family history but only noted the recorded information that focussed on the current presentation in the IMRs. Page 10 of 46  3. Single Agency Involvement  3.1 Greater Manchester Police (GMP)  3.1.1  The IMR was written by a detective sergeant from the Major Crime Review Unit and countersigned by a Force Review Officer.  The author’s role in conducting reviews includes an examination of practice to ensure that investigations are being managed effectively and that there is compliance with local and national policy; this review process should identify good and weak practice at an organisational level which will improve future investigative practice.   3.1.2 The IMR lists the sources of information as: Electronic records:  • The Operational Policing Unit System (OPUS). OPUS links with a number of other computer systems in GMP, such as the Public Protection Investigation System;   • The Cyclops Document Management System used in the Safeguarding Vulnerable Persons Unit and Public Protection Investigation Units (PPIU) to store investigation files and case conference files; • The Crime Recording System; • The Police National Computer.  3.1.3  The above databases have provided the IMR author with material relating to: • Relevant incident logs or FWINS (Force Wide Incident Numbers), which are created when an incident is reported to the police; • Relevant crime reports; • Relevant individual and address records of family members of Child W; • Relevant material held in the Public Protection Investigation System, such as investigation files and case conference files relating to Child W; • Material held in relation to previous Serious Case Reviews involving GMP.    3.1.4  The paper records used are: • Public Protection Investigation Unit (PPIU) records and associated documents relating to Child W; • Notes made by police officers involved in the PPIU investigations; • Police officers’ notes of strategy meetings held for Child W.  3.1.5  The author has also checked practice against the relevant policies and procedures, namely: • GMP Safeguarding Children Policy and Manual of Guidance 2010; • The National Crime Recording Standard 2002; • Working Together to Safeguard Children March 2010;  • PPIU Divisional Handbook March 2012.  3.1.6  As a result of reading the records the author has interviewed four staff members for some clarification of the detail. The staff members were: Page 11 of 46 • Police officers from a division of PPIU who were involved in potential non-accidental injury investigations relating to Child W; • Police supervisors from PPIU; • Police supervisors from the Public Protection Division.   3.1.7  GMP provides policing services to the whole of Greater Manchester and so have information on the database not only on MW and MPW but also on FW, FSS and ExPMW (previous partner of MW), PFW (a previous or current partner of FW) and ExMPW (the previous partner of MPW) and their child, CExMPW.  3.1.8  Prior to the timescale of the report GMP have a number of records relating to MW, her previous partners and MPW.              MW contacted the police: • Six times about damage to her property between July 2003 and May 2008; • Four times when FSS was at her property drunk, wanting access to SS1 and SS2 between May 2005 and September 2008 (after their estrangement); • Three times between June 2008 and July 2009 about a verbal threat of assault, theft of her mobile phone and ExPMW (when no longer her partner) arriving drunk and wanting access to the home.  None of these events resulted in arrests or further action.  3.1.9  GMP records on FW indicate convictions for dishonesty and violence from 1990. However the first incident of domestic abuse was when MW reported an assault in May 2011 when she was eight weeks pregnant. FW was prosecuted but the case was dismissed. MW has told the police that she has not seen him since this incident and he has not had access to Child W.  3.1.10  GMP records on MPW, other than the current arrest, are brief. When he was 14 years old in December 2001 he reported his mobile phone had been stolen. Prior to his relationship with MW there was one incident between MPW and ExMPW in May 2010 just after the birth of CExMPW. An argument between the two of them about MPW taking CExMPW to visit his parents had escalated. The situation was resolved by MPW leaving the house.  3.1.11 In the timescale of the report, other than three brief incidents involving FW, GMP only had contact with the family members when the strategy meeting was arranged on 28th June 2012. Two officers from GMP attended this meeting and the reconvened meeting on 29th June 2012.  3.1.12 Following the second strategy meeting it was confirmed to the supervising officer (DS1) that there was no evidence to support a police investigation. The GMP records note the bruise to Child W’s back was accidental and the fracture found on the skeletal survey was consistent in age and explanation with Child W having been dropped accidentally by the half-sibling. The rash on the feet was considered to be viral allowing discharge after the strategy meeting. Page 12 of 46  3.1.13 The next contact was attendance at a strategy meeting on 13th July 2012. A different officer attended from GMP. The officer having heard the details of the current injuries and the healing fractures from the skeletal survey agreed with the outcome to make the children subject to police protection and for the arrest of MW and MPW.  3.1.14 The IMR is concise and presents the information clearly and objectively. The key area of learning relates to not challenging the medical opinion based on inconclusive medical evidence in the strategy meeting. The author observes that it is difficult to challenge when a decision to take any further police action hinges on medical evidence but GMP still have a responsibility to take part in a Section 47 investigation as appropriate.  3.1.15 The other issue raised in this SCR relates to the recording of the strategy meetings. The IMR author attached three appendices, an extract from the PPIU Handbook which complies with WT 2010, and two versions of paperwork used by GMP when an officer attends a strategy meeting. Although there are recording formats some officers choose to record in their daybooks. This variation is unacceptable; a point which has already been made in a previous GMP IMRs (Manchester 2007 and 2008, and Rochdale 2009) and is discussed in detail in TOR 3.   3.1.16 The GMP IMR has one recommendation, to agree one format for the force to use for internal records of strategy meetings.  3.2 Children’s Social Care (CSC)  3.2.1   The IMR was written by the Central Area Safeguarding Manager and the Central Area Assistant Safeguarding Manager and countersigned by the Assistant Director, Safeguarding Provision. The authors used the MiCare electronic case file records to prepare the report. One author also interviewed SW1, AP1, TM2 and AP2 and had a telephone discussion with SW2. Following the interview with TM2, further information was submitted to the authors by e-mail.  3.2.2 Other than a record of the incident when FW was reported to have assaulted MW when she was eight weeks pregnant, the first contact for CSC was notification that Child W had an unexplained bruise and had been admitted to CMFT on 28th June 2012. The admission was related to possible meningitis but CSC began the process for assessment with allocation to SW1 and arranging a strategy meeting for that afternoon.  3.2.3 Cons1, who had asked SN1 to contact CSC was unable to attend the meeting and had not completed the paperwork, so the meeting was unable to make a clear decision. All agencies present agreed to a working arrangement for SS1 and SS2 to stay with MW’s father, while MW and her mother stayed at hospital. The meeting was chaired by SW2 in the absence of a team manager or advanced practitioner; she was the most experienced social worker available but this was not compliant with the MSCB or CSC procedures. Page 13 of 46  3.2.4 Following the strategy meeting TM2 telephoned Cons1 expressing concern that the bruise could not be explained by the incident of being dropped and checked that a full skeletal survey would be available for the re-arranged strategy meeting on 29th June 2012.  3.2.5 The second strategy meeting which was chaired by AP1 reached agreement; (although the notes indicated a further possible historical injury of a chip on Child W’s left foot and an injury to the back of the left knee); that there was no reason for further investigation. SW1 as the allocated social worker began a core assessment on 5th July 2012.  3.2.6 MW contacted SW1 on 10th July as she was still concerned about Child W’s swollen feet. SW1 advised her to seek further advice. The next contact was the request to arrange the strategy meeting on 13th July 2012.   3.2.7 The strategy meeting discussed all the current and historical injuries. As SS2 was at the hospital, the child was asked about the occasion when Child W was dropped. SS2 said Child W had landed on the head and so this incident could not have caused the bruise, chip or fracture discussed on 29th June.  3.2.8 The IMR raises the relevant issues. The strategy meeting arranged for 28th June did not include information from the GP practice and only partial information from Hospital 1. There was incomplete information about MPW, and on the basis of MW saying she never left Child W, the meeting considered only MW as a possible perpetrator. At the time of the June meetings, although old enough, SS1 and SS2 were not interviewed.  3.2.9 The strategy meeting of 29th June became diverted by discussion of the cause of the bruise and did not discuss the swollen foot. This was important as Child W was non mobile and so all possible causes should have been discussed. Cons2’s view that ‘on the balance of probabilities’ the injuries were accidental was accepted without challenge. Although the IMR states that AP1, the chair of the meeting, knew the meeting had been reconvened, the IMR states that she did not have the notes from the meeting on 28th June and did not know it was a different consultant who had raised concerns the previous day. The panel were concerned that this may not be accurate as there would have been some introductions made at the meeting and TM2 must have had the notes the previous day prior to the phone call to the hospital about the skeletal survey.   3.2.10 The format for recording a strategy meeting does not give prompts to ensure all relevant enquiries have been made and this allowed the meeting to be led to a view of probable accidental injury as suggested by Cons 2. The meeting did not discuss the concerns of unexplained bruising that led Cons 1 to ask for the strategy meeting.  3.2.11 In March 2012, all relevant CSC staff were circulated with the requirements for the recording of strategy meetings. This included the expectation that the notes of a meeting would be copied and circulated to each agency within 24 hours, and entered Page 14 of 46 on to Micare within seven days. For these two strategy meetings, the notes were entered onto Micare, but not copied to other participants.  3.2.12 The IMR identifies some key areas of learning: that it is essential that the chair of strategy meetings must be prepared to cover all relevant areas of enquiry and if necessary challenge medical opinion. This should include a greater understanding of the range of opportunities for perpetrators and wider exploration of the family history and relationships.  3.2.13 The factual information in the IMR is clearly presented. The IMR notes that CSC was not compliant with the expectations of WT 2010 or MSCB. However the panel are of the view that the second author has struggled to complete the report to demonstrate how the learning will apply to the agency as a whole.   3.2.14 There are three recommendations: • briefings for staff who may be involved in strategy discussions; • a requirement for all present to sign the document and agreed actions with circulation at the meeting; and • uploading of the template onto Micare within five days, or immediately in critical cases.  NHS IMRs  3.3 NHS Manchester  3.3.1 The IMR was prepared by two named doctors for child protection in Manchester as the first author was absent through sickness from the beginning of October and a second author was identified towards the end of the month (26th). The report authors used the General Practitioner computer notes for Child W, MW, SS1 and SS2 for preparation and interviewed GP3 and GP5. Additionally the authors took advice from a GP member of Manchester GP Safeguarding Steering Group.  3.3.2 The chronology demonstrates regular contact by MW for her own health with the GP surgery or GP out of hours service. There were eighteen contacts plus her new patient assessment (but two DNAs) between the 1st January and 4th July for a wide range of complaints and concerns. She had some diagnostic tests but on a number of occasions the outcome was ‘no further treatment’.  3.3.3 The chronology also shows that MW took Child W to the surgery eleven times as follows: • 25th January 2012 when MW reported the child was snuffly and short of breath; was seen to be healthy except for oral thrush and prescription given; • 2nd February 2012, reason for visit not given but oral thrush still evident as well as mild nappy rash; appropriate care described and prescriptions given for both complaints; Page 15 of 46 • 27th February 2012, for first set of immunisations; MW reported a ‘clicky knee’ and was advised to report it to the GP when examined for the 8 week check noted as due at the end of February; • 8th March 2012, MW took Child W, with MPW to out of hours doctor as she reported a spreading rash to the child’s face and neck, and some bruises to the bottom and thighs; a ‘cause of concern’ form was planned to be completed as an unexplained bruise was seen on the right thigh. Diprobase cream prescribed for the skin; MW was asked to monitor the bruise and take to the child GP in a week for a review; • 19th March 2012, attended with MW and MPW for 8 week check, (three weeks late); examination revealed no abnormality of the child’s ‘clicky’ left knee; • 26th March 2012, second set of immunisations given; • 30th April 2012, Child W was seen for the first time by the new practice, when MW took the child with MPW, SS1 and SS2, reporting diarrhoea and vomiting, plus redness to the bottom and genital area; the examination was completed by PN1, who noted MW wondered if the redness was caused by MPW bathing the child in too hot water, but also a crescent shaped bruise mark on the tongue; MW said Child W had bitten on a dummy; redness attributed to thrush and use of anti-fungal cream advised; tests taken on stools which were normal, and MW asked to return for results; described diet as including solids but no record of advice on timing of weaning; third set of immunisations were given; • 14th May, MW telephoned for advice as Child W still not well, but there was no answer when GP1 returned the call; the matter was followed up by GP3 on 15th May and Child W examined, (although not recorded that the nappy area was checked); GP3 diagnosed upper respiratory chest infection and advised to return for weight check in seven days; • 23rd May, MW with MPW took Child W to the surgery and reported to GP3 their attendance at A&E on 21st May; advised to continue to encourage feeds and to use the antiviral cream as prescribed by Hospital 1  for the Herpes on the lip; • 26th June 2012, MW telephoned GP3 to discuss the hospital admissions linked with loose stools and a rash on Child W’s legs; after examination later that day, GP3 requested a paediatric assessment to understand the cause of spots on the inner left ankle and left arm; • 9th July 2012, MW had a planned telephone conversation with GP3 and updated on hospital attendance, noting that a possible fracture had been found and None Accidental Injury (NAI) discussed; GP1 examined Child W on 10th July 2012 and prescribed an ointment.  3.3.4 In February 2012 MW began the process of changing her GP registration back to that of GPs 1, 2, and 3 where she had been removed from the list because of non-attendance at appointments. MW, SS1 and SS2 were accepted by the practice on 2nd April 2012, with summaries of the two children’s attendances at surgeries and hospital recorded.  3.3.5 The chronology shows that the relevant GP surgery was notified of each presentation at Hospital 1 and Hospital 2 except the detail of the visit on 25th May 2012 to Hospital 1 is not recorded.  Page 16 of 46 3.3.6 The IMR notes that MPW was present with MW on six occasions when she took Child W to one or other of the GP practices, (out of 11 visits).  3.3.7 The IMR draws out a number of issues that could have been followed up differently by the GP practice. These can be summarised as: • Querying the frequent attendance;  • Completing a formal Mental Health assessment when MW had her ‘new patient’ assessment which would have identified the previous prescription, or some follow up after the prescription of anti-depressants was given;  • Consideration of domestic abuse when MW said she was depressed and described her bruising on her abdomen; • Lack of follow up to Child W’s bruise seen by OOHs both by the OOH service and by the GP when the notification was received on 9th March, with no consideration of possible causes;  • Lack of consideration of possible evidence of neglect for SS2, as the child had missed four appointments with the Orthoptist, and had six teeth extracted;  • The IMR notes it is good practice for a baby to be examined by a doctor if there is diarrhoea and vomiting as on the 30th April visit;  • On the same visit, there was no consideration of cause of the bruise to Child W’s tongue or the redness in the nappy area; • The eight week check (completed when nearly twelve weeks) should have included a whole assessment of presentations and admissions, prescriptions and concerns.  3.3.8 In particular there were seven occasions (23rd February, 9th March, 15th May, 23rd May, 8th June, 13th June and 9th July) when it would have been appropriate to either discuss the family with the HV service, or to ask for a follow up visit to provide support.  3.3.9 With hindsight staff at the GP practice can identify some possible indicators by MW of NAI. For example on 30th April MW stated clearly that Child W had been alone with MPW when the bruise on the tongue was seen and the redness in the nappy area; on 9th July, the GP should have been alert to the suggestion of NAI raised by MW on phone. A referral should have been made to CSC or to the on call paediatrician for consideration of the cause of the swollen foot either following the telephone call or the next day (10th July) when he examined the swollen foot. At the time (10th July), the GP practice was not aware of and had not been invited to the June strategy meetings and this omission exacerbated the lack of awareness of possible NAI.  3.3.10 The IMR identifies some key areas of good practice and learning: • Provision of good care for both MW and Child W in terms of prompt returned telephone calls and appointments;      but the IMR highlights: • The importance of knowledge of the signs of physical abuse of a young baby; • Improved communication with the HV service, especially at a time of further structural change in primary and secondary NHS services; • Recognition of the importance of highlighting important historical information in GP records; and Page 17 of 46 • Acceptance of the role of the GP in strategy meetings.  3.3.11 The panel also considered that some consideration of the pattern of presentation with illness or injury of the mother and child together would have been beneficial within the practice, possibly as a case study.  3.3.12 There are four recommendations which should ensure that: • All staff in the OOH’s service and GP practices are adequately trained in safeguarding, including alerts to injury in non mobile babies; • There is regular established communication between professionals in the primary health care teams (GPs, HV and midwifery services); • Communication from OOH service to the GP practice should be clear with explicit follow up action highlighted; • GP records are read coded and flagged to highlight key information on domestic abuse and mental health history.  3.4 Pennine Acute Hospitals Trust (PAHT)   3.4.1 The IMR was prepared by the Named Doctor for Safeguarding Children and was countersigned by the Head of Safeguarding for Pennine Acute Hospitals Trust. The records used to write the IMR were: • Full medical and nursing notes; • Medical report by DR 13 which was compiled following review of GP records; • Accident & Emergency notes from ‘Symphony’ electronic system.  Child W was born at Hospital 1, (a hospital within PAHT) following a normal delivery weighing 4265 grams. Following the birth, in the timescale of the SCR, MW went to A&E services three times concerned about her own health, first shortly after Child W’s birth with pains and shortness of breath, and a couple of months later (in March) with a long standing chest infection.   3.4.2 On the same day in March MW also attended A&E about an hour later with MPW, reporting he had collapsed after feeling dizzy. A history of Obsessive Compulsive Disorder (OCD) was noted, but no treatment was given and he was advised to see his GP.  3.4.3 MW took Child W to A&E at Hospital 1 seven times on: • 7th February 2012 with a snuffly nose, reported blue lips, sleepy, feeding less and with oral thrush; after observation the child was discharged with no follow up; • 21st May 2012 with a swollen mouth and lip ulcer,  a diagnosis of herpetic lesion was treated orally with community follow up; Child W was noted to be well; • 3rd June 2012 when dropped by SS2; Child W had vomited once and had a 2 cm bruise on the back of the head; following observation the child was discharged and the HV notified; • 4th June 2012 for readmission as Child W had blood in the mouth when the child vomited; a CT scan was normal and presentation matched the explanation so Child W was discharged; Page 18 of 46 • 7th June 2012 seeming lethargic, irritable, feeding less, with a rash; although Child W seemed well the child was referred to the paediatric team where pin point petechial rash on both upper arms, an ulcer under the tongue and under the left upper lip were observed. Following blood tests which showed high infection ‘markers’, intravenous antibiotics were prescribed with follow up from the community nursing team and continued oral treatment for thrush; • 26th June 2012 when swollen warm sore feet with a nodular pattern on the soles, non blanching spots on the  left inner ankle, and a few purple spots on left upper arm and right  lower thigh were observed. The blood tests were normal but blood cultures were taken and a further set of intravenous antibiotics were prescribed; and • 12th July 2012 when MW was concerned that Child W still had swelling and puffiness over the dorsum of the right foot but no tenderness; an X-ray apparently revealed no fractures.  3.4.4 When MW took Child W to A&E on 12th July she did not indicate that MPW was also present in A&E with pain on the left side of his chest, radiating down his arm. He indicated he had just been treated for costocondritis and reported his recent attendance at A&E and that he was awaiting a psychiatric appointment. He said he had relationship difficulties and problems with a child but did not mention MW and Child W’s presence.   3.4.5 As indicated in paragraph 1.9 above when the X-ray of Child W was reviewed a number of fractures were revealed and MW was asked to bring the child back to the hospital. A full examination revealed the injuries noted in the same paragraph.  3.4.6 The IMR notes some examples of good practice. The thorough approach of DR13 and exploration of all available information by DR16 is commended and will be used as an example of ‘what good looks like’ throughout the Trust.  3.4.7 Other staff were less good in checking, questioning and ensuring all available historical information was used as part of a diagnosis. This is particularly the case in relation to asking about caring responsibilities and relationships. The attendance of MW and MPW on the same day in March, and later in July at the same time could have raised questions about the care of Child W and the family relationships.  3.4.8 The learning in this IMR is linked to the concerns in paragraph 3.4.8 and is set out in two recommendations: • To use the case in a half day training event focussing on good practice; and • To develop a strategy to ensure establishing caring responsibilities of patients is part of the routine assessment.  3.5 Central Manchester University Hospitals NHS Foundation Trust (CMFT)  3.5.1 The IMR was written by the Named Nurse, Safeguarding Children (Community Services) and the Named Doctor, Child Protection (Acute Services) and was countersigned by the Medical Director/Lead Director for Safeguarding.  Page 19 of 46 3.5.2 The introduction gives helpful information on the organisation of services within Hospital 2. The acute hospital based services and Children’s Community Services (CCS, which include the HV services and CCNT) in Community Health Services are separately managed. Both parts of the agency provided services to Child W, but it is important to understand that at the time of the events communication between the two would be as if they were completely separate agencies. The IMR has separated the events and actions into separate sections to facilitate understanding.   3.5.3 The records used from the HV service were: • Manchester Health Record (community): with subsections relating to a. Chronology of significant events b. Family and social record section c. Adult health section d. Nursing record (child health section); • Manchester Child Health System; • Safeguarding Children Team (community) consultation documentation.  The author also interviewed five staff, two managers and three practice staff.  3.5.4 The records used from CMFT were: • CMFT Patient Nursing and Medical  records; • CMFT Safeguarding nursing team records; • CMFT Paediatric Emergency Department Integrated Medical and Nursing Record.  The author also interviewed Cons 1, Cons 2, and CPN and looked at practice as expected in the CMFT Child Protection Policy and Child Protection Practice Guidance.  3.5.5 The initial paragraphs in each section provide helpful information on the organisation of the specific community and hospital services. The CHS section gives demographic data on the area of Manchester where Child W lived and the current planning for future community services. The data suggests that the area has statistics which show there is a lower life expectancy and higher mortality. Manchester is ranked as the 4th most deprived local authority and the area where Child W lived is one of the most deprived areas in Manchester. The HV service had provided some continuity to MW, with SN4 consistently providing a service from 2004 but this is in the context of the service having caseloads considerably higher than national recommendations.  Children’s Community Services  3.5.6 The IMR gives some historical information on the pre-school years of SS1 and SS2. While there were some missed appointments and delays in immunisations, MW sought advice and followed it appropriately. In relation to MW’s health, the only notes on her are in relation to a chest infection and support to stop smoking in 2004.  3.5.7 The records for the HV service indicate first contact within the timescale for this review (after receipt of routine birth and midwifery records and a visit to the clinic Page 20 of 46 on 20.01.12) was the primary home visit on 31st January 2012. MW took Child W to the GP’s surgery and the clinic for routine immunisations and checks. The next contact (SN4 and StuN) was the follow up primary home visit on 26th March 2012, following a failed (although arranged) appointment on 6th March 2012.  Child W’s progress was appropriate with the only concern a mention of loose stools. MW was advised to seek advice at the clinic if this continued. Most of the visit was taken up with MW describing her own health, and her view that neither her GP nor secondary services were fully considering what might be wrong with her. Her description included possibly pneumonia, feeling depressed and pelvic pains.   3.5.8 SN4 followed up the visit with a consultation with a health visitor and then telephoned MW on 27th March to advise to either go to A&E or to her GP to ask for a second opinion about her health. MW was not receptive to either of these suggestions and reported that additionally she had stabbing pains in her legs and calves. SN4 advised MW to go to A&E and suggested what she should ask about when seen.  3.5.9 MW followed the advice and attended A&E the same day. An X-ray confirmed MW’s lungs were clear and so Child W was able to have the BCG vaccination the following week as the child had not been in contact with anyone with a lung infection. MW was not in for the next planned visit on 17th April but attended the clinic on 27th April. Child W was making good progress but MW reported that Child W had had some sickness and diarrhoea.   3.5.10 MW had not taken Child W for the BCG on 4th April but did attend for further immunisations on 30th April and the BCG on 2nd May 2012.  3.5.11 On 14th May MW telephoned SN4 to say Child W had been unwell for a few weeks, seeming lethargic, not feeding and sleeping a lot. She was advised to go either to her GP, the clinic or A&E. On 18th May MW took Child W to the clinic and reported that the child was gagging on food, (but not the information given to SN4). Child W’s weight was improving from the last visit, but MW was asked to bring the child back in four weeks to check.  3.5.12 CCS (the CCNT) received information from Hospital 1 about the attendance and admission for observation as Child W had a swollen wound on the mouth on 21st May 2012. There was a further notification of the visit to Hospital 1 on 3rd June. The CCNT followed up this notification of admission to hospital by telephoning both the hospital and the home. Child W had been readmitted on 4th June as the child was vomiting, following being dropped by SS2. Hospital 1 sent a safeguarding alert/referral asking for follow up as Child W had a head injury and was under 12 months old.  3.5.13 On 11th June the HV service was notified of a further admission on 7th June as Child W was lethargic and had a rash. This and the notification from 23rd May listed previous admissions including one on 7th February when Child W was recorded as unwell.  Page 21 of 46 3.5.14 The next information was a referral for administration to Child W in the community of intravenous antibiotics on 26th June. Not aware of this, SN4 visited on 27th June. The records have a full description given by MW of the events and illnesses of Child W over the last few weeks, as well as a record of observing some purple/brown non-blanching spots in patches, such as near the left inner ankle, on the right thigh, and on the left arm. SN4 noted that Child W’s left foot appeared to be swollen and was hard to the touch in parts due to the swelling and that there was a pink line across the middle of the sole of the foot. Child W’s right foot also appeared to be swollen and Child W was no longer weight bearing. SN4 was concerned about Child W’s presentation and advised MW to take the child to Hospital 2.  3.5.15 Following presentation at Hospital 2 HV1 attended the strategy meetings on 28th June and 29th June. The records of the meeting note agreement with discharge and the plan to complete a social worker core assessment, with clinical follow up of the rash and health visitor follow up.   3.5.16 HV1 visited on 3rd July and found Child W to be well, except for a swollen right foot. MW was advised to take the child to the GP. The family was also waiting for an appointment to follow up on the leg fracture.  3.5.17 HV1 made a series of notes as she was informed by CPN that Cons2 following the strategy meeting on 29th June was reviewing the injuries of Child W with Hospital 1. HV1 then attended the strategy meeting on 13th July 2012.  3.5.18 The IMR identifies some good practice in the community services: • Positive use of the team’s skill mix; and • Regular communication and a high standard of written records.  3.5.19 However there is some learning: • Robust and regular communication between the HV service and GP is essential to ensure both services have a clear picture of the history and current presentation of a family; this is not included as a recommendation as the HV Task Force, established to deliver the national HV Implementation Plan has already recognised the need and has asked its Partnership Task and Finish Group to develop a good practice guide. The IMR does not note that this is even more important as the HV service at times suggested MW should take Child W to A&E, and to a second hospital; • Improved dating and evidence of screening of information received from other NHS agencies; and • A mechanism is needed to ensure a history of domestic abuse is known by key community NHS staff.  Acute services  3.5.20 The initial paragraphs describe the management of diagnostic care in the paediatric unit in Hospital2. This is helpful as it gives the context for why Cons1 was not able to attend the strategy meetings on 28th and 29th June 2012 and the pressure of work experienced by the ‘hot week’ consultant (Cons 2). The ‘hot week’ consultant is the Page 22 of 46 lead consultant for all general paediatric admissions and inpatients for that week.  The ‘hot week’ consultant also oversees the daily ward round, allocating patients to be seen by the assisting consultant or attending registrar.  3.5.21 The first contact with Hospital 2 acute services was on 27th June 2012 following advice from SN4 who had visited as a follow up to the Hospital 1 visit of 3rd and 4th June. MW took Child W to Hospital 2 as she was concerned that there was no improvement in the swollen feet and rash. Although Hospital 1 had taken blood tests MW considered they were not taking her concerns seriously as she had presented Child W with the same symptoms three weeks earlier.  3.5.22 On presentation, the Junior Doctor (SHO1) referred Child W to the more senior doctors in the paediatric team because the baby seemed well in itself but had apparently persistent symptoms. When Child W was examined by the registrar (Reg1), the bruise on the back was noticed with no explanation of cause from MW. However the registrar omitted to mention the bruise to the consultant and so Child W’s care was managed by the assisting consultant (Cons 1) on 28th June, rather than the more experienced consultant, Cons 2. Reg1 and Cons 1 identified that the bruise could have been non accidental, and also were concerned that the purpura and swelling of the foot could be an inflicted injury. The observations and exploration of causes were well documented and explained to MW.  3.5.23 Cons 1 had left full notes of her reasons for beginning the process of investigating the bruise (and a previous mark mentioned by MW) as NAI and briefed Cons2. Neither consultant was able to attend the strategy meeting on 28th June as they only had ten minutes notice, but Cons 2 attended on 29th June 2012.  3.5.24 By the time of the strategy meeting, MW had met Cons2, expressed her concern at the lack of diagnosis, was plausible in her description that Child W was never left by her, and the bruise had faded, the swollen feet were improved and the rash subsiding. Cons2 cancelled the intravenous drugs and further tests linked with an infection and planned instead to investigate the possibility of an underlying bleeding disorder.  3.5.25 A skeletal survey done on 29th June showed a healing fracture of the left shin bone, about 2 – 4 weeks old and a possible chip fracture of the corner of the growth plate at the tip of the lower end of the shin bone. There was a recommendation for a follow up skeletal survey in particular with follow up of the left ankle and foot. The CT head scan was normal.  3.5.26 Discussion at the strategy meeting did not consider either the chip fracture or that the opinion of Cons1 as described in the referral for CP investigation may have differed from Cons2. With no disagreement, it was decided that the follow up would be the social work core assessment and follow up of the fracture and Child W was discharged home that day.  3.5.27 Cons2 when writing a summary of events for the records considered it would be helpful to include and reflect on information from Hospital 1. He contacted DR12 on Page 23 of 46 2nd July 2012 who agreed to seek the records and report back to Cons2. Cons2 was going on holiday on 7th July and as he had not heard back from DR12 by 6th July he alerted CPN, who in turn spoke to HV1, SW1 and her counterpart in Hospital 1.  3.5.28 The next contact was on 13th July 2012 when the safeguarding team at Hospital 2 was alerted to the presentation of Child W at Hospital 1 with a number of injuries. A further check was made of the skeletal survey from 29th June and a further injury was noted on Child W’s left foot.  3.5.29 The author of the IMR acknowledges that opportunities to protect Child W and prevent the further injuries recorded on 13th July were missed and that it is important that this review is used to learn and improve. The IMR includes commentary on the expected standards for an open approach to unexplained injuries by staff at different levels of qualification and experience. All medical terms are clearly explained so that non-medical readers can understand the significance of observations and test results.  3.5.30 The recommendations for each section of the IMR are set out together in section 7. As indicated CHS had only two recommendations, 7.1 a) and b): to ensure that information is shared consistently between staff, and that information from other parts of the NHS are reviewed and recorded in a timely on receipt.  3.5.31 The recommendations for the acute services are more extensive as the IMR author recommends a review of how the workload is managed in paediatric services. This should be combined with some specific training on patterns of injury for general paediatricians and safeguarding nurses. There should also be a review of training and peer review for individual consultants and a review of the role of the Safeguarding Nurse to ensure a more active contribution to decision making.  3.5.32 The IMR also, as with other reviews, recommends standardised record keeping for strategy meetings.   3.6 Manchester NHS Commissioning Overview Report (MNHS COR)  3.6.1 The Manchester NHS Commissioning Overview Report was written by the Deputy Designated Nurse and Designated Doctor for Safeguarding for NHS Manchester. It has been counter-signed by the Medical Director.  3.6.2 The authors have used the information from the three NHS IMRs, an integrated NHS chronology, interviews with the authors and panel discussion to prepare the report. In particular the chronology and discussion has identified a number of themes that are expanded on within the report.  3.6.3 The report confirms that each NHS IMR has met the expectations of WT 2010 and that as the SCR has continued the authors have monitored progress of the individual recommendations made in their reports. The authors endorse the analysis and recommendations of the individual NHS IMRs.  Page 24 of 46 3.6.4 The authors have summarised the presentations of and communication about Child W and have identified the six occasions when there was a missed opportunity. These are on 8th March, 30th April, 26th June, 29th June, 6th July and 9/10th July with a possible missed opportunity on 7th June. These occasions are noted in detail in the report and are all commented on in the analysis in section 4 of this report.  3.6.5 The MNHS COR identifies eight key areas of learning: • The role of the GP in child protection processes; • Communication within the primary health care team; • Communication between health service providers;  • Vulnerability of babies; • Working with plausible parents including the role of the male in a household; • Section 47 medical assessment and over reliance on medical opinion; • Functionality of S47 strategy meetings including chairing and recording; and  • Practice standards for paediatric consultants.  3.6.6 MSCB will be familiar with these areas of learning from previous SCRs and the authors of MNHS COR considered that it would be helpful to consider a different approach to ensuring action from all agencies. Only two additional recommendations have been made as recent MSCB SCRs have made recommendations on a number of points which are discussed further in section 5.   The new recommendations are: • NHS Manchester commissioners (now transferred to NHS England) of health visiting services to ensure that the current review considers the findings in this case around corporate caseload management and communication with GPs; and • Primary care commissioners to ensure safeguarding training to GPs and provider training programmes are strengthened further to ensure that the plausibility of parents is embedded in training programmes and The Core Info: ‘Bruising in Children’ and ‘Fractures in Children’ focusing on learning around the specific vulnerabilities of babies is embedded into training programmes. Page 25 of 46 4. Analysis  4.1 Review the decision making relative to Child W's marks and injuries observed between 30th April 2012 and the 13th July 2012. This to include marks or injuries observed during home visits and attendance at GP's surgeries and hospitals.  4.1.1 GMP and Manchester CSC had no opportunity to observe any of Child W’s marks and injuries independently of NHS agencies at the two strategy meetings. TM1 in CSC was concerned after the first strategy meeting that there was insufficient information on the unexplained injuries. She telephoned Hospital 2 to ensure that a consultant would be present the next day and that a full skeletal survey would be completed.  4.1.2 The individual IMRs indicate that there were a number of occasions when NHS staff could or should have made different decisions about possible causes and treatments. The agencies did not demonstrate the ‘healthy scepticism’ recommended by Lord Laming in his review of child protection systems in 2009.  4.1.3 The first occasion (although prior to the timescale of the TOR) was when the Out of Hours (OOH) service identified an unexplained bruise on the back of Child W’s right thigh on 8th March 2012. The matter was notified to the GP on 9th March, but not highlighted, and the service left the responsibility for review with MW. The recording suggests that NAI was not considered by the examining doctor, although recognised by the triage nurse, as there is no record of a conversation with MW about possible causes. The OOH service followed up the notification with telephone calls. The MNHS IMR considers that the OOH service should have been more proactive at the time of presentation. This is the first missed opportunity referred to in MNHS COR.  4.1.4 Child W was seen by the GP practice five times between 30th April and 13th July, and additionally MW spoke to the GP on the telephone four times in this timescale. On 30th April Child W had marks and injuries for which MW offered PN1 implausible explanations. While PN1 was thorough in checking causes of some of the presentation, (further tests and weighing), the information given should have raised queries of NAI and triggered a referral to the GP for further assessment. There was no questioning of who might have cared for Child W, or checking the relationship of MPW. This is the second missed opportunity referred to in MNHS COR.  4.1.5 MW took Child W to the GP on two further occasions, 15th May, and 23rd May, reporting the attendance at Hospital 1 on 21st May. On both visits treatments appeared appropriate for a single visit, but when taken with the record from 30th April and the visit to hospital, it could have prompted some further investigation of MW’s concerns about loss of weight, poor feeding and continued cold or chest infection. Although PN1 had recorded the unexplained red area in the bottom and genital area there is no record of further examination during these two visits.  Page 26 of 46 4.1.6 From the date of transfer from the midwifery service whenever the HV service saw Child W, the child seemed well and the weight was satisfactory. MW had reported a number of minor illnesses but these were not evident on contact.  4.1.7 During this timescale (before the events of 27th June) the HV service had seen MW with Child W at clinic on two occasions (2nd and 18th May). There was one telephone conversation with MW on 4th May, when MW was advised to take Child W to the GP, A&E or a walk in centre.  4.1.8 The assessments and treatments for the first three contacts with Child W by Hospital 1 (on 21st May, 3rd June, and 4th June) were all managed well with appropriate decision making. With hindsight, the presentation on 7th June could have been a missed opportunity.   4.1.9 On 26th June MW took Child W to the GP with swollen feet and a rash. The GP could not identify a cause and so contacted Hospital 1 to ask for a paediatric assessment. At Hospital 1 there was no X-Ray and NAI was not considered although the rash could have been caused by a firm pressure on the foot. The treatment was a further course (previously prescribed on 7th June) of intravenous antibiotics administered by the Children’s Community Nursing Team. This is the third missed opportunity referred to in MNHS COR.  4.1.10 On 27th June the HV service did a follow up home visit and found the marks were in a number of places on Child W’s body. SN4 also observed that both feet were swollen, tender and Child W was unable to weight bear. During this visit and the attendance on 18th May, MW made a number of comments about Child W marking easily. SN4 correctly advised MW to take further advice on the cause of the swollen feet, but did not consider NAI. Additionally there was no consideration of the reason why MW might be stressing that Child W marked easily a possible pointer to identification of unexplained injuries.  4.1.11 When MW took Child W to Hospital 2 on 27th June, following the examination the consultant (Cons 1) was concerned that there was evidence of NAI. Child W had an unexplained bruise on the right lower back as well as the swollen feet. Cons 1 noted the reasons for concern and checked the detail of the fall on 3rd June to confirm the bruise on the head was accidental. She began the process of a child protection investigation noting ‘whilst no explanation is offered this is highly likely to be an inflicted cause’. Cons 1 also organised immediate and full follow up with ophthalmic tests, a skeletal survey and a scan. Decision making at this point was appropriate however Cons 1 was unable to attend the strategy meeting, convened in accordance  with MSCB Safeguarding Procedures and held on 28th June.   4.1.12 On 29th June when the strategy meeting was reconvened, chaired by CSC, and attended by Cons 2 decision making was poor. The professionals present knew that Cons 1 had noticed a bruise on the back when examining Child W on the 27th June and had contacted CSC to convene the strategy meeting. There was limited clinical evidence, but there was the bruise on a non mobile baby, as well as one actual and one possible bony injury. It has been noted in research (Dale, P., Green, R. and Page 27 of 46 Fellows, R. (2002) What really happened?) that experienced paediatricians, health visitors and GPs may not detect or suspect non accidental injuries especially in young babies. However it is even more important to weigh the evidence in these circumstances. The mind-set of the meeting should have been to exclude NAI and not to be swayed by MW’s evident concern. The decision to discharge Child W was overly reliant on medical opinion which had not included discussion with a consultant radiologist and a consultant orthopaedic surgeon which was expected NHS practice, or with the GP which would have been good medical practice. This was not standard practice in strategy discussions at the time. However a decision was made for CSC to complete a core assessment. This is the fourth missed opportunity referred to in MNHS COR.  4.1.13 On 3rd July the HV service did a follow up home visit. Child W’s right foot was still swollen and MW was angry that Hospital2 had identified a leg fracture, not found by Hospital 1. The HV advised MW to take Child W back to the GP and to stop using the baby walker. MW, although she spoke to the GP about a matter for herself on 4th July, did not make contact about Child W until 9th July and arranged an appointment for 10th July.  4.1.14 Other NHS staff were unaware that Cons 2 had reflected on the strategy meeting of 29th June when he wrote up the records. He asked for further information from Hospital 1, but had not received it by 6th July, and was due to go on holiday on 7th July. He telephoned the CPN to note he was reconsidering his opinion and wanted to review the previous notes. CPN notified the safeguarding team at Hospital 1, and HV1, but took no action. This is the fifth missed opportunity referred to in MNHS COR.  4.1.15 MW also telephoned the SW who was completing a core assessment about her concerns on 10th July saying that she was due to see the GP that day. The SW had stressed that MW should ask the GP to refer Child W for a further assessment as she needed to understand the cause of the swollen feet. At the last attendance at hospital more attention had been focused on the bruise.   4.1.16 The GP saw Child W on 10th July and was aware of the hospital attendances and involvement of CSC as MW referred to the query about NAI in her conversation with the GP. Although there was sufficient medical concern as well as the possible NAI, he did not make a referral for a paediatric assessment or notification to CSC. This is the sixth missed opportunity referred to in MNHS COR and a failing on the part of all the agencies.  4.1.17 Two days later MW took Child W back to Hospital 1 as she continued to be anxious. She had spoken to the HV, the SW and the GP but no one seemed to be interested in finding the cause and treating the swollen feet. Following examination and an X-Ray in the clinic, there was no obvious cause. Routine review of the X-Ray on 13th July together with a review of the 29th June skeletal survey from Hospital2 led to a complete examination and listing of injuries as noted in paragraph 1.9. At this point the indicators for NAI were completely clear and decisive action was taken to protect Child W and the half siblings. Page 28 of 46  4.1.18 In all of the instances described, not just in the strategy meeting of 29th June, there is no apparent recognition of the age of Child W and the implausibility of any bruise or injury being accidental leaving Child W unprotected possibly from as long ago as early March 2012. All bruises in a non-mobile baby should be treated as suspicious. The MNHS Commissioning Overview report draws attention to another recent MSCB SCR NHS commissioning report which noted ‘All agencies involved in safeguarding should be aware of the high level of vulnerability of babies, should be especially vigilant and should have a low threshold for taking action if there are concerns about welfare.’   4.1.19 The MNHS Commissioning Overview report concludes that the missed opportunities     described above are evidence that there is a continuing lack of awareness at multi-agency strategy meetings of links with child protection when considering the cause of a number of injuries and illnesses in a small baby. However there are wider implications within the NHS for safeguarding children that will be noted later in the report.  4.1.20 Additionally the MNHS COR notes that the decision making at the strategy meeting on 29th June was inadequate. The tests commissioned by Cons 1 were cancelled by Cons 2 and Child W should not have been discharged in view of the fact that there was a disagreement between consultants.   4.2 Review the apparent opportunities for challenging decision making and why this did not happen.  4.2.1 Opportunities to challenge decisions were limited other than during the multi agency strategy meetings of 28th and 29th June. The only other opportunities were within the GP practice. The GP practice arrangements should ensure that a practice nurse refers a baby with Child W’s symptoms for attention from either himself or a specialist. This would have given the opportunity for a wider discussion about Child W’s presentation.   4.2.2 The GP could have noted that the OOH service notified the GP practice of an unexplained bruise without taking further action, or highlighting their concern. In the absence of any alert on the GP records, MW’s concern and openness was taken as reassurance that she was a caring mother who was seeking explanations. The GP was unaware of previous domestic abuse and did not query MW reporting bruising on her abdomen on 26th March, when none was evident. The NHS Manchester IMR recommends that the GP practices should continue with their work on improving their methods of flagging and read coding key elements of treatments and family events that may be future indicators of the need for investigation. This review, following the CPS decision of no prosecution raises wider concerns about the limitation of flagging and read coding to alert agencies of a possible risk to babies. This is commented on in Section 5.  4.2.3 The MNHS COR sets out the opportunities for NHS staff to challenge MW and MPW about how Child W was cared for. There have been a number of structural changes Page 29 of 46 which have altered the relationships between primary care services. It is important that whatever the agency structures, there are regular opportunities for primary care staff to discuss shared patients. This should allow for noting such information that MW was at times unreliable about her children’s care. It was recorded that MW missed two appointments for immunisations and was not at home for two pre-arranged visits. This had been a previous pattern when she was on the list of GP3. Because MW seemed to seek advice and treatment appropriately the less good element of her parenting was overlooked. The MNHS COR draws out that MW was left to challenge NHS staff, rather than the staff taking responsibility themselves.  4.2.4 When MW took Child W to Hospital 1 on 26th June the child had been referred by the GP as he was concerned that the swollen feet persisted with no explanation. Although two doctors saw Child W there was no consideration of further tests to identify the cause. The IMR suggests that at this point one doctor should have challenged and asked for an X-Ray of the feet.   4.2.5 However the main lack of challenge was at the two strategy meetings. On the 28th June in the absence of the referring doctor it seems that the concerns of Cons 1 were not discussed. The meeting, while appropriately adjourning for the attendance of a consultant did not ensure all the relevant history of the family and specific care of Child W would be available for the next day.  4.2.6 On 29th June Cons 2 attended the strategy meeting. The concerns of Cons 1 were not discussed. Cons 2 was confident with his explanation that the marks or injuries were not NAI, noting that the bruise which was discussed was not a ‘slap, hit or finger marks’. DC1 asked specifically how the injuries were accidental but accepted without challenge, as did the CSC chair, the reasoning of Cons 2 that his view was ‘on the balance of probabilities’. Within the SCR, HV1 agrees that she should have challenged this view, should have asked for discussion of the information from Cons 1 and made sure that each illness and injury was considered separately (see TOR 3).  4.2.7  While HV1 is noting this, the view of the SCR panel is that the CSC Chair of the meeting and CPN (the hospital based child protection specialist nurse) also had responsibility for ensuring that the decisions were consistent with the age and development of the baby. The meeting should have considered each injury and all possible perpetrators. There is considerable evidence from research (Burton 2009) and SCRs (Brandon et al 2008, Dale et al 2002; Reder and Duncan 2004;) that fixed views are influential in decision making about a child’s circumstances. The research found that professionals were found to have disregarded, dismissed or ignored contradictory information including parental behaviour if it did not confirm their original view of the family circumstances. This tendency should be managed through critical reflection and challenge, using peer group mentoring, supervision, management oversight and challenge from the multi-agency perspective.   4.2.8 The confidence of Cons 2 was overly influential as, while he reflected later that there was cause for further inquiry, he did not discuss the matter with the Named Doctor, leave his report for follow up, or transfer care to another paediatrician. The panel however was very aware of the deference, in this case to NHS professionals, often Page 30 of 46 present in multi-agency meetings that create an environment where it is difficult to challenge. This may have particularly relevant in this case as the social worker chairing the meeting was not at the correct grade. The panel’s view is that all present in a strategy meeting have a responsibility to ensure the decisions take account of uncertainty and are child focussed.  The MNHS COR demonstrates how the other NHS staff may have been reassured that the medical view was accepted by CSC and GMP, while equally, these agencies will have been reassured by the lack of challenge from the HV and CPN.   4.2.9 WT 2010 says in paragraph 2.6.3 that all health professionals not only should: contribute to child protection conferences, family group conferences and strategy discussions; but should understand risk factors and recognise children and young people in need of support and/or safeguarding; it is important to note the wording is ‘contribute to’ not ‘lead’ the discussion.  4.2.10 The meeting ended with a decision not to pursue a Section 47 investigation but for CSC to begin a core assessment.   4.3 Evaluate the planning, recording and decision making at the strategy discussions on the 28th June 2012, 29th June 2012 and the 13th July 2012.  4.3.1 It is evident from all the IMRs that the process prior to and within the strategy meetings was not compliant with the expectations of WT. The relevant extract from paragraph 5.56 is  ‘there should be a strategy discussion involving local authority children’s social care, the police, health and other bodies as appropriate (for example, children’s centre/school or family intervention projects), in particular any referring agency. The strategy discussion should be convened and led by local authority children’s social care and those participating should be sufficiently senior and able, therefore, to contribute to the discussion of available information and to make decisions on behalf of their agencies. If the child is a hospital patient (in- or out-patient) or receiving services from a child development team, the medical consultant responsible for the child’s health care should be involved, as should the senior ward nurse if the child is an in-patient. Where a medical examination may be necessary or has taken place a senior doctor from those providing services should also be involved.’  4.3.2    In this instance the GP was not informed of either meeting, or asked to provide any background information. On 29th June the radiologist who could have advised on the findings from the skeletal survey nor orthopaedic staff were invited to provide any information for the meeting. It is difficult for many NHS staff to attend meetings at such short notice. The General Medical Council (GMC) guidelines which took effect on 3rd September 2012 expect that if the paediatrician or GP is not able to attend information will be available to the meeting. The responsibility of the doctor is to ‘try to provide relevant information about the child or young person and their family to the meeting, either through a telephone or video conference, in a written report or by discussing the information with another professional (for example, the health visitor), so they can give an oral report at the meeting.’ Child protection procedures expect Page 31 of 46 the HV or  nursing service, as well as the CPN will attend the strategy meeting having gathered and collated the relevant NHS information.   4.3.3 The outcome of the meeting on 28th June ensured that all three children were protected but did not identify where further helpful information could be gathered in preparation for the next day. This meeting was chaired by a social worker of less experience than expected by paragraph 9.10 of MSCB procedures and this may have contributed to the limited discussion. It is to the credit of CSC and attending agencies that the strategy meeting was held so promptly. However WT 2010 allows up to three days and taking more time to plan the meeting may have ensured all relevant information was available and the meeting could have been chaired by a social work practitioner of correct status. The panel observed there could be a number of reasons for this. It is noted in the MNHS COR that the reason the meeting was convened so quickly could have been pressure to release the bed in the hospital or panel thought that as it was a Friday staff would be reluctant to leave the matter over a weekend.   4.3.4 Paragraph 5.59 of WT 2010 states that ‘Any information shared, all decisions reached and the basis for those decisions should be clearly recorded by the chair of the strategy discussion and circulated within one working day to all parties to the discussion. Local authority children’s social care should record information in the child’s file which is consistent with the information set out in the Record of Strategy Discussion (Department of Health, 2002).’  4.3.5 The IMRs indicate that each person attending made their own notes (in each case GMP, CSC and HV notes were full and factual) but there was no shared note and the meeting did not follow an agenda that allowed full discussion of the circumstances of Child W, the injuries and the care. The GMP IMR notes that there is differing practice across Greater Manchester Police divisions and as this has been a longstanding problem, GMP staff have found different solutions to the difficulty.   4.3.6 The specific matter of circulation of strategy meeting minutes has been a recommendation in a previous recent MSCB SCR.  The SCR Author could not find the Record of Strategy Discussion identified in WT 2010 paragraph 4.3.4.  Efforts were made to identify any formats from neighbouring LSCBs to Manchester that would ensure the discussion and recording is thorough and results in a full record.  Recent work almost concluded for MSCB should resolve confusion between the agencies.  4.3.7 The different agency records show that: • There was no shared record of people present or reports used in discussion; • Information on the previous ‘pinch’ mark (bruise seen at OOH service on 8th March) was not given;  • The observations and concerns of Cons 1 were not discussed at the 2nd strategy meeting but other people present did not know there had not been any conversation between the two consultants; • At this meeting the possible chip fracture was discussed but Cons 2 said it was not confirmed as an injury, (information from the radiologist would have assisted here); Page 32 of 46 • The fracture on the left lower leg was considered by Cons 2 to have been caused by the fall from SS2’s lap on 3rd June after his interview with MW. This conclusion was not consistent with the records held at Hospital 1 about the injuries observed when the fall was investigated; • There was no discussion about the context and position of the fall; • The bruise was considered to be caused by either the use of the baby walker, or catching on a door handle. It was accepted as not Non Accidental Injury (NAI) as it was not a fingertip bruise, slap or pinch; however no professional had seen Child W in the baby walker to see if the bruise was consistent and the only mention of a bruise being caused by a door handle was in the CSC records; • Cons 2 considered the evidence shows that MW is plausible and she reports and follows advice; • Cons 2 indicated that the swollen feet and petechial bruising were being treated; • As noted in paragraph 5.4.5 of the MNHS COR there was no overview of the family circumstances and history; and • The records held in agencies of 13th July suggest the meeting was chaired by DR13.    4.3.8 Finally, at the July 13th strategy meeting, no records were shared. The CSC record of this meeting was found towards the end of the review process but had not been entered on the system as required. All other agencies made their own detailed records. In particular the notes from DR 13 are extensive. As preparation for this strategy meeting, DR13 requested records from the GP surgery. The MNHS COR draws out the key point that in contrast the June meetings lost the expected focus on the child as the basis of all discussion. At the end of the meeting there was no plan to inform the GP of the outcome.  4.3.9 The GMP IMR notes that different sets of notes could cause difficulties in any criminal proceedings. The police are required to inform CPS of any information which may be of interest to the defence either because it undermines the prosecution or assists the defence. If the strategy notes from different agencies are contradictory a prosecution could be jeopardised.  4.4 To what extent did agencies and services take account of issues such as: race and culture, language, age, disability, faith, gender, sexuality and economic status and how did this impact upon agencies assessment and service delivery?  4.4.1 The records from each agency have recorded MW as White British and English speaking. CMFT had explored further and recorded that MW and MPW were claiming benefits but had no financial difficulties and had noted that there were no communication difficulties. The ‘Social record’ used by HV services is very helpful in providing context to family situations giving good information on MW’s previous partners and the fathers of her children.   4.4.2 Both the HV services and GMP had recorded that MW was a competent mother, with a note in the GMP IMR that she ‘knew her children’. CMFT IMR notes that with hindsight the HV service can see an unusual dependence on the NHS for a parent of Page 33 of 46 two older children. The CSC IMR acknowledges that MW may have been reticent about her relationship with MPW to prevent changes in their benefit claims.  4.4.3 Two IMRs identified some concern about the thoroughness of the records in those areas which give context to possible safeguarding matters. CSC IMR acknowledges that there should have been consideration of MW’s history of domestic abuse. The GMP IMR asks if agencies would have acted differently if the presentations to the GP and hospitals had been in a more sound economic area.  4.4.4 Agency responses in a known deprived area of Manchester form the key issue for this TOR. NHS Manchester IMR comments that the GP surgery completed a lifestyle assessment on MW (which is not required), but failed to include a mental health assessment and so missed the previous prescriptions of anti-depressants. The practice did not complete health assessments on SS1 and SS2 (also not required) when they transferred in to the GP practice. However the GP did respond to MW’s financial situation by giving a prescription for a routine ‘across the counter’ medication as, with a child under one year she had free prescriptions, when she had no money.  4.4.5 Economic status can be the cause of discrimination. IMRs from a number of agencies in a previous MSCB SCR indicated that there are areas of Manchester where lack of regard for culture might have had an impact on the services provided. The family lived in a part of Manchester where historically there have been lower aspirations for achievement in school and employment. In this context agencies have demonstrated less concern for a child’s wellbeing than the expectations set out in Every Child Matters.  4.4.6 However the wider context of MW was missed. The MNHS COR draws the different elements together, and also notes that the HV service and GP3 did not consider together the historical missed appointments (including for SS1’s sight), the four appointments missed for Child W in 2012 and the delays in acting on advice when MW was apparently very concerned about her child. Additionally MW failed to follow advice and continue treatments for her own health.  4.4.7 Perceptions of MW’s parenting appeared to influence the agencies in accepting the outcome of the strategy meeting on 29th June. She was seen as an experienced, competent parent with NHS staff not noting or acting on her assertion ‘that Child W marks easily’ (18th May and 27th June). A further difficulty for NHS staff was that MPW was often present at appointments or during home visits making it difficult to ask MW about any concerns in the family relationships. While the HV service knew of his status, there was no exploration by any NHS staff of his own history or caring responsibilities. It is now known that he has a lengthy history of seeking help for his anxiety and cocondrosis and that he is known to abuse alcohol. The MNHS COR notes in 5.5.4 the detail of how little staff asked about him or his role with Child W.  4.4.8 Both SS1 and SS2 had hospital admissions for teeth extractions. This is seen as ‘not unusual’ in this area of Manchester. Figures show that the North West is the worst region for childhood tooth decay and Manchester has the worst record in the North Page 34 of 46 West. The comparative figures for five year olds in the year 2007 – 08 are as follows (Sourced from Office for National Statistics): • Percentage of children with decay experience (i.e.: with one or more obviously decayed, missing (due to decay) and filled teeth) – England 30.9; North West 38.1, Manchester 51.4; • For those children with decay experience, the average number of obviously decayed, missing (due to decay) and filled teeth per child – England 3.45; North West 3.8; Manchester 4.63.  4.4.9 The SCR panel was concerned to hear that Manchester health authorities and the utility companies have resisted the introduction of fluoridisation in the water supply ignoring the evidence that demonstrates significant health improvement. Not only are many children disadvantaged by this policy (enduring pain and the trauma of hospital admissions), but there must be a high cost to the NHS. In Birmingham the percentage of tooth extractions has halved since the introduction of fluoridisation.  4.5 To what extent, if any, did agencies communicate effectively and work together to safeguard and promote the continued well-being of Child W?  4.5.1 Some issues relating to communication have been noted in previous TORs; for example, not inviting the GP to or informing of the strategy meetings, and the absence of the notes made by Cons 1 for use in the discussion. The GMP IMR contrasts the quality of discussion on 13th July with that of 29th June. The IMR indicates that if all the information available from primary care and Hospital 1 on MW and MPW had been discussed, the context of the injuries would have been seen very differently.  4.5.2 The MNHS COR notes that if background information on the whole family had been available, the strategy meeting would have seen some less good parenting by MW of SS1 and SS2, with a longstanding pattern of missing appointments. MW’s determined presentation with Child W on consecutive days could have suggested a different purpose of drawing the injuries to the attention of the NHS (and by telephone to CSC).  4.5.3 The GPs and HV service have considered whether there should have been more communication between them. The Manchester NHS IMR lists the events when it would have been appropriate to check with the HV service or to ask the HV service to make a follow up visit. In both IMRs the professionals acknowledge that there were opportunities missed, and the NHS Manchester IMR author considers it would have made a difference to their management of Child W’s needs. For example, the HV service did not know about MW’s previous episode of depression, or that she had asked for a further prescription after Child W’s birth.   4.5.4 The MNHS COR confirms that this poor communication was an important element in Child W being left unprotected for some weeks. Additionally the report identifies the three missed opportunities when the GP and the occasion when Hospital 1 should have notified CSC.   Page 35 of 46 4.5.5 As noted in paragraph 4.4.7 above, MW’s persistent presentation to NHS agencies clouded any view that there might be safeguarding concerns. Reading the integrated chronology demonstrates the less caring approach at times to the care of Child W. For example, MW discussed a series of concerns with SN4 on 14th May, but did not follow the advice to take the child for immediate assessment by a doctor until the next day when she telephoned GP3; the HV saw the swollen foot on 3rd July (knowing of it from the strategy meeting on 29th June) and advised MW to take Child W to the GP. MW did not take Child W until 10th July.   4.5.6 While not attributing blame to the other agency, both the GP and the HV service had confidence that they would be contacted if other professionals had any concern. The trigger for concern had of course been overlooked when the GP did not follow up the unexplained bruise as a matter to be followed up when alerted by the OOH service. The HV service had the historical information on domestic abuse and if asked to follow up the unexplained bruise may well have escalated concern into child protection systems. Communication did not feel necessary as MW always reported back. However it should not be the expectation that the parent is the message taker between professional staff especially where there are identified concerns. All professional staff should acknowledge their own responsibility for safeguarding and that of each agency.  4.5.7 Factual information was sent routinely by Hospital 1 after presentations at the hospital, but it was sometimes received some days later, and did not include any context, or raise any concerns that might have been discussed.  4.5.8 Even when the GP referred to Hospital 1 for further assessment, there was no feedback to the practice, and the practice did not seek it presumably confident that a written report would arrive at some time.  4.5.9 Hospital 1 did not seek any feedback when Child W was brought in again on 12th July, and CMFT had not sent across any outcome following the events of 27th – 29th June. This meant that Hospital 1 had no information on the safeguarding concern until the 13th July when DR 16 asked for the relevant information from the skeletal survey when he reviewed the X-Ray.  4.5.10 The routine communication by Hospital 1 with CCNT for administration of intravenous antibiotics and with Hospital 2 on 27th June, when MW took Child W was good, meeting the expected standards. Equally communication between the different staff in the HV service and the communication between CCNT team and the HV service was good. Hospital 1 also commended CSC and GMP for quick responses when contacted with safeguarding concerns.  4.5.11 The SCR panel agrees with the author of the PAHT IMR that the practice of DR13 on 13th July and the subsequent medical report and action taken to safeguard Child W was of exemplary standard and should be highly commended.    4.5.12 However the PAHT IMR notes some less good practice in relation to attendances at A&E by both MW and MPW. Neither adult was asked at any time about caring Page 36 of 46 responsibilities. This was poor especially as on one occasion MW had only recently given birth and MPW indicated on 12th July that his stress could be caused by ‘child and relationship’. This contravenes PAHT policy.  4.5.13 The MNHS COR once again draws attention to the lack of focus on the child’s well-being (paragraph 5.4.5) and makes the link to the need for open communication. At the strategy meetings on 28th and 29th June communication was poor. The meeting made decisions without resolving the difference of opinion between Cons 1 and Cons 2, with no information from other key NHS staff including the GP. This difference should have been resolved or discussed with the Named Doctor. The meeting on 29th June relied heavily on medical evidence that said ‘on the balance of probabilities it is not NAI’ instead of considering the vulnerabilities of a young baby. Any unexplained injury should be investigated as a cause for concern. However there was no discussion with the Named Doctor about this uncertainty either.  4.5.14 Finally on no occasion did the GP take responsibility for Child W’s wellbeing when the practice had a number of opportunities to contact NHS colleagues to share information or ask for the family to be checked or monitored more closely. Equally the HV service, who at times recommended MW should take some action using different NHS agencies, did not notify or explain the reason for any recommendation to the GP. While there is an option of ‘choice’ in the NHS with a young baby it may be more important to ensure continuity of treatment. At least if communication had taken place, it would have become obvious to the GP much earlier that MW may have needed more support to care for Child W and that at times her story changed in some important details.   Page 37 of 46 5. Summary – What do we Learn?  5.1 There are six key messages to take from this SCR. These are:  • All agencies have a proactive responsibility for safeguarding children; • A wider understanding of the significance of injuries in young babies is needed in all agencies; • There should be more routine enquiry and need for challenge of adults where risks emerge about living arrangements, relationships and patterns of care;  • Consistent multi-agency citywide agreement and guidance on how strategy meetings are managed and recorded should be developed urgently ensuring full compliance with relevant statutory regulation and guidance;  • There should be greater stress on the importance of clear written and verbal communication within and between NHS agencies; and • Identification of how to flag significant risk from those without formal convictions.  5.2 The MNHS COR describes how there were six missed opportunities for NHS staff to identify or rule out non accidental injuries. The other agencies (CSC and GMP) also missed opportunities to investigate fully unexplained injuries in the strategy meeting on 29th June. The difficulty at times was an assumption that another agency had conclusive information, or that the contextual information on the family was not important.  5.3 The panel were mindful that the recommendations in the IMRs echo or are similar to those in previous SCRs presented to MSCB. This SCR demonstrates that while agencies have taken steps to implement previous recommendations, babies and children may still be at risk in situations where agencies could and should take responsibility for further challenge and investigation.   5.4 In discussion the panel considered that making repetitive recommendations would not be helpful, but instead should draw attention to the possible repetition and seek reassurance from MSCB that lessons have been and will continue to be learned in the multi-agency forum with full multi agency ownership.  5.5 In preparation of this report the author has had access to two recent independent reports commissioned by MSCB to examine the process of SCRs from 2007 but also to look at similarities in the circumstances of the children reviewed and the recommendations made.  MSCB has considered both reports and so appreciates that the matters raised in paragraph 5.1 may be familiar to the Board.   5.6 MSCB has a thorough process for implementing multi-agency recommendations. Historically, when SCRs were signed off by the Board, single and multi-agency recommendations were monitored by staff within the MSCB Business Unit. They would collate evidence that the recommendations had been implemented. The evidence would then be archived into a folder in a secure database and a summary of progress entered onto a master schedule. MSCB would then receive periodic progress reports.   This process has recently strengthened and currently when an SCR is signed off by the Page 38 of 46 Board each agency is forwarded a template to complete with evidence of progress on the implementation of single agency recommendations. Staff within the MSCB Business Unit have responsibility for populating templates on progress of the implementation of multi-agency recommendations. Progress reports on the implementation of single and multi-agency recommendations are received by MSCB approximately six months following the sign off date.  Wider understanding of the significance of injuries in young babies is needed in all agencies  5.7 In this SCR, all three NHS IMRs and the MNHS COR recommended some training or briefing on patterns of injuries in young babies. Previous SCRs have recommended inclusion of some specific elements within the single or multi-agency training. Recommendations have been made in five SCRs about missed appointments, and in three about ‘silo’ thinking, and both of these are relevant in this SCR.   5.8  ‘Child protection concerns not identified’ was relevant in some reviews with ‘missed appointments’ often a key indicator.  Part of the commentary in this SCR on responses from agencies includes the lack of understanding of the significance of missed appointments by MW for herself and the children, both during the timescale of the review and historically. There has been a thorough approach to implementing past recommendations with, for example, NHS Manchester developing a pathway on missed appointments  to prevent further examples of risks to children being overlooked. The Manchester hospitals have also implemented similar pathways and are currently reviewing how they can be simplified into combined documents.   5.9 More important is the lack of recognition by a number of NHS professional staff of probable non accidental injuries in a non-mobile baby. WT 2010 requires all LSCBs to ensure relevant staff are trained to recognise the indicators of abuse. Clearly for Child W there were a number of themes of which missed appointments and unexplained bruising are only two. MSCB had responded to similar concerns in 2010 with an up dated level 1 multi-agency training as well as a separate Child and Young Person Development Course. This is not mandatory and none of the staff involved in the relevant strategy meetings had attended it. MSCB is planning much wider circulation of the details of the course but NHS agencies expect such training to be included in agency courses. Managers at Hospital 2 have developed some training in response to another recent MSCB SCR which should improve recognition.  5.10 ‘Failure to recognise safeguarding responsibilities’ was also identified in previous reviews. There is a tendency for agencies to think in ‘silos’ not recognising their responsibility to consider parenting capacity. The MSCB revised the core safeguarding procedures in 2010 to stress the wider responsibility for recognition of child protection concerns. The revised multi-agency level 1 training also included the key message of responsibility for safeguarding in all agencies. Some agencies have developed this further with MCC Strategic Housing providing safeguarding sessions for registered social landlords and a system of Housing Safeguarding Champions. This recognises that contact with safeguarding is a rare occurrence for staff in some agencies and a forum provides support. Page 39 of 46  5.11 The evidence following the decision not to take the 8th March unexplained bruise into the child protection system supports a commonly held view that left unchecked, inflicted injury in young infants is likely to continue and to escalate in severity. Further when concerns do arise it is unacceptable for parents, no matter how plausible, to be entrusted alone to pursue the investigation as was the case on 9th July.  5.12 This SCR also demonstrates the key role played by general paediatricians in recognising and responding to suspected non accidental injury. General paediatric consultants are central to child protection and their understanding is essential; but with current workloads a better system is needed to support them to identify and support the full investigation of unexplained injuries.   There should be more routine enquiry and need for challenge of adults about living arrangements, relationships and patterns of care   5.13 Discussion in panel centred on how little agencies knew of the relationship between MW and MPW, and how they shared parenting responsibilities between them. However as the review has progressed it has become clear that at times MW was less reliable than her presentation suggested, with:  • some lack of following of advice; • different descriptions of Child W’s symptoms;  • concentration on her own health at times; and  • not acknowledging how much MPW took responsibility for care.  5.14 The MNHS COR sets out some expectations that any adult presenting at A&E should be asked about caring responsibilities with a standard question included in A&E recording systems. However the paediatric, GP and HV services should have enquired more about MPW’s role in the home, especially as he was present on a number of occasions. Some questioning may have uncovered MPW’s stress and the potential for stress when caring for three step children.  Since June 2010 this element (details of the father and role in child care) has been included in maternity booking sessions and NHS Manchester children’s assessments.  5.15 However as well as some factual information a recent MSCB recommendation was ‘Training needs to be developed to assist practitioners in challenging parents and patients when key indicators of risk have been identified’.     5.16 Obviously this theme is only relevant if the risk or injury has been identified. CMFT has specific training on challenging parents when key indicators of risk are present. Children’s Social Care has amended the Social Work Handbook and provide specialist training on the role of fathers and males as part of the training for completion of Core Assessments. Compliance with the Handbook is monitored. Practice guidance on risk assessment was implemented from September 2010.  5.17  The recommendation in the NHS Manchester report will provide some additional information, when GP practices read code or flag previous history, and treatment, to highlight risk indicators. A previous recommendation has been ‘Flagging of children and Page 40 of 46 their families to indicate they are “at risk” should be promoted, as has been recommended. The death of a child should be included with flags placed on the records of parents and other siblings.’ There has been great improvement in use of flagging supported by the GP Steering Group. As GPs are independent practitioners MSCB cannot require this action but should identify the best method of active promotion so that the implications are understood.   5.18 ‘Flawed assessment’ has been noted locally as well as in Ofsted evaluations when there is a dearth of information about fathers or male figures in the household. Even if the events in March had proved inconclusive an investigation could have raised some of the issues to identify the risk factors in Child W’s family. MSCB understands the ease with which agencies can concentrate on the positives as happened at the strategy meeting of 29th June, and was echoed by the GP and HV service when MW was discussed as part of the preparation of the IMRs.   5.19 The other element that was not spotted by agencies was MW’s apparent concern and wish for diagnoses. It is only with the opportunity to see the integrated chronology that this is fully clear, but the MNHS COR has identified each opportunity when there should have been further questioning or investigation.   5.20  ‘Difficulties engaging some families’ is a familiar theme for SCRs. MW was difficult in that she was clearly very worried about Child W, but was unable to give clear messages about any concerns she had from her relationship with MPW. With hindsight it may be that she 'engaged selectively’ with the agencies.   There should be greater stress on the importance of clear written and verbal communication within and between NHS agencies  5.21 The heading discussed in paragraphs 5.13 to 5.20 can only be remedied if there is good and regular communication whenever there is an unexplained situation relating to the care of babies and children.  5.22 This review has found some excellent written agency records, specifically in the HV service, Cons 1, DR13, ophthalmology and radiology. However until the strategy meeting on 13th July, the pattern of presentation of Child W and historical information was not taken into account. Importantly regular communication between the GP and the HV service was missing. An early check would have identified the discrepancies. In particular when the HV service recommended MW should take Child W for immediate attention, the GP should have been verbally notified and had the concerns explained.  5.23 The GP practice has accepted that they ‘took a back step’ when secondary services were involved, and while the GP has a primary responsibility, secondary services could have provided more contextual information for the GP to add to their records. Neither the HV service nor the GP reviewed notifications with any questioning. There appears to have been a belief that because the family were not hidden and appeared to be Page 41 of 46 proactive in seeking medical review this decreased rather than increased the need for information sharing and clarification.   5.24 Equally there was poor communication between Hospital 1 and Hospital 2. Clarity on the reason for presentation and previous treatments are essential at CMFT where by necessity as a regional centre, any examination and diagnosis will involve multiple professionals to deliver the care for any individual patient.   5.25 Communication is often raised in SCRs. A previous MSCB SCR recommended ‘that a joint health information sharing system should be developed and implemented across all Manchester Trusts that addresses the lessons learned in this serious case review.’ This would be a huge piece of work and while there has been much progress, there is still work to do.  The relationships between the different community, acute and specialist services in Manchester are complex, but some work has been completed to ensure a joint pathway for maternity services. In relation to communication between primary and secondary care, the procedures for sharing information have been revised to provide written information to the GP practice within 48 hours of a hospital attendance. There is current consultation on an electronic system to notify of attendance at emergency services.   5.26 A number of elements outlined in paragraphs 5.22, 5.23 and 5.24 have recently been reported to MSCB within the MNHS COR for a recent SCR which stated:  ‘This suggests that following protocols is not sufficient to effectively protect a vulnerable child. The CMFT IMR author comments that it was the actions of health staff which enabled the timely detection of the child’s injuries. However, the author feels that surveillance by health staff and multi agency liaison should have prevented the harm occurring and detection once it had occurred was too late.  Other recent SCRs have highlighted the role of GPs in safeguarding and the important part they can play in the process. In recognition of this a GP child protection steering group was set up in Manchester to advise on the implementation of recommendations.  Previous recommendations include flagging of GP records of children subject to a child protection plan and their families. These recommendations have already been implemented. There is work ongoing to increase GP involvement in child protection case conferences. There is a programme in Manchester to train all GPs in safeguarding and to provide an enhanced level of training for the identified GP safeguarding lead in each practice. The NHS Manchester IMR author recognises the need for further development of the role of the GP in her recommendation to flag at risk families and not restrict flagging to children subject to a child protection plan.  There is work currently taking place to ensure GPs are informed as soon as possible by fax when a child has had a child protection medical in any setting in Manchester so that they do not have to wait to be informed until the full report is ready which may take several days.  Under the new arrangements for commissioning set out in the Health and Social Care Act, GPs* will be responsible for commissioning services and monitoring the quality of safeguarding services. They will also have a statutory duty to sit on the MSCB. They therefore need to be kept fully informed of safeguarding issues affecting their patients. This has to be considered by both partners in health and by other agencies. The author and Designated Nurse meet regularly with the GP Steering Group and with the nominated Page 42 of 46 Responsible Officers for the Clinical Commissioning Groups to continue to highlight safeguarding issues in general practice.’ *now implemented through Clinical Commissioning Groups   5.27 In the light of such a recent discussion the panel considered further multi-agency panels would not be helpful but that MSCB must satisfy itself that previous recommendations are being implemented in a robust manner. The MSCB noted there is already progress which will contribute to this challenge: • The work on HV and GP pathways and communication have already set up a pilot which includes an Early Years New Delivery Model; and • The HV Task Force has had accepted an increase of 71 whole time equivalent staff by 2015.  Consistent citywide multi-agency agreement and guidance on how strategy meetings are managed and recorded is urgently needed.  5.28 This heading is also a repeat of previous recommendations but the panel strongly consider that there is no reason that prevents full and early implementation of a robust mechanism for strategy meetings. All the IMRs comment on the crucial role of the strategy meetings in this SCR.  5.29 The panel is aware that a number of strategy meetings (as acknowledged in WT 2010) are telephone conversations between GMP and CSC. However the panel’s view is that if following some investigation, there are still unexplained circumstances, a meeting should be arranged with a NHS representative to ensure appropriate information sharing from all relevant NHS services.  5.30 The panel appreciates that this proposal will require some multi-agency discussion. However the importance of agreement cannot be stressed too much as Child W was subjected to some serious abuse because the system currently in place was inadequate.  5.31 Comments from GMP have already been included in paragraphs 3.1.15 and 4.3.9. Examination of the notes of the strategy meetings on 28th and 29th June showed some poor recording, with the records not signed or dated, people present not recorded, and pages unnumbered. The requirement should be: • a competent chair, appropriately experienced to manage the complexity of the case; • timed to include relevant agency representatives; • following a routine format; • with less reliance on medical evidence, rather a challenge for explanations of bruises or markings;  • a greater questioning of who has cared for a child, and their background; • with discussion based on full information from NHS staff who have seen the child as part of their routine service or as an acute episode. Page 43 of 46 5.32 The current MSCB procedures for managing and recording strategy meetings are not as clear and helpful as they could be (paragraphs 9.12 and 9.11) and revision following discussions should be completed.  5.33 The procedure should stress that all participants have equal status and a professional from any agency can check detail. When strategy meetings are held in a hospital the role of the CPN should be understood by all present. This should allow a better challenge of plausible parents and of the view that there will not be abuse where a family is socially stable and settled in the community.    5.34 MSCB at the January 2013 meeting had agreed to commission a report, with the initial one available for the board at the end of January 2013 outlining: a) Is sufficient priority and time being invested in S47 meetings? b) Are the right people invited? c) Do those who need to know receive the plan? E.g. GP, Examining Paediatrician, School, Health Visitor? d) Is every child considered for an ‘Achieving Best Evidence’ Interview and the rationale for a decision recorded?  5.35 As indicated in paragraph 3.2.12 the panel do not consider it to be helpful to make another recommendation when there is apparent activity in a number of agencies. The Safeguarding Practice Improvement Group (SPIG) has set up a task and finish group which has almost completed the work on a pro forma and flow chart. The panel was unsure how this links with the proposed joint audit by GMP and CSC of eight weeks of strategy meetings described in CSC IMR paragraph 7.1.4. As part of another recent MSCB SCR, PPIU are developing a pack for use in GMP. The strategy meeting is where the focus is specifically on making key decisions about the child and so the SCR panel sees it as crucial that some priority is given to finding solutions.   Identification of how to flag significant risk from those without formal convictions  5.36 This is the final lesson for this SCR in ‘what we have learned’. It introduces an element for MSCB to consider that has not been raised in previous SCRs. The panel had a long discussion about the limitations of current systems to alert staff in any agency raising a concern about a child being at risk. The difficulty is that once CPS has made the decision to not proceed with a prosecution there is no mechanism of alerting a professional to the concern. It was felt that there should be wider consideration of how NHS agencies in particular but also the police and social care can be alerted to the risk presented.   Conclusion   5.37 The panel in light of the evidence from the agency reports agreed that the injuries to Child W, possibly from March 2012, and certainly from the end of June 2012 were preventable. If agencies had considered information about MPW and taken into account the detail of MW’s sometimes contradictory presentations, it is possible that Child W would have been considered as ‘at risk’. However this judgement is made with hindsight and the severity of the assaults could not have been predicted.  Page 44 of 46 5.38  Instead of a list of recommendations the panel asked MSCB to consider this report (April 2013) and that agency representatives on the Board should agree how to bring evidence of change to future boards to demonstrate the messages and learning of the recent SCRs have been integrated into all agencies. MSCB met again on 9th May to plan their response to the six challenges set out below. A brief summary of the proposed timetabled programme of implementation is included below and MSCB will submit the detailed plan as the action plan.   6. Multi Agency challenges  1 - All agencies have a proactive responsibility for safeguarding children  This is an overarching responsibility for MSCB. It is important that each agency contributes and does not assume that one role or agency has a greater responsibility than others. For this reason it is essential that all agencies adequately identify the responsibility for safeguarding children in each agency’s procedures. SCRs have commented on the human bias of optimism when an agency knows a parent over some time, or is making an assessment when there is a ‘plausible or compliant parent’. It is important that this tendency is well understood, objectively managed and appropriate action taken.   Question: How will MSCB ensure that each agency has robust procedures that are effectively used to protect children and then demonstrate/satisfy itself that all relevant staff and professionals are proactive in discharging their safeguarding responsibilities effectively?  2 - A wider understanding of the significance of injuries/symptoms of injury in young babies is needed in all agencies  It is important not only to ensure that all staff in all MSCB member agencies understand the vulnerability of young babies, but that explanations and context will contribute to an objective assessment of probable cause. This SCR has demonstrated that even highly qualified medical and nursing staff can overlook the likelihood of inflicted injuries in non-mobile babies. It is important that staff appreciate there may be no evidence of an injury but there will be symptoms of pain, or discomfort which could also have a medical cause.  The MNHS COR identifies the difficulty of raising issues when there is a professional deference within health and to health professionals by other agencies, so MSCB has to help create a culture where openness to challenge, when there is uncertainty, is expected by all agencies. Included in the challenge to colleagues at child protection meetings is the promotion of a healthy and non-judgemental approach to seek more specific explanations from parents. This expectation can be difficult for the more senior as well as the junior staff and so there should be a system of rigorous support for quality supervision/mentoring across agencies.  Question: How will MSCB make sure that the use of training and briefing sessions is integrated into practice and seek evidence of the openness to challenge within child protection meetings? Page 45 of 46 3 - There should be more routine enquiry and need for challenge of adults about living arrangements, relationships and patterns of care  Any assessment of risk or vulnerability has to be based on clarity of information on the roles and relationships within the family. In this instance the role of MPW was unclear both in relation to his care giving and frequency of presence. The review has not considered the role of MW’s parents but it is known that they also provided support. All agencies should check at initial enquiries and in assessment interviews about who lives in a household, frequency of visits of partners not living at the home, and their role in care giving. For this to be completed routinely staff must understand how the nature of adult relationships contribute to uncertainty of strengths for caring for babies and young children.   Question: How will MSCB satisfy itself that all agencies have systems for routine enquiry that can be used as an evidence base when risk or vulnerability is identified?  4 - Consistent multi-agency citywide agreement and guidance on how strategy meetings are managed and recorded should be developed urgently  There have been previous recommendations about strategy meetings. This panel asks MSCB to give clarity to their expectations for future strategy meetings with a revised multi-agency procedure which complies with statutory guidance that has MSCB approval. As there will be regular changes of staff it is important that compliance with the multi-agency procedures is monitored.  Question: How will MSCB ensure the management of strategy meetings is continuously compliant with revised and agreed multi-agency procedures?  5 - There should be greater stress on the importance of clear written and verbal communication within and between NHS agencies  NHS agencies must have some expectations for staff to communicate to GPs verbally and in writing when they have a first or unexpected contact with a child. When a child is taken to different hospitals there is a responsibility to communicate in a timely way with the GP but also to seek information either from the GP or the other hospital on previous presentations. It is important with the city having a complex arrangement of health care that there is continuing evidence of improvement. The panel discussed the possibility that MSCB might consider requiring a full review of communication systems from the health agencies.  Question: How will MSCB satisfy itself that there are robust and timely communication systems between community services, GP practices, out of hours services and acute services?   6 - Identification of how to flag significant risk from those without formal convictions  The panel discussed how agencies decide when and how to share information especially with CSC or GMP when there is some evidence of non-accidental injury. The limitations of current systems became clear when CPS decided not to pursue a prosecution. The outcome is that an adult, who has been the subject of police investigation in relation to significant Page 46 of 46 harm to a child but has not been prosecuted or convicted, is living in the community but agencies have no knowledge of the history. This is complicated in this particular case where MPW has an address in another Greater Manchester local authority and a birth child in a third authority area. Information about the arrest and investigation, together with access to forensic information will be available locally through GMP Force Intelligence System and nationally though the Police National Computer. However this will only be available at the point of an enhanced CRB check, or a strategy meeting. It is more likely that information would be available through GP flagging or read coding. However the issue is wider than MSCB or even the North West.   Question: What action could MSCB take to raise the matter for wider discussion or action?   Summary from the draft implementation programme from MSCB:  MSCB has started a number of pieces of work in response to this SCR as well as continuing with plans from the recent previous SCRS. This includes: • reviewing all agency safeguarding procedures to ensure they comply with WT 2013; • dissemination of the learning from this SCR particularly in the areas of challenge and understanding of the vulnerability of non-mobile babies;  • training  and launch (planned for August 2013) of the recently completed paperwork and guidance for chairing and participating in strategy meetings;  • continued improvements to arrangements for single processes between hospitals, and clearer expectations of communication between HVs, midwives and MCC Early Years; • strengthening monitoring of compliance with all procedures and in particular testing the robustness of strategy meetings; and • taking advice so that the MSCB can raise at national level the implications for safeguarding when there is no prosecution potentially leaving other young children at risk from a perpetrator.   The SCR panel did not meet after MSCB prepared the responses to the challenges. However in discussion the independent chair and author considered some of the responses were not sufficiently robust to prevent further similar future recommendations. The two main areas of concern are: • the planned training on the vulnerability of non-mobile babies across all the relevant agencies; and  • how NHS agencies will complete more thorough enquiries about family circumstances to rule out or identify risk factors when there are questions over the cause of injuries or symptoms.    Final message: This is an unusual ending for a SCR Overview Report but it has been written in this format in the expectation that all MSCB members will have some clarity about their responsibility to pro-actively improve safeguarding responses to young babies and children.   