Death of an 11-week-old girl in January 2013, as the result of serious injuries consistent with violent shaking. Post mortem found subdural and retinal haemorrhages and signs of damage to the brain and spinal cord. Skeletal survey revealed an old fracture to the left radius bone and another possible healed fracture in the same bone, believed to have occurred 6-8-weeks prior to the injuries leading to Child D's death. Father was found guilty of Child D's manslaughter. Mother experienced abuse in the family as a child and, as a result, was made the subject of a child protection plan in 2006. During the review process a number of professionals expressed concerns that mother might have a learning difficulty; none of the professionals who had been in contact with mother in the 5-years previously felt she had a learning difficulty. Findings from a detailed assessment following Child D's death identified mother as having an IQ score which placed her in the lowest 3 per cent of the population and identified significant difficulties with memory recall. Father was seen by GP as a young adolescent, in relation to problems with his temper, depressed mood and verbal aggression. Following the incident father admitted assaulting mother on two occasions, neither of which was reported to professionals prior to Child D's death. Following Child D's death, mother reported that Child D had been bruised on three occasions when in the care of father. One of these bruises was seen by four health professionals prior to Child D's death. Identifies themes including: how vulnerable young people who might need additional support when they become parents are identified and helped; the value of information, including social information, being held in GP records; engagement of the father and assessment of his role; professional responses to bruises in small babies; working arrangements between health visitors and GPs; and assessment of parental learning difficulties and their impact on parenting. Makes various recommendations.
      
 Title:  Overview report: services provided for Child D and her family. LSCB: Luton Safeguarding Children Board Author: Keith Ibbetson Date of publication: 2015  This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC.  This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above.                            1   Serious Case Review  Overview Report Services provided for Child D and her family      Luton LSCB Independent Chair  Professor Michael Preston-Shoot Lead Reviewer Keith Ibbetson October 2015    2 Preface by the Chair of Luton Safeguarding Children Board  Between March 2013 and June 2014 Luton Safeguarding Children Board conducted a Serious Case Review triggered by the death of an 11 week old baby who died as a result of injuries caused by shaking. The infant is referred to in this document as Child D. This report presents the full findings of the review of provision made by agencies in Luton and at Great Ormond Street Hospital in London. The publication of this report was delayed in order to ensure that it did not prejudice the criminal investigation into her death. Child D’s father was convicted of her manslaughter in July 2015. The functions of the Serious Case Review are to provide a rigorous analysis of the actions and decisions of professionals and to identify ways in which services for other children and young people can be improved. I am grateful for the cooperation of everyone who has supported the work of this review. It is a matter of regret that members of Child D’s family have not responded to offers to participate in the review.  The findings of the overview report are presented in the following way:   Part 5 of the report is an Executive Summary which provides an overview of the key events, findings and recommendations  Parts 1 and 2 explain why and how the review was conducted  Part 3 gives a detailed narrative which will enable readers to understand the key events, decisions and actions taken. It also contains a critical appraisal of the services provided highlighting both strengths and shortcomings. This will be of particular interest to those who work within or manage similar services.  Part 4 provides a full explanation of the most important findings of the review. Some are findings directly relevant to the death of Child D. Others refer to wider learning for services to safeguard children. I hope that by setting out the report in this way it will be possible for readers with different objectives to find the information that they need.  Alongside this report the LSCB has published a formal response to the findings of the Serious Case Review and a plan setting out in detail the actions that agencies and the board have taken since 2013 to improve services.      Professor Michael Preston-Shoot Independent Chair  Luton Safeguarding Children Board  October 2015    Services provided for Child D Serious Case Review Findings   1. Arrangements for the Serious Case Review 1 2. Method used to undertake the Serious Case Review  6 3. Narrative of events 9 4. Evaluation of the services provided and the wider implication for professional practice and service provision 26 4.1 Introduction   4.2 How vulnerable young people who might need additional support when they become parents are identified and helped  26 4.3 The identification of risk or vulnerability in relation to Child Y (Child D’s older half-sibling)  30 4.4 Support and help provided in relation to Child D’s medical condition 32 4.5 Engagement with the father and assessment of his role 33 4.6 Professional responses to bruising in small babies - the recognition of possible signs of abuse of Child D and the action taken by professionals  35 4.7 Working arrangements between GPs and health visitors in relation to the 6-8 week health review and other aspects of the Healthy Child Programme  43 4.8 Access to urgent and emergency health care in Luton for babies and small children 47 4.9 Assessment of parental learning difficulties and their impact on parenting 49 5. Summary of findings and recommendations 52  Appendices  I  Membership of the SCR review team 55 II  List of documents and material considered by the SCR review team and roles of professionals who have contributed  56 III  Principles from statutory guidance informing the SCR methodology 57 IV  References  58    1 1 ARRANGEMENTS FOR THE SERIOUS CASE REVIEW Introduction 1.1 This report was prepared for Luton Safeguarding Children Board (the LSCB) in order to fulfil the requirements of the statutory guidance Working Together to Safeguard Children 2013.1 The guidance sets out the arrangements for the local interagency review of serious child protection cases. The LSCB is required to identify opportunities to improve the provision that is made for vulnerable children. This overview report provides a public statement of the findings of the Serious Case Review (SCR). In keeping with statutory requirements the LSCB has published the SCR overview report in full. Reasons for conducting the SCR 1.2 The SCR primarily concerns the provision made by health agencies to an infant (referred to as Child D) who died in January 2013 at the age of 11 weeks. 10 days before her death Child D had been admitted to the local general hospital with injuries which gave rise to strong suspicion of serious physical abuse. She was then transferred to Great Ormond Street Hospital (GOSH). The infant was already known there because immediately after her birth Child D had received surgical treatment for a medical condition that had been identified during pregnancy. 1.3 Post mortem examination of Child D confirmed three findings that are strongly associated with injury caused by violent shaking: subdural haemorrhages; retinal haemorrhages and signs of damage to the brain and spinal cord.2  1.4 A skeletal survey undertaken shortly after the serious injuries were identified revealed an old fracture at the lower end of the left radius bone (the forearm near the wrist) and another possible healed fracture in the same bone. In children such injuries are often found to have been caused by abrupt pulling, twisting or swinging, though in Child D’s case the family court has ruled that their cause could not be determined.  1.5 These injuries are believed to have occurred 6 – 8 weeks before the serious injuries that caused Child D’s death. They would not have contributed to the child’s serious illness or death. They would also not have been noticeable in the course of day to day contact with the baby or during the routine medical examinations that Child D underwent during this period. The existence of these injuries is however central to the findings of the SCR because if other signs of possible abuse had been                                             1 HM Government, Working Together to Safeguard Children – 2013. Chapter 4. This guidance has been superseded, but this has no significant implications for the review 2 That is 1) bleeding into the space between the brain and the skull; 2) bleeding in the back wall of the eye and 3) damage to the brain. Among clinicians and in the courts there continue to be differences of opinion as to whether this ‘triad’ of symptoms can be viewed as diagnostic of such injuries. However in this case there was a consensus among the expert medical witnesses who provided evidence for the care proceedings that injuries caused by shaking had caused the death.    2 reported and investigated these injuries are likely to have been identified. The reasons for this are set out in full in Section 4.6 of this report and in its conclusions in Section 5. 1.6 Child D had an older half sibling (subsequently referred to as Child Y). After the death of Child D the local authority made a successful application for a Care Order in relation to this child. In these proceedings the court found that the injuries that caused Child D’s death were inflicted by her father, but that he did not injure her intentionally. This finding and others made during the course of these proceedings have informed the SCR.  1.7 The SCR has reviewed the provision that was made for Child Y who had for a number of years received services because of concerns about her behaviour and development. There had been no identified safeguarding concerns in relation to her, she had not been the subject of a child protection plan and she had never been in care. 1.8 Working Together 2013 states that the LSCB in the area where the child lived should conduct a SCR when a child has died and ‘abuse or neglect is known or suspected’.3 The circumstances described fit this criterion and the LSCB decided to conduct a SCR. The recommendation to hold the SCR was made by the LSCB SCR group meeting on 11 March 2013. The independent chair of the LSCB Professor Michael Preston-Shoot immediately made the decision to undertake the SCR. Work began at that point to agree the scope and focus of the review.  The scope and focus of the Serious Case Review bearing in mind the circumstances of the death and the involvement of agencies with other family members 1.9 The purpose of the SCR is to provide a ‘rigorous, objective analysis’ of the services that were provided to the child and family ‘in order to improve services and reduce the risk of future harm to children’. The LSCB is required to ‘translate the findings from reviews into programmes of action which lead to sustainable improvements and the prevention of death, serious injury or harm to children. 4  1.10 It is for the LSCB to determine the scope and focus of the SCR. In its initial discussions the team conducting the review agreed that the SCR would focus on the following areas:  The steps taken to identify and assess the mother's vulnerability and parenting capacity (including the impact of possible learning difficulties)  The extent to which the father engaged with services  The provision made in response to the identified emotional and behavioural difficulties of the older half-sibling (Child Y)                                             3 LSCB Regulations 2006 (Regulation 5) 4 Working Together 2013 4.1 and 4.6    3  The provision made for Child D and other family members up to the point when the serious injuries were identified  Any vulnerability arising from Child D’s pre-existing medical condition and the care provided in relation to this  The response of professionals to any indicators of risk identified in relation to Child D. These were not fixed terms of reference. During the course of the SCR it became clear that the following aspects of provision should also be addressed:  The arrangements in Luton for the 6-8 week child health assessment  The arrangements for access to emergency and urgent health care in Luton for babies and small children  1.11 These matters are considered either because they were found to be significant in relation to the outcome for Child D or because evaluation of them helped understand services for children more widely. In each part of the evaluation (Section 4 of the report) the focus of the finding is made clear. 1.12 The review has considered both the work of individual agencies and multi-agency working and it has sought to understand the role that individual, professional and organisational factors played in shaping the actions taken and decisions made. The task of the SCR is to understand the reasons for any strengths or shortcomings in services. Findings and recommendations 1.13 The SCR has made recommendations to individual agencies or to the LSCB on areas where services can be improved. Some are simple practical steps. In some instances the SCR has produced findings which require further work by the LSCB and member agencies before deciding what action to take. Alongside the publication of the SCR report the LSCB has published a statement setting out the action that the LSCB, member agencies in Luton and Great Ormond Street Hospital have taken in response to the review and how the steps taken will impact positively on services for children. Key periods of agency involvement covered by the SCR 1.14 The SCR has taken account of events during the period between 2007 (the mother’s pregnancy with Child Y – the half sibling) and January 2013 (the admission of Child D to hospital with serious injuries). The review has concentrated most attention on the period between April 2012 and January 2013. It does not consider events that occurred after it had been identified that Child D had been seriously injured.    4 Agencies involved  1.15 The SCR considered the work of the following agencies and contracted professionals. Those with the most significant involvement with the family actively participated in the review:  Luton Clinical Commissioning Group (formerly Luton PCT and NHS Luton) – which commissions health services in Luton  Cambridge Community Services NHS Trust – which provides community health care for children in Luton, including health visiting services  A playgroup; a nursery and a school (all in Luton) attended by Child Y  Luton and Dunstable University Hospital NHS Trust – which provided midwifery, child health and emergency department services  GP surgeries, the GP Urgent Care Clinic (located at the general hospital)  Great Ormond Street Hospital NHS Foundation Trust – which provided surgical services  Bedfordshire Police (background information)   East of England Ambulance Trust   Cambridge University Hospitals NHS Foundation Trust – which provided a specialist ambulance service. The SCR review team 1.16 A full list of the roles and job titles of SCR review team members is set out in Appendix 1. Review team members are experienced clinicians or managers in member agencies or designated health professionals with substantial experience of safeguarding children. Keith Ibbetson acted as lead reviewer and prepared this report on behalf of the review team. He does not work for any of the agencies involved in the review or have any relationship with those involved in the case. He is an experienced SCR author and chair.  1.17 The review team met on six occasions to conduct the review. Review team members were involved in carrying out interviews with professionals who had been involved with the family. Section 2 of this report contains details of the steps taken to conduct the review. Parallel processes that have impacted on the conduct of the SCR 1.18 Bedfordshire Police conducted a criminal investigation into Child D’s death. The review team has been kept informed of relevant information gathered during the course of the investigation. The local authority obtained a Care Order in order to safeguard Child Y (the surviving half-sibling).  1.19 The SCR review team has sought advice from the police and the local authority legal department in order to ensure that the review does not prejudice the legal or civil proceedings. Information from the fact finding    5 civil hearing has informed the SCR findings. The way in which this has been done is described in Section 2 of the report. Agreed extensions to the normal timescale for completion of the SCR 1.20 The SCR has taken longer to complete than the six months set as a guide in Working Together 2013. This was due to a number of factors including the time taken to receive the full post mortem examination findings (which is normal in such cases) and the need to involve a professional who was critical to the review findings who now works overseas.  1.21 The LSCB agreed to delay completion of the report in order that it could consider the findings of the care proceedings. This has enabled it to take account of evidence provided by the parents about events and the full range of expert opinion, both of which have been tested in detail by the court.  1.22 The Independent Chair of Luton LSCB and central government have been briefed about the progress of the review. The LSCB Executive and participating agencies have taken action on areas where immediate concerns about practice were identified during the review process. Involvement of family members 1.23 The mother and father of Child D were informed about the decision to undertake the SCR via their solicitors and invited to contribute. Neither solicitor responded to or acknowledged the correspondence. It was recognised that it was always unlikely that the parents would wish to contribute at a time when to do so might prejudice their position in relation to the care proceedings and to the criminal investigation. Neither wished to contribute after the trial. This has meant that the SCR has been unable to learn from their experience of involvement with services or test their accounts of events. Agreement of the SCR findings and arrangements for publication 1.24 A draft SCR overview report was discussed by the SCR review team and agreed after amendments. The findings of the review have been discussed with staff who were directly involved. The report has been agreed by participating agencies. It was presented to Luton LSCB on 18 June 2014 and accepted by the Board.     6 2 METHOD FOR UNDERTAKING THE SERIOUS CASE REVIEW 2.1 Working Together 2013 sets out principles that should inform the methodology for SCRs. These are reproduced in Appendix 3 and the review has sought to adhere to them. The review process and methodology 2.2 The review was conducted by a team consisting of the independent reviewer, designated health professionals employed by Luton Clinical Commissioning Group, senior staff (Named Nurses, the Named GP and Named Professionals) employed by the main health bodies that had worked with Child D and her family and members of the Luton LSCB Business Unit. Full details of the roles of review team members are set out in Appendix 1. None of the members of the review team had had any previous contact with Child D or other family members. Initially meetings of the review team were led by the lead reviewer. Later meetings were chaired by a senior representative member of a local agency which had had no involvement with Child D in order to provide additional scrutiny of and challenge to the findings.  2.3 The review team compiled a chronology of key events based on the written and electronic agency records.  2.4 Members of the review team conducted interviews with key staff who had been involved with the family and with senior representatives of the agencies who could advise on agency policy and organisational matters. The roles of those interviewed are listed in Appendix 2. The intention was to understand as fully as possible the actions that had been taken and the reasons for them. The review sought to understand events as they had been perceived and experienced by the professionals involved at the time.  2.5 Transcripts and detailed notes of the interviews were discussed at meetings of the review team. The team also reviewed copies of some individual case records and background documents. A meeting between two review team members and key early years and school staff was digitally recorded. The record of this meeting (which related to Child Y) and local authority notes relating to behaviour support and education services were additionally reviewed by Luton Borough Council’s Principal Educational Psychologist in order to provide further expert scrutiny and challenge. 2.6 A decision was made to delay the completion of the review in order to enable it to take account of the findings made by the judge in the care proceedings. This was done so as to ensure that    7 the review was able to take account of all of the information that had become available and of the findings of fact made by the judge. The SCR has not had the opportunity to make any independent assessment of the evidence presented in the court. 2.7 The lead reviewer prepared a draft copy of this report which was discussed at a review team meeting. The findings of the review were then discussed at meetings with staff and managers who had been directly involved.  2.8 The revised overview report was circulated to participating agencies for formal comment and agreement before being submitted to Luton LSCB for discussion and agreement. Camden LSCB has also considered the findings. The framework for making judgements about the actions and decisions of professionals 2.9 Self-evidently there is value in reviewing the history of a case, knowing the outcome and with a fuller knowledge of events. However along with the clarity that hindsight brings the review has been aware of the danger of what is termed ‘hindsight bias’. This arises when the evaluation is unduly influenced by knowledge of the outcome because ‘looking back the situation faced by the clinician is inevitably grossly simplified’.5  2.10 It is easy to criticise the decisions and actions of professionals because they can now be seen to be part of a chain of events that had a tragic outcome. If decisions and actions are judged out of the context in which they occurred it is likely to reduce the value of the investigation. More valuable learning can be obtained by seeking to understand and explain why decisions were made and actions taken taking full account of the influences over professionals arising from the context within which they were working. The SCR has therefore sought avoid hindsight bias.  2.11 In keeping with this approach judgements about actions and decisions take into account the information that was available to the professionals who took them. At certain points it is necessary to evaluate the overall service provision in relation to information that was known to the network of professionals as a whole or ought to have been available if relevant information had been shared.  2.12 The review has been particularly mindful of the danger of hindsight bias in making use of information from the care proceedings, since the court has had the advantage of material                                             5 Charles Vincent (2010) Patient Safety (second edition ) Wiley-Blackwell BMJ Books, pages 50-52    8 (including admissions made in evidence to the court) that was not previously known to professionals. The report therefore distinguishes clearly lessons based on professional knowledge at the time and information that is now known.  2.13 The review has sought to judge the actions of professionals and agencies against established standards of good practice as they applied at the time when the events in question took place. Nevertheless where the actions of individuals, groups of professionals or agencies as a whole are found to fall short of established professional standards this will be stated, together (where it can be established) with an explanation of why that happened. An organisational or systems approach 2.14 As well as focusing on the actions of the individuals who were directly involved with the family, the SCR has tried to understand and distinguish the influence of a range of organisational factors in the decisions and actions taken. The additional focus on the team, the service, the agency as a whole and the collective actions of agencies together does not diminish the responsibility of individuals to act professionally and to work effectively. It explains the factors that sometimes make it harder for them to do so. Recognition of strengths in professional practice 2.15 Research points to the value of identifying strengths in practice, ordinary things that were done well and the steps that professionals took to provide a good service when faced with difficulties.6 Agencies need to learn from these and promote them as well as learning from shortcomings. When these are judged to be significant, they have been highlighted.                                              6 See for example Vincent, Patient Safety (op cit); E Hollhangel et al, Resilient Health Care; E Rowley and J Waring (eds) (2011) , A Socio-cultural Perspective on Patient Safety, Ashgate    9  3 NARRATIVE  3.1 This section contains a narrative of events. In Section 4 key episodes are evaluated in more detail where this assists in identifying measures that will improve safeguarding. In relation to Child D this is a full narrative of a short period of agency involvement. This is because the most important learning from the review has arisen from a very detailed evaluation of the interactions between professionals and the family and between professionals working in different agencies at a number of critical points in the case history. The mother’s personal background and family history 3.2 Child D’s mother experienced abuse in the family in which she grew up. As a result she was made the subject of a child protection plan in 2006. Her first child (Child Y) was born in late 2007. In late 2012, during the latter stages of her pregnancy with Child D, the mother gave evidence in civil court proceedings about this abuse. This assisted in protecting younger members of her family. This is referred to further in Sections 3.25 – 3.28 below. The extent of professional knowledge about the mother’s history of childhood adversity and the extent to which this was taken into account in the work that professionals undertook with her when she became a parent is highlighted at a number of points through this narrative and is evaluated in Section 4.2. The father’s personal background and family history 3.3 The GP records of Child D’s father show that in 2004 when he was a young adolescent he was seen by his GP because of problems with his temper, depressed mood and verbal aggression. He was referred for counselling but there is no information to indicate whether he attended.  3.4 None of the professionals who worked with Child D knew about this history or asked the father anything about his background. The father had a different family GP to other family members.  3.5 No other adverse information has been identified about the father’s history. During the care proceedings that followed the death of Child D he admitted assaulting Child D’s mother on two occasions but neither incident had been reported to professionals before Child D was seriously injured.    10 The contact that professionals had with Child D’s father and the limited amount of information that was obtained about him are discussed further in Section 4.5. Professional involvement with the mother during her first pregnancy 3.6 In May 2007 Child D’s mother was referred to the Luton and Dunstable University Hospital (LDUH) for ante-natal care. The mother saw the specialist Teenage Caseload Midwife (TCM) who provided additional support for very young mothers. The TCM gained a good understanding of the mother’s background and family history, including the fact that she had been the subject of a child protection plan and the reasons for this. She understood that the mother had left school early without obtaining any qualifications. The mother was referred to a number of support services and remained in touch with the specialist midwife throughout her pregnancy.  3.7 There was no major medical concern during the pregnancy but the mother was very anxious and arranged to be admitted to the ante-natal ward on several occasions because of back pain and other difficulties.  The SCR judged the involvement of the Teenage Caseload Midwife (TCM) to be a strength in service provision which should continue to be promoted and supported by commissioners of health services and the LSCB. Information about the extensive support which the specialist midwife gave the mother and the information she obtained might not have been available to the midwives that cared for the mother during her pregnancy with Child D because at that time (2007-2008) the specialist midwives kept separate paper records of their involvement which were not merged with the hospital’s main medical records. This system has now been changed so that women’s medical records would include information about previous pregnancies. In this case the midwives who dealt with the mother’s pregnancy in 2012 referred to previous medical records and spoke to the TCM to make themselves aware of the mother’s childhood difficulties. This should also be recognised as a strength in their practice.     11 Provision made for Child Y 3.8 Shortly after the birth of Child Y (the older half-sibling) the mother moved approximately 25 miles to the town in which that baby’s father and his family lived. The father had been identified during the pregnancy but had had little contact with services. He was ten years older than the mother. During this time the mother gave her health visitor accounts of conflicts involving the father’s family, which she perceived to be controlling and interfering. There were suspicions of domestic violence which were only confirmed after the couple separated. 3.9 The mother and baby lived close to the father’s family until 2010 and kept a high level of contact with the local health visitor. They moved between the two towns before the relationship ended and in 2010 the mother returned to Luton with Child Y (the half sibling), where they were given temporary housing. 7 3.10 Full written health visiting records were transferred to Luton. The information received by the health visiting service in Luton was that there were ‘no safeguarding concerns’ but that the health visitor had had regular contact with the family because of concerns about ‘temper tantrums, poor feeding and parenting skills’.  3.11 During late 2010 – mid 2011 the mother saw her first Luton health visitor on several occasions. She recognised that there had been domestic violence in her previous relationship and that this could have had a negative effect on Child Y. At one point the health visitor recorded suspicions that the mother might be a victim of abuse from a new boyfriend because she saw her with bruises on her arm. This was explored and the mother denied that there was any problem. 3.12 In January 2011 Child Y started to attend a nursery located near the family’s temporary accommodation. She attended regularly for almost a month until moving to another nursery because the family moved to more permanent accommodation. 3.13 In mid-2011 the mother told her health visitor that she was going through a ‘difficult patch’ because there were going to be court proceedings about the abuse in her family of origin. She was offered support and advice about counselling but refused the offer, saying that at the time she felt well supported by her new partner (the father of Child D) who she had been with for about three                                             7 The father of Child Y had no further major role in the life of the family during the period under review and he played no role at all in relation to Child D.    12 months. It has been confirmed that this was not the man referred to in paragraph 3.11 above. 3.14 For one term between March and July 2011 Child Y attended a second nursery, located near to the new family home. Her attendance at this was just under 70% though this was not viewed as unusual or concerning because she was not of compulsory school age.  3.15 In September 2011 Child Y moved to another nursery, linked to a church school. Given the family’s religious background this pattern of school and nursery moves was quite normal. The child attended this school for the remainder of the period under review. The mother was entirely open with the nurseries and the school about the moves and the reasons for them and gave contact details of the schools to her health visitor. There is no evidence in this case for believing that the school changes should have been viewed as a potential cause for concern.  The LSCB has conducted reviews on a number of children in Luton where the pattern of frequent school moves has been identified as a concern, particularly when a move takes place after concerns about children’s welfare have been raised. This was one of the concerns which led to the development of the LSCB’s safeguarding in schools strategy.  3.16 Between January 2011 and January 2013 the three nurseries and schools identified concerns about Child Y’s behaviour. Symptoms included her difficulty in following instructions, interfering with the play and activities of other children and an inability to sit still and concentrate on activities. At times Child Y was aggressive to adults and other children.  3.17 Staff in the nurseries and schools tried a variety of approaches to assist with these difficulties including:  Portage – in which a worker made visits to the family at home to encourage the mother to adopt strategies to manage behaviour which were consistent with the approach being taken at school  Discussion at the school liaison meeting which led to a referral for assessment to the Integrated Services for Children with Additional Needs  One to one teaching assistant support was provided first for the morning sessions and then for the whole day.    13 3.18 In addition the health visiting service made provision for the family through additional visits by nursery nurses and health visitors in order to support the mother at home.  3.19 In late 2012 the school referred Child Y to the Child Development Centre (CDC). The child was on the waiting list at the time of Child D’s death. It is now understood that in addition to her attachment and parenting difficulties, an underlying medical problem is likely to have accounted for some aspects of Child Y’s behaviour. 3.20 The response of agencies to these problems is evaluated in Section 4.3. There are no concerns about the provision that was made and there is no evidence that any signs or symptoms of abuse were missed. Professional contact with the mother during her pregnancy with Child D 3.21 The mother contacted her GP in March 2012, early in her pregnancy with Child D. Her first foetal scan identified a potentially serious abnormality that would require close monitoring during the pregnancy and surgery immediately after the child’s birth. At her ante-natal booking at the LDUH the mother disclosed a history of depression, which she said had not been treated, three years previously. She identified her current partner as the father of Child D. 3.22 Subsequently the mother regularly attended her planned ante-natal appointments and an outpatient appointment at Great Ormond Street Hospital (GOSH) to discuss the planned surgical procedure. 3.23 The midwives at LDUH obtained previous medical notes and discussed the mother with the specialist TCM midwife to establish if there was any relevant history. The mother was perceived as being young and vulnerable with little support from her own family. However she engaged very well with the ante-natal service, was concerned about the baby’s wellbeing, keen to understand as much as possible about the surgical procedures that would be required and worried about the possible outcomes for the baby. The mother was found to understand instructions and advice if things were put simply and she was diligent in following them. The father was noted to be older than the mother. He attended some of the appointments and was present during the ante-natal home visit. Midwives had no concerns about his presentation or behaviour.  3.24 Conditions observed during the home visit were satisfactory and there were no concerns about Child Y.    14 3.25 Late in the pregnancy the mother was required to give evidence in the family court about the abuse that she had suffered as a child. This successfully helped to protect younger family members. At this time Child D’s mother had contact with the Luton Borough Council social worker who was responsible for the younger children. The social worker visited Child D’s mother at home before the hearing in order to establish how it was affecting her and whether she wanted any additional support or counselling over what had happened. Information and leaflets were provided about possible services.  3.26 The mother said that she did not want to access this straight away because she was focused on her pregnancy and birth and that she was getting good support from her mother and the father of Child D (who were both there). She knew and understood about the medical needs of the baby and the surgery that would be required. She could talk to her boyfriend about what had happened in the past and he was supportive. There was discussion about whether at this point Child D’s mother wanted to make a formal complaint to the police and trigger a criminal investigation about the historic abuse. The social worker explored this with the police, though subsequently the mother did not do so. 3.27 The social worker did not feel that there was any need to discuss what the mother had said with the midwife as it was clear that Child D’s mother had good arrangements in place. The social worker was in fact much more concerned about another family member who was going to give evidence who seemed to be having considerably more difficulties. 3.28 Midwives who were in contact with the mother at this stage knew about the mother’s childhood problems but did not know that the mother was giving evidence in these court proceedings, because she did not mention it. Midwives had to rely on the mother disclosing information about the court case. The circumstances were unusual and so likely to have eluded any normal line of enquiry about her health or welfare. The social worker who was dealing with the rest of the family considered informing other professionals who were working with the mother about her involvement in the court case, but decided that on balance it was not necessary. She discussed this with the mother who told her about the contact that she was having with the hospital and gave her the impression that she was receiving all the support she needed. It is also important to note that the social    15 worker’s main concern at that point was the complex court case because 1) the current protection of a number of other children in the mother’s family of origin was at stake and 2) she was particularly concerned about the welfare of one of the other witnesses.  The review has identified that the mother’s midwife did not complete a safeguarding or information sharing alert in relation to the pregnancy. Within LDUH safeguarding alerts are the main mechanism for flagging potential risks to patients and unborn babies. This was because she did not view the mother’s pregnancy as concerning from a social point of view. This decision was understandable, given the mother’s full engagement in the antenatal service and the absence of any specific concern. Because of her medical condition Child D followed an unusual care path after her birth. Taken together these two factors meant that less information was subsequently shared with the health visiting service than the circumstances merited.  Even though using the safeguarding alert system in this case might have meant that more information have been subsequently passed to the health visitor the SCR decided that this case did not point to any need to change the current arrangements.  There has to be a proper threshold for creating an alert, otherwise the entire system becomes devalued. That threshold must rely on professional judgement. The operation of the system is regularly reviewed and monitored, both within the hospital and through reports to the LSCB. The hospital safeguarding team learns from errors and omissions in its use. This will continue. Provision made in relation to Child D’s medical condition 3.29 Child D’s birth was routine and after being stabilised in the Neo-natal Intensive Care Unit at the LDUH she was transferred to GOSH for surgery. The ambulance crew’s notes indicate that shortly before the transfer the father became very angry. This was because of a reported need to change the hospital that would carry out the operation and incorrect information being inadvertently given over transport arrangements. The ambulance staff involved had no additional specific recollection of events. It is likely that this was viewed as the understandable anxiety of a father with a very ill, vulnerable new-born baby. These notes were passed to GOSH (and became part of the hospital record) but there was no evidence that the father was still angry by the time the family reached the hospital.    16 3.30 Based on the referral information from the LDUH, GOSH noted that there were ‘no social concerns’, because from the LDUH perspective nothing had happened to indicate risk to Child D.  3.31 The planned surgery was carried out successfully and Child D and her mother stayed at GOSH for 3 weeks. During the stay the mother asked to see a hospital family support worker, who in turn referred her to a social worker. The mother was seeking financial support while staying at the hospital – which was provided – but she was also very open about her family background and gave details of her family history of abuse. She identified family members who she did not want to visit. She also indicated that Child Y was staying with the maternal grandmother with the agreement of the local authority. The hospital social worker made contact with a Luton social worker who confirmed that there were family members who might pose a risk to children and should not be allowed to visit Child D in hospital.  3.32 Shortly before discharge the hospital arranged for a play therapist to see the mother to provide advice about how Child Y might react to the appearance of the baby in hospital and the arrival of the baby at home and how the mother might handle this. The parents responded positively to this advice. 3.33 Throughout this admission the mother was regularly observed in her interaction with Child D by nursing staff, medical staff and members of the GOSH social work department. She was perceived as being caring and focused on Child D’s needs. No concerns were raised about her care of Child D and indeed it was noted that she carried out some delicate practical tasks linked to the infant’s medical treatment with skill and confidence. In discussing her childhood problems the mother was viewed as being someone who wanted to take control of her life and prevent any abuse of her own children.  3.34 The father attended one meeting with the GOSH social worker. He was perceived as being concerned and affectionate towards Child D and there were no concerns identified. 3.35 On 7 November 2012 LDUH sent the mother’s GP notice of the transfer of Child D from LDUH to GOSH and confirmation of the child’s medical diagnosis. A copy was sent to the health visiting service and noted on the child’s record. Shortly after, the health visitor made contact with family members to confirm what was happening. On 27 November the allocated health visitor sought an update from the family and was told that Child D remained at GOSH. This was a different health visitor to the one who had dealt    17 with Child Y in 2010 – 2011, but she remained the allocated worker for Child D. 3.36 On 28 November 2012 Child D was transferred back to the LDUH. This was normal practice after treatment of an infant at a tertiary centre and allowed the local hospital to establish the child’s feeding, to monitor the care of the child and to plan a coordinated discharge. This worked effectively and no concerns were noted about the care provided to Child D by the mother. The LDUH sent a discharge letter to the family GP and health visitor who arranged to make her home visit on 3 December 2012. The discharge letter focused on current medical matters and did not contain information about the mother’s social background. An appointment was also made for Child D to be brought to the paediatric ward on the same day. Details of the first GOSH outpatient follow up appointments were confirmed along with a further LDUH paediatric department appointment. The health visiting records confirm these details. From the paediatric ward perspective Child D was treated as a child being discharged from surgery in a tertiary centre, not a baby being taken home for the first time. This did not adversely affect Child D’s health care but it meant that there was no direct contact between the midwives and health visitor and so no information sharing between them. This meant the health visitor was not informed about the mother’s childhood difficulties, which would normally have happened in similar circumstances.  Child D’s need for tertiary care at GOSH appears to have caused this disruption in information sharing. In all other respects this was a well-planned and coordinated discharge which optimised the support to Child D and her parents.  3.37 On 3 December 2012 Child D was brought to the paediatric assessment ward at LDUH, weighed and examined. Observations were recorded in the hospital records. 3.38 The health visitor attempted to phone and then to visit the mother and Child D on 4 and 5 December 2012. The health visitor – who had not yet met Child D - was concerned that it was proving difficult to make contact and established that the baby had attended at the paediatric clinic as planned. No further attempted visits were made before 12 December 2012 when the health visitor made a successful unannounced visit to carry out the new birth health assessment.    18 3.39 The health visitor established the medical history from the mother and weighed and examined Child D. The records set out the information obtained. By this time Child D had been home for a week and was feeding well and regularly. There were no concerns about the surgery and the arrangements for medical follow up were clear. Child D had been sick on one occasion after feeding, but this was not considered to be anything abnormal and the parents were advised to take Child D to the GP if she appeared to be ill again. 3.40 The health visitor’s view (provided to the SCR in interview to supplement her records) was that the mother ‘seemed on top of things and there had been no concern from either hospital in respect of her parenting skills’. There was discussion during the visit about the mother’s level of literacy and she said that she had ‘not gone to secondary school just primary school’. She was given information about adult literacy classes at the nearby Children’s Centre.  3.41 As both parents were fit and well and the baby clinic was located very close to their home, they were advised to attend there weekly for Child D to be seen and weighed. The health visitor believed that there was no reason to involve a nursery nurse to provide additional home visits. Attendance at clinic and universal provision under the Healthy Child Programme (HCP) was to be monitored by the Heath Visitor from the electronic records (which would show up any missed clinic appointments).  3.42 The health visitor established that the man present at the new birth visit was the baby’s father. His details were entered into the child health records and linked to Child D’s. This did not give the health visitor access to his health records and there was no reason for the health visitor to think that this was necessary. The health visitor was not aware of the nature and extent of the mother’s childhood difficulties. The reasons for this are described above and considered further in Section 4.2. Given her knowledge of the family and her assessment at the new birth visit the judgement about the level of care required made by the health visitor is viewed by the review team as being justified. 3.43 On 14 December 2012 Child D was taken to a hearing screening, which proved to be ‘normal’.  3.44 On 16 December 2012 Child D was not taken to the Child Health Clinic. The health visitor spotted this and as required by the trust’s procedures undertook a vulnerability assessment. This noted a    19 number of potential risk factors (‘new baby, surgical condition, mother can’t read, financial problems, new relationship, did not attend clinic, phone contact difficult as mum seldom has credit’ and as a result it was agreed to schedule health visitor home visits once a month, rather than rely solely on clinic contact. However there was no urgent need to make a visit because nothing had occurred which had changed the fundamentals of the previous assessment. As a result a home visit and review date was scheduled for 15 February 2013. This took account of the normal scheduled GP 6-8 week check, weekly health clinic appointments and the outpatient paediatric appointment which would have happened in the meanwhile. 3.45 According to the mother’s evidence to the care proceedings at some point over the following two weeks Child D received the first of three bruises which she noticed after the father had been caring for her. She did not bring these to the attention of any professional at the time.  3.46 Child D was taken to the child health clinic on 2 January 2013 which – because of the holidays – was the next available date. Everything was judged to be well and the mother was advised to continue attending weekly. No bruises were observed. 3.47 The following day (3 January 2013) the mother took Child D to her GP for the scheduled 6-8 week check. This check was taking place just after the end of the 6-8 week window because of the inpatient hospital admission and the holidays. 3.48 This check was satisfactory and Child D was noted to be thriving. During the check the GP noticed and recorded a small bruise on Child D’s forehead. The mother explained that this had been caused by the infant’s head resting on a plastic toy in a Moses basket. The mother had brought the toy with her so the GP could see it and the GP noted that it had a hard protruding centre. He noted his intention to liaise with the health visitor, but he did not do so. The record of the care proceedings notes a comment from the GP indicating that the explanation ‘would fit’ the injury; however this comment was not found in the medical records or given to the SCR by the doctor concerned. 3.49 The GP made the record of the 6-8 week check on the surgery’s electronic patient record. The surgery uses a system called EMIS. As part of the normal information sharing arrangement a copy of the record of the 6-8 week check – which included a reference to the bruise - was passed to the community health trust’s child health department. This happens routinely and was not the result of the GP’s desire to communicate with the health visitor. The    20 reference to the check – including the reference to the bruise - was manually copied by an administrator into the Health Visiting records on SYSTMONE (system one) which is the electronic patient record system used by the health visiting service (and a number of Luton GP practices, though not the one attended by the family). 3.50 The health visitor had access to SYSTMONE but there was no reason for her or anyone else in the community health service to refer to the records until the next planned contact or the next scheduled clinic attendance. 3.51 On 9 January 2013 the mother phoned the GP surgery in relation to a minor medical problem linked to Child D’s recent surgery. She attended the surgery and Child D was seen by a different GP. The same bruise was noted, without further action being considered. It is now known that the mother was sufficiently concerned about the bruise herself to take a photograph of it on her mobile phone between the two GP appointments, though no professional knew this at the time. Some months after Child D’s death she reported that this was the third bruise that Child D had suffered, and that one of the previous bruises had been more serious.  These episodes are evaluated in detail in Section 4.6 which considers in detail the response of professionals to the bruise on Child D’s head. Section 4.7 evaluates the current arrangements for the 6-8 week check and considers whether there are grounds for involving health visitors in these checks to a greater degree. 3.52 Early on the morning of 10 January 2013 the mother phoned 999 reporting that Child D had stomach pain. She was triaged over the phone by the ambulance service control and advised to contact her own GP. She did not do so, possibly because Child D had an outpatient appointment at GOSH later the same day.  The ambulance service has reviewed this contact and believes that on the basis of the information provided, the correct advice was given. 3.53 At the GOSH outpatient department Child D was weighed by a clinic assistant prior to seeing a surgeon for scheduled outpatient follow up of the surgical procedure. The assistant noticed a small bruise on the child’s forehead and asked how it had happened. The mother gave the same explanation as before (which was documented in the paper outpatient record and passed to the    21 surgeon). The clinic assistant also told the review team that the mother had said that the bruise had already been seen by the GP or health visitor (she was not sure which). This remark was not recorded.  3.54 The clinic assistant felt concerned by the bruise but was not entirely sure that a small bruise was necessarily an indication of abuse. She wanted the surgeon to look at the bruise and seek a more detailed account from the parents before referring Child D to the hospital social work department. Before Child D was seen the clinic assistant tried to speak to the surgeon to share her concerns but she did not because when she went into the consulting room he was examining another patient behind a screen. She therefore made an entry on the outpatient assessment form ‘baby has a bruise on her forehead. Mum says a toy on the Moses basket caused the injury’. This was written at the top of the section where the surgeon would write the notes of his examination and marked with a prominent ‘star’ in the margin.  3.55 Between booking other patients the clinic assistant made further attempts to discuss this with the surgeon but each time he was occupied with patients. Before the end of the clinic (when she felt that she would have had an opportunity to discuss the bruise either with the surgeon or with the staff nurse in the clinic) she was called to cover a clinic in another part of the hospital. 3.56 The surgeon examined Child D and made notes relating to the recovery from surgery. There were no concerning complications of the surgery and he asked for Child D to be seen again in four months. These notes were directly below the clinic assistant’s written entry about the bruise. Child D left the hospital without any action being taken over the bruise. The surgeon told the review team that he had no specific recollection at all of seeing this patient.  These contacts are evaluated in detail in Section 4.6. Attendance at LDUH emergency Department / Out of Hours GP 3.57 In the evening of 13 January 2013 Child D’s mother called the ambulance service indicating that the baby was ‘struggling to breath’. An ambulance attended the family home. The ambulance service contact is very thoroughly documented. On arrival the crew found Child D sleeping in the mother’s arms. The infant was carefully examined and a detailed history taken, including details of existing medical conditions. The paramedics saw no bruising. The account given by the mother was different from the account    22 given over the phone; this time she indicated that Child D had taken food, vomited, screamed, gone blue and then gone limp but only briefly. 3.58 They did not believe that Child D needed hospital admission, however the paramedics agreed to take Child D and her mother to the LDUH Emergency Department (ED) where she could be seen by a doctor. In effect they were providing reassurance and transport. On arrival at LDUH the mother joined the normal system for patients waiting to be advised whether to attend the ED or to attend the GP Urgent Care Clinic which is based at the LDUH. The ambulance crew gave a copy of their notes to an unidentified member of LDUH staff and left. The notes were subsequently processed and became part of GP and other health records, though they were not seen by the out of hours GP who saw Child D in the GP Urgent Care Clinic that evening. 3.59 Child D was seen by a nurse who carried out the functions of the ‘streaming nurse’ (who signposts patients attending the LDUH as to whether they should attend the LDUH Emergency Department or the GP Urgent Care Clinic). The mother provided an account of Child D’s history and she was advised to take him to the GP Urgent Care Clinic. The nurse (who is a very experienced and highly qualified practitioner) recalls seeing a baby in her mother’s arms and being given an account of ‘vomiting after feeds’. The mother did not mention the history of surgery and made no statement to suggest collapse or ‘not breathing’. It was not the nurse’s role to physically examine or formally triage patients. He felt that the presentation gave no cause for alarm and that Child D should be seen by the GP at the Urgent Care Clinic, rather than referred to the Emergency Department.  3.60 In keeping with the LDUH’s agreed arrangements, the streaming nurse kept no record of his contact, as he was in effect simply pointing patients to the apparently most appropriate service. 3.61 The GP Urgent Care Clinic GP took a history from the mother and examined Child D undressed and on an examination couch. The mother’s version of the history was close to that which she had given the ambulance crew i.e. that Child D had developed a cough and runny nose for past few days and although feeding well had been vomiting after some feeds. On that day Child D had stopped breathing after vomiting following feeding and then went blue for three minutes. On examination Child D was alert and well, had no fever or respiratory distress, was well hydrated and showed no signs of neurological impairment. The GP saw no bruising and felt    23 that the mother appeared to be genuinely caring and appropriately worried.  3.62 Judging by the current clinical picture, the GP felt that the episode would have appeared to a caring parent to have been more grave than it actually was. He did not believe that Child D had stopped breathing for three minutes (because a child who had done so would have been seriously ill) but he understood why in panic an anxious parent might believe that. He saw no reason to admit Child D to hospital and discharged her home with a note to be given to the registered GP stating that the baby had presented with vomiting. Details were provided of the blood sugar levels taken by the ambulance crew and the Urgent Care GP.8 These were within the higher normal range and it was noted that investigation for possible diabetes might be warranted. Further advice might also be needed over the vomiting if it persisted. This hospital attendance has been scrutinised in great detail – both by the SCR and in the care proceedings - because it occurred some 12 hours before Child D was seriously injured. The SCR found no grounds for criticism of the ambulance crew, the streaming nurse or the GP Urgent Care Clinic GP, all of whom are judged to have acted appropriately given the clinical presentation, the circumstances and their roles.  It is not clear who the ambulance crew gave their notes to and why they did not find their way to the GP Urgent Care Clinic immediately. It appears that the records were temporarily misplaced, probably because Child D was transported to the hospital by ambulance but then joined the normal public queue. There is no reason to believe that the fact that these notes were not transferred with the patient to the GP Urgent Care Clinic GP had any adverse effect on Child D’s care. The East of England Ambulance Service told the SCR that it had no other evidence of handover arrangements not working smoothly at LDUH.  The view of the SCR about the examination undertaken by the GP Urgent Care Clinic GP has been endorsed by the findings of the judge in the care proceedings who found it to be ‘comprehensive and thorough’, ‘careful and professional’. It was agreed by all the expert witnesses that Child D could not have received the injuries that caused her death before this examination because these injuries would have caused an immediate collapse which would have been readily identified by any of the professionals who were                                             8 Blood sugar was elevated at 12.6 mmol/L when tested by the ambulance crew but it had come down to 8 mmol/L when seen at the Urgent Care Centre which was reassuring.    24 involved. Section 4.8 comments in detail on the factors that have led to the development of the streaming nurse role at LDUH and the wider implications for services. Serious injury to Child D, admission to Luton and Dunstable Hospital and transfer to Great Ormond Street Hospital 3.63 The following morning (14 January 2013) the ambulance service attended the family home as Child D was reported to have gone ‘lifeless’. The baby was clearly gravely ill and was transported to LDUH, before being transferred to GOSH. 3.64 The finding of fact in the care proceedings was that Child D’s father caused the injuries that led to her death on the morning of 14 January 2013 while her mother was in a different part of the home. He is judged not to have done so deliberately.9 3.65 The paramedic records made during this incident note an ‘old bruise’ on Child D. The mother gave doctors at both hospitals an account of Child D having a bruise on her forehead and the same account of its cause. The consultant paediatrician who examined and treated Child D at LDUH that morning is clear that there was no noticeable bruising (other than marks resulting from current and previous medical treatment).  3.66 Child D died some days later.  There are no concerns about the care and treatment provided to Child D on the morning of the serious injury.  It has not been possible to clarify – because they have no more detailed recollection - what exactly the paramedics meant when they noted an ‘old bruise’ on Child D that morning, or why it was described as being ‘old’. It is noted that it is impossible to age bruises with certainty.  If there was an old and noticeable bruise on Child D’s head that morning it is extremely surprising that it had not been recognised by the paramedics, the streaming nurse and the GP Urgent Care Clinic GP who had dealt with Child D the previous evening, two of whom had made detailed examinations. Nor was it seen by the consultant paediatrician on Child D’s admission to LDUH on 14 January 2013. On admission to GOSH later that day Child D was noted to have                                             9 As the parents did not contribute to the SCR there has been no opportunity to consider this beyond the finding of the court.    25 what was noted in the records as being a ‘resolving bruise’ in a slightly different position on her head to the previously recorded bruise. The age and cause of this injury are impossible to ascertain.     26  4 EVALUATION OF THE SERVICES PROVIDED FOR THE CHILDREN 4.1 Introduction 4.1.1 This section addresses all of the topics set out in Section 1.11 above, as well as additional matters identified in the course of the review: 4.2 How vulnerable young people who might need additional support when they become parents are identified and helped 4.3 The identification of risk and vulnerability in relation to Child Y (Child D’s older half sibling) and the provision made as a result 4.4 Support and advice given in relation to Child D’s medical condition 4.5 Engagement of the father and assessment of his role 4.6 Professional responses to bruising in small babies - the recognition of possible signs of abuse of Child D and the action taken by professionals 4.7 The 6-8 week health review, the Healthy Child Programme and working arrangements between GPs and health visitors  4.8 Access to urgent and emergency health care in Luton for babies and small children  4.9 Professional understanding and assessment of the impact of parental learning disability on parenting capacity 4.1.2 In relation to each theme the report evaluates whether this was significant in relation to the outcome for Child D and in wider service provision for vulnerable children. 4.2 How vulnerable young people who might need additional support when they become parents are identified and helped 4.2.1 Child D’s mother came from a family with severe social difficulties, in which she had suffered abuse. There is no evidence that the Child D’s mother harmed either of her children; however her vulnerability led her to live in relationships in which she and her children were victimised. The family court proceedings judged that her childhood experience had made her less able to protect her children because she did not have the trust and confidence to speak openly to professionals when she instinctively recognised that she and her children were not being treated properly.  4.2.2 The review has considered how information about the mother’s background was transmitted between professionals who knew her in adolescence and those who later worked with her as a young mother,    27 and whether more support could have been offered to her. This seeks to identify whether there are wider lessons for services in Luton.  4.2.3 Section 4.9 deals separately with the question of whether the mother had learning difficulties and how this was assessed and understood by professionals. These two matters are linked.  4.2.4 The preservation and sharing of information about vulnerable adolescents who have become parents has important implications for the identification of risk to children, particularly in the first year of life. In its summary of findings of SCRs dealing with the deaths of infants under one year old OFSTED identify a number of common shortcomings, including the lack of pre-birth assessment; underestimation of the needs of young parents and insufficient support being provided, bearing in mind the vulnerability of babies.10  4.2.5 These are all more likely if the decisions that inform them are based on incomplete information. For example lack of information about a young person’s experience and behaviour as an adolescent may adversely influence a decision about whether or not to undertake a pre-birth risk assessment. This makes it important to understand why information about childhood difficulties may or may not be shared between agencies that worked with a parent when they were a child or adolescent and the agencies later providing antenatal and post-natal care.  4.2.6 The review has tried to understand how this might occur - not in general but in the working arrangements of specific local services. When serious concerns have been identified the responsibility to gather information is likely to fall to local authority social workers. When the local authority is not involved – as in Child D’s case - reliance is placed on information sharing between health professionals. The value of information held in GP records 4.2.7 When the mother became pregnant with Child D, the local authority social care service was involved with younger members of the mother’s family but it had only very limited direct contact with her. She had been removed from a child protection plan five years previously. This is not an unusual set of circumstances. There may be a gap of several years between the involvement of the local authority with a young person and that young person becoming a parent. In the meanwhile the young person may have moved far from where he or she grew up; or there may be no reason for the agencies to be in touch. It can never be guaranteed that information held historically by agencies such as a Youth Offending Team, children’s social care or                                             10 OFSTED, (2011) Ages of Concern: Learning Lessons from Serious Case Reviews a thematic report.    28 school will be shared with health professionals who are dealing with a young mother or father, unless the agency concerned is asked for it. 4.2.8 The most reliable route to preserve information about the young person so that it is available when he or she becomes a parent is via the GP records which should provide a continuous record of the young person’s contact with health agencies. This places considerable reliance on the GP obtaining, collating and being able to recognise the significance of information about a child or young person that may be relevant to their capacity as a parent and then make the right use of it. 4.2.9 In relation to Child D’s mother her GP practice had information to indicate that she had been subject to a child protection plan, but that information was not summarised or highlighted and no one in the practice was actively ‘mindful’ of it. Understandably the mother’s removal from the child protection plan in 2006 had been viewed as a positive event. However information about her childhood difficulties should have informed everyone’s future work with her.  4.2.10 The safety of small children can be improved by increasing the quality of information that is held about their parents and by making GPs more mindful of its potential significance. Inclusion of social information in GP antenatal referrals 4.2.11 The best opportunity for information about the parent’s history to inform future care is the GP referral for ante-natal care. Currently in Luton there is no consistency about whether GPs include significant background social information in referrals for antenatal care, even when it is held in their records. There are numerous reasons for this. Records may not contain information about important events. The GP records of many troubled young people may not be complete, especially if they have moved home a lot. GPs may not appreciate the potential significance of the social information that they hold in their records. They are not always prompted to provide information by the referral system.  4.2.12 The LDUH has described how this combination of factors leads to huge variation in the information provided by GPs to the antenatal service in Luton: With regards to the referral letters received by GPs for pregnant women there is no standard template / proforma which is used between the GPs and the hospital. This is very much done on an individual basis and varies greatly between GPs. Some are very good and will include relevant medical and social information, some only medical information, whilst others will literally inform us of a woman's pregnancy and could she be seen for care, some are typed and some    29 … is hand written. There is no standardisation of the information received.11 4.2.13 Further variation is added because women may also self-refer to the hospital for maternity services. When this happens ‘they phone in and speak to an admin person who fills in a proforma…this doesn’t take into consideration medical / social information as it is the midwife's responsibility to collect this information by reviewing previous hospital notes and GP records and on seeing the woman at the booking appointment’. Midwives then obtain information directly from GP records although ‘the level of access to records is dependent on the (information sharing) “rights” that the surgery gives the midwife’. 4.2.14 Some women have no GP, in which case relevant social information may be archived or at another GP surgery and very difficult to obtain. 4.2.15 Discussions with health professionals outside Luton indicate that other areas have a more structured approach and have developed template referral letters which prompt GPs to provide a range of relevant background social information. Without wider research it is not possible to know whether there is wide compliance with such approaches and whether different protocols produce better outcomes. The SCR has made a recommendation in relation to this. Significance in relation to wider service provision for vulnerable children 4.2.16 The OFSTED evaluation of SCR findings in relation to children under the age of 12 months stresses the importance of an accurate assessment of the factors that may affect a young parent’s care of his or her child. This relies on collaborative working between antenatal services, health visitors and GPs during pregnancy and throughout the first year of life and on relevant historical information being made available. The evaluation in this case history highlights the factors that can make it more difficult to do that successfully. 4.2.17 In any complex case, health professionals need to be conscious of the need to retrieve as much information as they can from other agencies. They also need to recognise that there may be useful background information held by agencies that knew the mother or father as a child.  4.2.18 The quality of antenatal care could be improved and the support for vulnerable young parents could be targeted more effectively if GPs were more aware of the significance of historical information that they may hold and they were more aware of the value of sharing it with antenatal services and health visitors.                                              11 Information from the Named Safeguarding Midwife    30 4.2.19 There is no single procedural solution that will ensure that this happens, but GPs, NHS England (which commissions GP services), the Clinical Commissioning Group in Luton and providers of maternity care should research this further and develop a strategy to promote better information sharing at this critical point in care. Although this is not a factor that impacted directly on the outcome for Child D, it is important in relation to the wider vulnerability of children. The SCR has made a recommendation in relation to this. 4.3 The identification of risk and vulnerability in relation to Child Y (Child D’s older half-sibling) and the provision made Significance in relation to the outcome for Child D 4.3.1 The review team has considered whether there were indications of risk or vulnerability in relation to Child D’s older half-sibling and if so how professionals responded.  4.3.2 The causes of Child Y’s behavioural problems were unclear to professionals working with her. The care proceedings have now clarified that there are likely to have been a number of contributory factors, including an organic cause, exposure to family conflict and a small number of episodes of domestic abuse and inconsistent parenting. Child Y’s father (who was in contact with her between her birth and the age of three) and her stepfather (who came into contact with the family when she was five) admitted handling Child Y roughly or threatening her. These admissions were made in the court proceedings after the death of Child D. 4.3.3 Given the pattern of Child Y’s behaviour (described in Section 3 of this report) none of these factors comes as a surprise (especially taking account of the mother’s vulnerability). The difficulty is that without specific evidence of the causes – which would always be likely to come from disclosure by a family member – only the symptoms shown by the child can be addressed.  4.3.4 The SCR team carefully reviewed the interventions that were made with Child Y, based on the information that was available at the time. This was done through review of records and detailed discussion with the teachers, nursery nurses and other professionals that had worked with the child in the three pre-school and school settings. This was also discussed in interviews with the health visitor who had had contact with her during 2010 – 2011. Luton Borough Council’s Principal Educational Psychologist offered additional expert scrutiny and comment. 4.3.5 It was apparent that all of the staff who had contact with Child Y had a very clear memory of her as an individual and had been very aware of her needs and difficulties. In all three education settings records of    31 concerns and interventions were thorough and detailed. It was clear that the nurseries and schools had considered carefully how to respond to the child’s difficulties and used a range of interventions that both at the time and with hindsight were appropriate to the problems that she presented. Shortly before the death of Child D the school referred Child Y to the local Child Development Centre, leading to the identification of her organic disorder. 4.3.6 Throughout there was close liaison between nursery and school staff, health colleagues and educational support and advisory services. The child’s mother was attentive and concerned, kept appointments and made considerable efforts to implement the advice given on emotional support and behaviour management. When it became known that the mother was pregnant and then when Child D required surgery immediately after the birth Child Y’s school was responsive to the change in family circumstances, offered additional support and had contact with members of the extended family who were caring for her.  4.3.7 There is no indication that there were grounds for a referral to social care to have been made at any stage. 4.3.8 Even though it could not identify all of the causes of Child Y’s difficulties the support that the older child and her mother received in playgroup, nursery and school should be considered to be a strength in services.  Significance in relation to children in Luton more widely 4.3.9 Over the last two years the LSCB has carried out reviews of a number of children’s cases which have touched on the safeguarding arrangements made for other children in other Luton schools and nurseries. Provision in relation to safeguarding has not always been satisfactory and as a result in 2013 the LSCB launched a strategy for safeguarding in schools in order to address this.  4.3.10 The review has noted that in relation to Child Y there was no handover from the health visiting service to the school nursing service, even though the health visitor had remained actively involved with Child Y until shortly before the child started to attend school. Although the service specification for the health visiting service takes account of the need to identify and transfer vulnerable children this is recognised as being a persistent problem in Luton. That is because over a number of years there has been insufficient capacity in the school nursing service. There is no indication that this lack of handover had any negative impact on the provision made to Child Y as she received a range of supports and was referred directly to the Child Development Centre by the school.    32 4.3.11 This difficulty has been brought to the attention of the Director of Public Health, who on behalf of the local authority currently commissions the school nursing service. The local authority and the NHS trust that provides the school nursing service are already undertaking a review of the provision in Luton which will take account of the need to improve transfer of cases from health visitors. The findings of this review will be reported to the LSCB under its normal working arrangements. 4.4 Support and help provided to the parents in relation to Child D’s medical condition Significance in relation to the outcome for Child D 4.4.1 The SCR has examined the provision made in relation to Child D’s complex medical condition. 4.4.2 The provision made by GOSH to Child D in this regard met her medical needs and was of a high quality. The hospital social work and family support service responded positively to the difficulties associated with a long inpatient stay some distance from the family home. 4.4.3 Between Child D’s discharge from LDUH on 29 November 2012 and 14 January 2013 when serious injuries were identified, Child D’s health care was the responsibility of the GP practice and the health visitor.  4.4.4 The GP offered appropriate advice and undertook the 6-8 week check. This is considered further in Section 4.7. 4.4.5 The health visitor undertook the new birth health assessment approximately a week after Child D was discharged from the LDUH. She persisted after missed appointments because she was aware of Child D’s medical condition and wished to undertake the assessment promptly. 4.4.6 She did not know the details of Child D’s mother’s childhood difficulties and so could not explore them further with her or evaluate how they might impact on her parenting. The main reason for this was that the normal handover arrangements between ante-natal and health visiting services had been bypassed because Child D had been admitted to GOSH for surgery immediately after her birth.  4.4.7 The health visitor’s judgement was that Child D’s health needs would be met if she were taken to weekly clinic as well as planned GP and hospital outpatient appointments. As the parents showed every indication of understanding what needed to happen and of coping well, the health visitor judged that more regular home visits by a nursery nurse (whose role would have been to advise on parenting skills) were not needed.     33 4.4.8 Later when a clinic appointment was missed the health visitor arranged additional contacts. This was an appropriate response to changed circumstances. 4.4.9 At no point did the health visitor notice any concerning aspect to the care that Child D was receiving. 4.4.10 The review has considered whether the judgements of the health visitor about the care provided to Child D might have been different if she had been informed about the extent of the mother’s childhood difficulties. There is no reason to believe that this would have been the case as the very positive picture of care currently being provided to Child D would not have been altered. 4.4.11 Working arrangements between the health visitor and the GP are considered further in Section 4.7. 4.5 Engagement of the father and assessment of his role 4.5.1 The SCR has examined the role of Child D’s father because the involvement of fathers in relation to services for safeguarding children is a matter of public policy interest and is stressed throughout government guidance on the Healthy Child Programme. The absence of information about men who subsequently proved to be a risk to children has been widely examined in the research on safeguarding children.12  4.5.2 The family court has determined that it was the father who caused the fatal injuries to Child D, though that could not have been apparent to any professional at the time.  Significance in relation to the outcome for Child D 4.5.3 Compared to the mother, Child D’s father had little contact with professionals. In comparison to some fathers he was quite involved, attending some ante-natal appointments at LDUH and the antenatal appointment at GOSH. He was present at the new birth health assessment. His details were obtained by midwives and the health visitor but nothing significant was noted. 4.5.4 The father had no criminal record of significance in relation to safeguarding and there was nothing that happened in the case history that would have prompted anyone to check for evidence that he had posed a risk to children in the past. There was no such evidence.                                             12 S Shribman and K Billingham / Department of Health (October 2009) Healthy Child Programme – Pregnancy and the First Five Years of Life See for example HM Government, Brandon et al (2008) Analysing Child Deaths and serious injury through abuse and neglect: what can we learn? (England, 2003-2005)    34 4.5.5 The only incident of note occurred immediately after the birth of Child D when he lost his temper during a mix up over the transport arrangements to GOSH. This was properly detailed in the notes of the transfer made by the ambulance crew and copied as part of the package of material handed over to GOSH. The fact that the notes were handed over without comment suggests that the incident was not viewed as being significant. The staff involved have no further specific recollection. 4.5.6 On admission GOSH were focused on the surgery needed to rectify Child D’s medical difficulties and did not pay further attention to the entries in the notes about the father. In their subsequent dealings with him they had no concerns about his conduct.  4.5.7 Overall professionals sought to involve the father and achieved a good degree of success. Generally procedures and training in Luton reinforce the need to involve fathers in assessment of parenting and discussions about safeguarding.  4.5.8 There is nothing arising from this review to add to what is already known on this issue or to prompt different action. This is an area that the LSCB and its member agencies should continue to keep under regular review as it is a long established area of vulnerability in safeguarding services. However there is no new learning arising from this SCR which points to the need to a specific recommendation to be made in this regard. 4.6 Professional responses to bruising in small babies - the recognition of possible signs of abuse of Child D and the action taken by professionals Professional views of the overall standard of care provided for Child D by her parents 4.6.1 There were no general concerns about the care provided to Child D. All of the professionals who had contact with Child D and the family formed the view that the mother provided care of a good standard.  4.6.2 The SCR has seen and heard considerable evidence which would have supported this, including the following:  Evidence of the mother’s concern for the wellbeing of the unborn child, advice followed and appointments kept both at the local hospital and at GOSH during the antenatal period  Her detailed interest in the baby’s medical condition and compliance with all advice given  Observation of the mother’s attention to Child D’s health needs, and skill in carrying out tasks required of her to care for the baby during the inpatient hospital admission    35  Warm, interested and engaged care observed by all professionals – including in hospital ward settings where staff are experienced in picking up parenting difficulties. 4.6.3 As the mother was the main carer and took Child D to most of her appointments there is less positive evidence of the quality of the father’s care for Child D. However he was noted to be concerned and affectionate, he visited Child D in hospital on several occasions and also attended a number of appointments. 4.6.4 Professional contacts with and views about the father have been described and evaluated in Section 4.5. 4.6.5 The couple were seen interacting with the baby by several professionals and were noted to be responding to the baby and to each other like any ‘normal family’. 4.6.6 The only clear indicator of possible child abuse was the bruise on Child D’s forehead which was observed by professionals on three occasions between 3 and 10 January 2013 as follows:  By the child’s GP at the 6-8 week check  6 days later by a second GP at the same surgery  At GOSH the following day. Some months after the death of Child D the mother indicated that she saw at least two other bruises on the baby’s face which occurred while she was in the care of her father and indeed that she took photographs of them. No information about these other bruises was ever provided to professionals.  Significance in relation to the outcome for Child D  4.6.7 Clinical experience and research on the significance of bruising in an immobile baby as a symptom of possible physical abuse is clear. A recent research review summarises the position as follows: The Welsh systematic review group 13 provide a clear research evidence base for having child protection concerns when there is any bruising on any pre‐mobile baby….Because physical self-control and independent movement is very limited in young babies, it is extremely difficult for them to bruise themselves. Any bruising is likely to come from external sources. The younger the baby the more serious should be the concerns about how and why even very tiny bruises on any part of the child are caused. The explanation …that a pre‐mobile baby hurt                                             13 This is an established and highly regarded group based in Cardiff that has undertaken systematic reviews on medical aspects of child abuse. Its work has influenced the current NICE guidance on child abuse and wider paediatric practice.    36 herself while in her cot needs to be scrutinised very carefully and treated with suspicion.14 4.6.8 This research has in turn informed NICE guidance to health professionals which states that health professionals should ‘suspect maltreatment if there is bruising in a child who is not independently mobile’.15 4.6.9 As a result – and because of the great vulnerability of small infants – such presentations are treated in child protection training (including on foundation courses) as a significant indicator of potential risk. Universally child protection procedures and guidance indicate that an immobile infant with a bruise should be referred to social care for investigation or to an experienced paediatrician for advice and consultation. Both the Luton LSCB safeguarding procedures and the GOSH procedures are clear on this.16 Luton’s procedures apply to GPs and GOSH procedures cover the roles of all hospital staff. 4.6.10 It has now been confirmed that Child D’s bruise (and possibly some other bruises not seen by professionals) were caused by the baby being roughly handled by the father and that this was a potential warning sign for more serious injuries. It is very likely that if the bruise had been investigated thoroughly other injuries – including her fractured wrist – would have come to light. That being the case action could have been taken to protect Child D before the serious injuries that caused her death. 4.6.11 The SCR has examined these episodes in detail. For the different professionals involved the reasons that they did not report the bruise for further investigation were different, influenced by a range of factors that shaped their judgement and the circumstances in which they saw Child D.  Contacts at the GP surgery in Luton 4.6.12 GP1 noticed and recorded the bruise at the 6-8 week check. He asked the mother what had caused it and the mother showed him a plastic toy explaining how the baby might have rolled onto it in a Moses basket. This appeared to the GP to be a plausible account because the toy had a hard centre, because the mother was otherwise considered to be caring and because he had no other concerns about the child. He                                             14 Marian Brandon et al (2011) Child and family practitioners’ understanding of child development: Lessons learnt from a small sample of serious case reviews University of East Anglia (page 5) 15 National Collaborating Centre for Women’s and Children’s Health - Commissioned by the National Institute for Health and Clinical Excellence (July 2009) When to suspect child maltreatment 16 Luton and Bedfordshire Multi-Agency Child Protection Procedures, http://bedfordscb.proceduresonline.com/index.htm and Great Ormond Street Hospital Child Protection Procedures    37 told the SCR review team that ‘had he any additional concerns at the time he would have referred this to a paediatrician to examine but in the absence of any such concerns he did not’.  4.6.13 He was sufficiently uneasy to have noted that this should be discussed with the child’s health visitor, though he made no attempt to contact her. There is no evidence that it is hard to contact the health visitor, at the least to leave a message. It is more significant that the GP was ambivalent about whether the presentation was concerning or not. 4.6.14 The GP told the SCR that he regretted the absence of the health visitor at the 6-8 week check. This is a practice that ended a number of years ago in Luton and it is not considered by the review team to have been a critical factor in his decision making. However the SCR has considered the involvement of GPs and health visitors in tasks within early years health provision as a wider issue of potential learning and service improvement. This is discussed further in Section 4.7. 4.6.15 Six days later Child D was brought to the surgery again over minor medical concerns. This time the baby was seen by a different GP who also noted the bruise. The SCR knows less about this incident because the GP had no specific recollection of the event. However this was potentially the more significant interaction. At that point there were two options open to the GP. The first was to treat the issues as one which had been resolved by the earlier contact. Psychologically and practically this was the easier option, especially as the first GP was the surgery safeguarding lead and knew the mother. The second was to re-evaluate the significance of the bruise because by that point it would have been less likely that the bruise – if it had been caused by a small baby leaning briefly on a plastic toy – would still be so obviously visible. The doctor chose the former course. Given the clinical consensus about the significance of bruising described above, this was disappointing but it is easy to see why it might have happened.  Contacts at Great Ormond Street Hospital 4.6.16 The following day Child D was taken to a surgical outpatient appointment at GOSH. The clinic assistant has given the SCR a very detailed account of her observation of Child D and her interaction with the family. She noticed the bruise while taking routine measurements prior to the child seeing a surgeon. She was concerned about it, but decided that she wanted to seek the surgeon’s opinion and to give him an opportunity to ask the family how it had been caused. In this she was influenced by three factors. First, the bruise was very small and she did not feel that it was necessarily indicative of abuse. Second the parents said that they had already discussed it with another health professional. This was true though the clinic assistant did not know    38 that. Third, she wanted to consult the medically qualified, more experienced and more senior member of staff present before acting. 4.6.17 A strict interpretation of the hospital’s procedures indicates that as well as telling the surgeon it was her responsibility to refer the child to the social work service. However in the circumstances it would not have made sense to do this without first speaking to the surgeon. Her decisions and reasoning were considered and responsible. Her action in highlighting the existence of the bruise in a prominent position in the medical record where in common sense terms the consultant ‘could not miss it’ was sensible. It was reasonable of her to conclude that he would see it and evaluate it further.  4.6.18 She planned (and tried) to talk to the surgeon directly to highlight her concerns but she chose not to interrupt consultations with other patients. Before the end of this clinic she was redeployed to cover another clinic. She has given much thought to the alternative ways she could have used to flag her concerns, including finding a staff nurse. Hospital records show that the clinic assistant had previously made referrals to the social work service over child protection concerns and undertaken quite challenging tasks in cases where there had been suspicions of abuse. She had attended safeguarding training at the level expected by the hospital and a number of more recent less formal updates from the hospital safeguarding team. 4.6.19 The surgeon has no detailed recollection of seeing Child D. Unlike the clinic assistant for whom this was a very unusual event which she had been trained to consider, the evidence is that the surgeon viewed this as a routine outpatient surgical appointment and he noticed nothing unusual. He told the review that ‘my role on the day of the clinic was as the consultant from the paediatric surgical team reviewing a post-operative infant. I was looking for any complications of her previous … surgery and making a plan for … ongoing follow-up’. It is not clear whether the surgeon noticed the bruise or the prominent entry that the clinic assistant had made in the medical record drawing it to his attention. 4.6.20 As he does not remember seeing the clinic assistant’s entry in the medical notes, he cannot explain why he did not act on it. Given the lack of recall the SCR can only highlight factors that it believes may have been significant. The surgeon appears to have understood that his task was to focus on Chid D’s existing medical condition, rather than her overall health and welfare. The lack of a holistic approach to the patient is a recognised deficiency in the ‘medical model’. There is a risk that it may be exaggerated among surgeons, who rely on a highly specialised division of labour in order to accomplish tightly defined and often very challenging tasks.    39 4.6.21 The outpatient clinic is a busy one, however there is no indication that this was a factor reducing the likelihood of the bruise being identified and referred to the social work department in the proper way. 4.6.22 The surgeon’s lack of focus on ‘the whole child’ and on safeguarding responsibilities is likely to have been reinforced by lack of training. Despite a lengthy association with the hospital the surgeon had received only very limited safeguarding training. His last training session was an update session for consultants in 2004 which ceased to be ‘current’ in 2007. Not surprisingly his knowledge of the hospital’s actual child protection arrangements was very general, though he told the SCR that he had been involved in one complex safeguarding case.  4.6.23 The surgeon displayed a worrying attitude to his lack of training when communicating with the SCR, noting that ‘I have received child protection training, but I cannot remember when this occurred’.  4.6.24 The hospital is clearly at fault for not ensuring that annual appraisals addressed the lack of training required by professional guidance and hospital policy. The hospital’s training records show that at the time of Child D’s death its compliance with some aspects of national professional training requirements was poor.17  4.6.25 The GOSH system for regularly monitoring compliance had only been set in place in late 2012. In February 2013, 59% of junior doctors (at grades up to and including senior and specialist registrars) had up to date safeguarding training at level 3. At November 2013 this stood at 69% and in June 2014 it stood at 65%. In February 2013 37.9% of consultant physicians and 31% of consultant surgeons had been trained to level 3. By November 2013 this had risen to 97% and 84%. The level expected during regulatory inspections of hospitals is 80%. 4.6.26 These figures include only staff who have been in post for over 12 months. This is in keeping with the wording of the intercollegiate guidance document. However as training levels are likely to be lower among staff in post for shorter periods the figures given above may overestimate the overall level of staff who have been trained. It would be useful for the hospital to know what the position is in relation to newer members of staff, not least as this would enable it to plan and target training more effectively.18  4.6.27 An additional vulnerability may have arisen from the fact that the surgeon had an honorary role at GOSH. Figures for visiting honorary staff were below 10% in both February and November 2013, although more had completed some online programmes and partly complied                                             17 Royal Colleges of Paediatrics and Child Health, (September 2010) Safeguarding Children and Young people: roles and competences for health care staff, Intercollegiate Document 18 The hospital has separately provided a description of its arrangements for staff induction under the inter-collegiate guidance document    40 with national requirements. In June 2014, 58% of honorary medical staff had completed level 3 safeguarding training.  4.6.28 GOSH has a very large number of honorary staff who fulfil a wide range of roles, some purely observational. This complicates the monitoring of compliance with training. Some staff have received training in the health trusts and institutions in which they are normally based. The hospital recognises that it needs to continue to monitor the position of honorary and visiting staff so as to ensure that safeguarding training is made available when that is required. 4.6.29 The hospital needs to work to continue to improve its performance in relation to child protection training, ensure that gaps in safeguarding training are identified in staff at all levels through the appraisal process and then that action is taken. Those who have this responsibility need in future to have the full support of trust’s board members in ensuring that this task is prioritised. GOSH needs to ensure that all consultant staff have up to date safeguarding training and that they are in a position to lead their teams on this issue, rather than rely on more junior members of staff to take responsibility for safeguarding. 4.6.30 Attendance at training sessions or involvement in online training will not provide a complete answer. The hospital needs to ensure that all staff are able to reflect on the particular difficulties that may inhibit the implementation of their safeguarding knowledge in the circumstances in which it needs to be applied, such as a busy outpatients clinic in which there is a constant flow of medically challenging cases. This is a more complex task than achieving compliance with numerical training level targets. 4.6.31 The SCR has considered whether the professional hierarchy had a negative impact on the ability of the clinic assistant to assert her concerns in the face of the consultant surgeon’s ‘busyness’. She says that it did not and all the indications are that she is a confident member of staff. However this can be an important factor in inter-professional discussions which the hospital should also address as part of its safeguarding strategy and training programme. Staff at all levels need to be assisted to develop the sort of ‘soft skills’ that are needed to challenge more senior staff when they feel that to be necessary. Significance in relation to wider service provision for vulnerable children  4.6.32 Bruising in an immobile baby is one of the most commonly cited ‘strong’ indicators of physical child abuse. Inexperienced professionals attending foundation training programmes will often correctly identify    41 it as a very concerning presentation. The difficulty is in the transfer of learning from the classroom to the real world.  4.6.33 A recent review of SCRs which studied the importance of professional knowledge of child development identified a number of cases in which professionals had failed to respond to bruising of immobile babies in keeping with the potential level of risk. These all point to other factors in the assessment which served to distract attention from the significance of the bruising. 19 4.6.34 In relation to Child D the main contributory factors in relation to the failure to refer the bruise for further investigation were uncertainty about its seriousness due to its small size (first GP and clinic assistant); factors associated with the task being undertaken (surgeon) and the context in which staff were working (clinic assistant); lack of training and mindfulness of safeguarding as a potential concern (surgeon); failure to question a previous assessment in the light of new circumstances (second GP). This indicates that as well as providing more training the different factors that inhibited action over a strong indicator of potential abuse need to be addressed in the context in which they occur.  4.6.35 This case history should also serve to dispel the belief that a bruise on an immobile baby is less significant because it is small. 4.6.36 One of the factors not cited in the research but cited in some SCRs and anecdotally of importance is that professionals fear 1) damaging relationships with parents and 2) making an allegation that proves to be unfounded. The evidence given by the mother of Child D to the care proceedings is instructive in this regard. At the time it appeared that she was presenting professionals with a definite account of the circumstances in which the bruising was caused. She later admitted that she had no idea how it had happened and that when she described the cause of the injuries (with apparent certainty) she had in fact ‘gone to the doctors with guesses’. A more challenging and sceptical approach might have helped her face up to the fact that the bruise had been caused by her partner’s mishandling of the baby. 4.6.37 Luton LSCB should consider whether there is at present sufficient guidance for professionals on the pathway for discussing and referring                                             19 The reasons given by professionals were that 1. children had complex health needs or disabilities and the bruising was somehow (but implausibly) connected with this; or  2. the child’s development was otherwise good; or  3. the person who posed a perceived risk of harm to the child (e.g. a dangerous male figure) was believed to be out of the picture; or  4. the parents were hostile or difficult and somehow stopped the practitioner from seeing clearly.  Brandon et al Child and Family Practitioners’ Understanding of Child Development: Lessons Learnt from a  Small Sample Of Serious Case Reviews (2011) DFE RR100    42 concerns about bruising and the threshold for doing so. A number of LSCBs have developed specific bruising ‘protocols’ and the board should consider whether this should be done.20 If this work is commissioned it should involve consultation with relevant professionals (including GPs) to make it as relevant as possible to their needs. The LSCB should consult with and seek to learn from the experience of other LSCB areas where revised arrangements for responding to bruising have been implemented. 4.6.38 GOSH should satisfy itself that the take up of safeguarding training is rapidly brought into line with the expectations of professional bodies, commissioners and regulators and that training impacts positively on the performance of its staff at all levels. 4.6.39 Reviews commonly refer to the need for professional curiosity.21 This case highlights that as well as understanding the need for this quality ‘in theory’ agencies need to address the difficulties that arise in exercising professional curiosity in the everyday work context. Curiosity should not be viewed solely as a personality trait. Organisations must encourage and enable their staff to be curious. 4.7 Working arrangements between health visitors and GPs in relation to the 6-8 week child health review and other elements of the Healthy Child Programme 4.7.1 This section of the report looks in depth at the approach taken to the 6-8 week check and to working arrangements between GPs and health visitors. This is of wider significance to services for infants and small children in Luton. It stands in addition to the more specific findings on bruising in section 4.6. Working arrangements between health visitors and GP practices  4.7.2 GP1 told the SCR that he ‘regretted the absence of the health visitor at the 6-8 week check which was a practice in the past which was very useful in complimenting medical checks with wellbeing checks and also facilitated person to person discussion and hand over of any concerns’.  4.7.3 The system described by the GP (whereby health visitor allocation was determined by the child’s GP practice and each practice had its own health visitor) ended in Luton some years ago. Health visitors’ perceptions of such arrangements – in Luton and elsewhere – were frequently negative as they often felt themselves to be the junior                                             20 For example http://www.4lscb.org.uk/documents/Hampshire%20Docs/BruisingProtocolflowchart.pdf ; http://berks.proceduresonline.com/chapters/p_recog_resp.html#phys_abuse  21 See for example K Broadhurst et al (2010), Ten pitfalls and how to avoid them - What research tells us www.nspcc.org.uk/inform     43 partner in the relationship, left by some GPs to sort out the ‘social problems’ with difficult families. 4.7.4 Luton’s health visitors now have caseloads drawn from a number of GP practices. They lead small teams of health care professionals. This is an established national way of organising services which is not going to change in the foreseeable future. Of course no system is without disadvantages. 4.7.5 In Luton there are arrangements which should allow each GP practice to identify the health visitor who is responsible for each child so that GPs can communicate any concerns. Each practice has a ‘link’ health visitor who will identify the child’s allocated health visitor and liaise if there are problems.  4.7.6 The health visitors involved with this family were asked by the SCR to comment on the current approach. They felt that it worked in a satisfactory way, though (inevitably) GP practices related in different ways to the health visiting service. Some link health visitors regularly attended meetings at their GP practice, while others were not invited. Relationships between the health visitors and the GP practice where the mother and Child D were registered were described by health visitors as being ‘good’. 4.7.7 GP practices that use the same electronic recording system as the community health service can agree to ‘share’ information automatically and send one another tasks and updates. Used properly this allows professionals to alert one another to significant developments. Child D’s GP practice used another widely known electronic system which cannot communicate directly with SYSTMONE. Communication between the GP and the health visiting service 4.7.8 Section 3 of this report has noted a range of factors that complicated the provision of health care in this case: the mother had a troubled and abusive family background; Child D had an acute medical condition which resulted in a long hospital admission and disrupted the normal course of post natal discharge; Child Y (the older half sibling) had behavioural problems that had led to a referral to the Child Development Centre.  4.7.9 Despite this degree of complexity at no point during Child D’s life did the health visitor and the GP communicate directly (i.e. by phone, email or face to face) about their contacts with the family. Information about the outcome of the 6–8 week check was added to the community child health record, which the health visitor could access, as part of the routine sharing of information. The GP thought about talking to the health visitor about the bruise seen at that check but did not do so. Tasks and responsibilities were undertaken separately.    44 4.7.10 Recognising this does not imply individual criticism of either party because this approach would be considered normal by most GPs and health visitors. The Department of Health ‘Healthy Child Programme’ envisages a series of contacts with health professionals in the first 3 years of a child’s life. These are ‘opportunities for screening tests and developmental surveillance, for assessing growth, for discussing social and emotional development with parents and children, and for linking children to early years services’.22 Government guidance sets expectations about the quality of each element, while paying little attention to the way in which the different professionals involved might work together more effectively. That is left to local working practice. 4.7.11 In Luton – as in most areas - these checks and assessments are commissioned to be conducted by different health professionals. The service specification of the health visiting service in Luton is to conduct the new birth visit and to ‘promote attendance at all health surveillance checks including the 6-8 week review by the GP and developmental reviews at 12 months and at 24 months’ (emphasis added). It permits greater collaboration and this may happen in some cases. 4.7.12 The SCR review team has considered whether there are ways in which GPs and health visitors could work in a more collaborative fashion in relation to the key tasks in the Healthy Child Programme. This case shows how undertaking more tasks collaboratively, in cases that meet certain agreed criteria, might be beneficial. The health visitor undertook the new birth visit to Child D with no knowledge of the family background – which was readily available from the GP records. The details of the new birth visit – which included details of the plan made by the health visitor to meet Child D’s additional health needs -were never known to the GP. The findings and outcome of Child D’s new birth assessment would have been of potential interest to the GP and given him a much fuller picture of the child’s context before undertaking the 6-8 week health check. 4.7.13 There is a strong case that when an infant has been assessed as having needs beyond those that can be provided by the universal child health programme, developmental assessments and checks that are currently carried out as a single agency or professional responsibility should be undertaken more collaboratively. This would strengthen safeguards for more vulnerable children.                                              22 Department of Health, (2009) Healthy Child Programme Pregnancy and the first five years of life (page 37). ‘Scan at the 12th week of pregnancy; the neonatal examination; the new baby review (around 14 days old); the baby’s six to eight-week examination; by the time the child is one year old; and between two and two-and-a-half years old.’    45 4.7.14 Information about the outcome of the 6-8 week check on Child D had been copied onto the electronic record system of the health visitor (SYSTMONE) but under current arrangements she had no reason to seek it out. If she had had this responsibility because Child D had been identified as being vulnerable or had the GP actively identified the existence of the bruise as being something for her attention it would have offered an opportunity for a professional with a fresh pair of eyes to spot a potentially significant sign of abuse. 4.7.15 It is easy to imagine the advantages of GPs and health visitors collaborating more than they currently do, but much more difficult to work out how to make it happen without disadvantaging other important tasks and relationships. For the reasons described in paragraphs 4.7.2-4.7.4 above this is very unlikely to happen through the regular direct involvement of health visitors in examinations at GP practices. However it should be possible through increasingly available means of communicating electronically and sharing records.  4.7.16 At present many discussions about this focus on the difficulties of achieving greater integration, such as the fact that different providers are free to purchase different systems which sometimes do not ‘talk’ to one another. From the LSCB perspective the emphasis needs to be placed on solving the problems by commissioners of health services making clear the basic requirement that every electronic patient record system is able to share information with linked services used by the same vulnerable patients.  4.7.17 Increased use of electronic information sharing of information may open up possibilities but it is not always without disadvantages. It may make professionals less likely to communicate by talking to one another or having meetings (though in this case the GP and health visitor did not talk to one another about Child D).  4.7.18 While there may be no obvious solution which does not have potential disadvantages, there is clearly value in health visitors and GPs in Luton (and those who commission their services) using the published findings of this SCR as a starting point for discussions about how they could implement the Healthy Child Programme differently in relation to particular groups of vulnerable children. The SCR has made a recommendation in relation to this. 4.8 Access to urgent and emergency health care in Luton for babies and small children  Significance in relation to the outcome for Child D 4.8.1 Child D was taken by the ambulance service to the LDUH the evening before she was admitted to hospital with serious injuries. Child D was    46 ‘streamed’ by a nurse and seen by a GP working at the GP Urgent Care GP clinic at the hospital. (The term ‘streamed’ is explained below). The GP Urgent Care GP clinic is provided by a private healthcare company. 4.8.2 There is unanimity among medical experts that the injuries that caused Child D’s death were inflicted after that visit. The practice of the professionals did not impact on the outcome for Child D. However Child D’s attendance at LDUH highlights features of the normal way in which children and babies access services at LDUH which merit further consideration.  The patient pathway at Luton and Dunstable University Hospital Emergency Department 4.8.3 Members of the public arriving at the Emergency Department (ED) at LDUH are met by a qualified nurse whose role is to ‘stream’ patients (including young children) signposting them to attend either the LD or the GP Urgent Care Clinic which is located at the hospital.  4.8.4 The purpose of this arrangement is to enable members of the public to obtain the right service quickly and to avoid the unnecessary use of ED, when this will bring no added benefit.23 Efforts to reduce inappropriate use of ED also reflect a concern to reduce waiting times and costs (because the hospital makes substantial charges for each patient seen at ED). These are national concerns but they are particularly pertinent in Luton which has a lower than average rate of permanent GP registration, which in turn encourages ED attendance. 4.8.5 Patients who are not obviously gravely ill or injured arriving at LDUH (or in the case of children their carers) are interviewed and visually assessed by a screening nurse. This is a senior and experienced member of staff. The streaming arrangement avoids the need for duplicate payment to be made to LDUH and the GP Urgent Care Centre and locates accountability for the treatment provided with the service that receives the patient after the streaming process.  4.8.6 LDUH does not expect the nurse to make a record of the contact, the advice given or the reasons for it. The term ‘stream’ is used in contrast to the usual ‘triage’ which suggests a clinical input.                                              23 According to the Luton CCG specification for this service national evidence suggests that approximately 30% of self-attendees at ED have problems that can be managed effectively by a GP or another primary care professional and at least a further 20% have conditions that are amenable to being seen in a primary care setting. National estimates of the proportion of patients who could be treated outside of ED vary between 10% and 40%. Figures quoted on this topic are potentially confusing because they are used to illustrate different perspectives on the problem. Higher figures identify the proportion of patients who might in theory be treated away from ED. Lower figures identify the much smaller number who can in reality be treated away from ED taking into account the actual availability of alternative provision in the local health economy. (Today, Radio 4, 21 May 2014).    47 4.8.7 Whilst this system may seem unnecessarily complex to the ordinary person, it is common for EDs to develop arrangements such as this to manage the relationship between ED and GP Urgent Care. Some hospitals have developed systems which default to the assessment of small children at ED. At LDUH the current arrangement is viewed as being an improvement on the previous system which was to employ trained hospital receptionists to undertake the task with support from a doctor or a nurse if required. Significance in relation to wider service provision for vulnerable children 4.8.8 Prior to the implementation of the streaming arrangement all children under the age of 6 months who presented at LDUH ED were referred to a paediatrician in the ED. The SCR was informed that some professionals at the LDUH had reservations about the introduction of the current system because it meant that fewer children would be seen in ED and because there would be no record of the advice given to the patient being streamed.  4.8.9 When Child D attended the LDUH all infants presenting at the hospital were streamed. When the SCR report was finalised (June 2014) the arrangements had been modified so that the following groups of children were referred directly to ED:  any infant under six months  any child with an apparent head injury  any child arriving at LDUH by ambulance. 4.8.10 Whilst the SCR is clear that Child D’s contact with the GP Urgent Care GP was of a high clinical standard and had no bearing on her death, the fact that this matter has been highlighted offers an opportunity for the health commissioner, the LDUH and the provider of the GP Urgent Care Clinic service to review how the streaming arrangement is working specifically in relation to small children. 4.9 Assessment of parental learning difficulties and their impact on parenting 4.9.1 During the planning phase of the SCR it was noted that a number of professionals dealing with Child D’s mother had expressed concerns that she might have a learning difficulty. This was explored through the review of records and interviews with staff. In order to provide a longer term perspective the review obtained information from social care and education records from the mother’s adolescence.  4.9.2 The SCR was also able to review information from the fact finding in the care proceedings. Prior to this there had been no formal assessment of the mother’s intellectual and cognitive ability. This    48 material showed marked contrasts between the perceptions of professionals who were involved at different points.  4.9.3 The mother’s learning difficulties have no direct bearing on the death of Child D; however it is likely that if their impact on her capacity as a parent had been better understood more or different help might have been offered.  4.9.4 None of the professionals who had been in contact with the mother during the five years prior to the death of Child D felt that she had a learning difficulty. Midwives noted that she had what she described as dyslexia (this was in response to a question asked to all parents in antenatal clinic). However she was in practice able to complete a detailed, written birth plan for Child D’s delivery and showed a very good understanding of her pregnancy and labour and the medical procedures that would be necessary after the baby’s birth. 4.9.5 Very similar comments were made by the nurseries and schools that had contact with the mother over Child Y. They found her able to discuss and understand their concerns about Child Y’s emotional and behavioural development and to implement and review the strategies and suggestions that they made. The social worker at GOSH was impressed with the understanding that the mother had of her past abuse and her determination not to allow anything similar to happen to her own child. 4.9.6 None of the professionals who saw Child D’s mother believed that she had obvious learning difficulties or that this was a factor that might adversely affect her care of Child D. None felt that there was the need to carry out a formal assessment or diagnosis to confirm this and none had the means to do so. Given the material that the SCR has seen relating to the period before the death of Child D there was no apparent need for this to happen. 4.9.7 The mother’s school records present a mixed picture. The mother completed secondary school but did not achieve any qualifications. One secondary school record notes that she had ‘moderate learning difficulties’ and needed additional help. Most records attribute her difficulties in school to low self-esteem and family problems which severely demotivated her. 4.9.8 After Child D’s death the mother underwent a very detailed assessment by a forensic clinical psychologist. The findings contrast markedly with the recent professional views. This assessment identified the mother as having an IQ score which placed her in the lowest 3% of the population and identified significant difficulties with memory recall. The conclusion of the court was that the mother ‘would find independent living quite difficult and would be dependent on other    49 people for more complex daily problem-solving skills’. This in turn would mean that she ‘would find the more complex aspects of parenting difficult, such as those which required quick decision making and prioritising of information’.  4.9.9 The court treated this as an important aspect of the mother’s vulnerability. However the impact of the assessment was a complex matter for the court because after careful consideration it also decided that it was right to place considerable weight on her recollection of events and her credibility as a witness. The court concluded that the mother herself ‘underestimates her abilities’. 4.9.10 An assessment based on only short term contact with a parent who was at the time under a great deal of stress may have limitations. However there is no reason to doubt the psychologist’s overall finding and to recognise that if a more detailed assessment had been triggered sooner it might have offered professionals very useful additional information. This might in turn have influenced the interventions that were made. 4.9.11 This serves to highlight the importance and complexity of assessing whether a person has learning difficulties and the extent to which they may impact on the care of vulnerable children. Child D’s mother had no difficulty in providing practical care for children, either in a general sense or when asked to carry out complex tasks to meet Child D’s health needs. She had no difficulty understanding and implementing plans to help her daughter’s behavioural problems. However the combination of a degree of learning disability and her generally low self-esteem made it difficult for her to manage independently, to judge the actions and intentions of others and to take the actions necessary to protect her children.  4.9.12 So the assessment of learning difficulty has to be related to the person’s social context. For Child D’s mother these aspects of parenting were made even more challenging by the fact that her only other likely source of support – her own extended family – included a number of abusive individuals. She knew that she could not rely on her family to help care for her children safely. Both aspects echo the circumstances of a very vulnerable parent whose child was injured and about whom Luton LSCB conducted a SCR in 2011.24 4.9.13 It is a common experience that full assessments of the impact of learning difficulties on a person’s parenting capacity are usually only available in two circumstances: either when a case has reached care proceedings (as specialist resources are available to support cases in care proceedings) or when the learning difficulties are very marked                                             24 Child B SCR Executive Summary http://lutonlscb.org.uk/learning.html     50 (and the parent independently meets the criteria for learning disability services). 4.9.14 It is much more difficult for professionals working in circumstances where there are lower levels of identified need (either adult needs or needs of the child) to access assessment and advice on this topic. However it is clear that assessments of parents’ intellectual level and cognitive ability need to be more widely available – and at an earlier point - because they can add to the understanding that professionals such as midwives, health visitors, GPs and social workers have of the factors that are likely to impact on parenting. 4.9.15 This is not a simple matter. Steps to improve services may include commissioning of different services, raising awareness, improved training and making available advice and consultation to staff working with potentially vulnerable parents. Luton LSCB should consider how it can make the most useful contribution to improvements in this provision. The SCR has made a recommendation in relation to this.    51 5 Summary of findings and recommendations The provision made for Child D and other family members 5.1 The SCR was conducted because the post mortem examination of an 11 week old infant, Child D revealed three findings which are strongly associated with injury caused by shaking. In care proceedings it was subsequently determined that the injuries that caused Child D’s death were inflicted by her father and that she had also been roughly handled on one or more occasions by him. The family court determined that the child’s mother did not at the time know how the injuries had been caused. The father was found guilty of Child D’s manslaughter.  5.2 Child D’s mother has also admitted that she shook Child D ‘gently’ when she seemed to have stopped breathing. It is apparent from evidence given in care proceedings and in the criminal investigation and trial that neither parent was sufficiently aware that shaking an infant could cause very serious harm.  5.3 After the death Child D’s mother stated that the baby had been bruised on three occasions when in the care of her father. One of these bruises (possibly not the most serious) was seen by four health professionals on three occasions in the two week period prior to the time when serious injuries were inflicted on Child D.  5.4 After she had been seriously injured it was found that Child D had two fractures, believed to have been 6-8 weeks old. The cause of these has not been determined, though they are of a type and in locations that are consistent with a clinical picture of physical abuse. There are however other possible explanations. Whatever their cause the fractures would not have contributed to the child’s serious illness or death and would not have been noticeable in the course of day to day contact with the baby nor when Child D underwent routine medical examinations. However if they had been identified it is very likely that they would have been treated as indicators of possible abuse and investigated thoroughly. 5.5 Child D had a medical condition identified during pregnancy. Surgical treatment for this potentially serious condition was carried out immediately after her birth. It went well and there are no concerns about the health service support that the child received in relation to this, either at Great Ormond Street Hospital (GOSH) or after her discharge. 5.6 The mother of Child D came from a family in which there was abuse and other social problems and at different times she received a good level of support from professionals over this. Local authority social care services had been involved with the mother in 2006 over this, but    52 had had no substantial recent involvement. The health visitor who provided care to Child D and her mother was not aware of this significant background.  5.7 The antenatal service knew about this but the information was not shared with the child’s health visitor for three reasons 1) during the pregnancy there had been no concerns about the mother and father’s capacity to care for Child D 2) because of her complex medical condition Child D followed an unusual ‘care pathway’ i.e. rather than being discharged straight home after birth the baby was admitted to GOSH for a lengthy inpatient stay, then to a local paediatric ward before going home for the first time and because 3) potentially significant information about the mother’s childhood held in the GP records was not identified and shared with other health professionals. 5.8 Child D’s mother did not harm her but she was less able to protect the baby because of her troubled background and her learning difficulties. The latter had not been apparent to the professionals who had been in contact with her.  5.9 Child D had an older half-sibling who experienced behavioural difficulties from the age of two onwards. A number of factors contributed to these including a medical condition, attachment problems and exposure to incidents of domestic abuse in two of the mother’s relationships. Health and education agencies in Luton responded to the child’s behavioural problems by seeking assessment and involving a range of support services. Their response was entirely appropriate to the needs presented. There were no safeguarding risks identified in relation to Child D’s half-sibling, though there were some shortcomings in the way in which she was cared for. 5.10 The only sign of potential risk to Child D that was observed during the baby’s life was that on three occasions professionals observed a small bruise on the baby’s head. This is a strong indicator of concern in an immobile baby but – for a variety of reasons – the professionals did not refer Child D to the local authority or seek advice from a child protection specialist such as a Named Doctor or Nurse.  5.11 It is not possible to say with certainty what the outcome of such a referral or discussion would have been, but it is very likely that it would have led to further more detailed investigation of the nature of the injury, the plausibility of the explanation given and the context in which the injury had occurred. It is possible that this investigation would have led to the discovery of the fractures that Child D had previously suffered and steps being taken to safeguard Child D before she suffered further injury.     53 5.12 The SCR has examined the specific circumstances in which bruising to Child D was seen but not acted on. It has sought to understand fully the actions and decisions taken and to examine the circumstances in which professionals were operating. It has made recommendations which are designed to reduce the likelihood of similar shortcomings in services occurring again. The wider implications for services to safeguard children 5.13 The review team has used the detailed assessment of the provision made to Child D as a starting point for identifying evidence of wider vulnerabilities in the arrangements to coordinate health services for vulnerable children in Luton and at GOSH. This applies not only to obvious and specific concerns about practice episodes which may have impacted negatively on Child D but also on the way in which health provision is ordinarily made that have been highlighted by the review. Attention has focus on patterns of service provision that occur more commonly and are thus likely to have a wider impact on children. Recommendations and proposals for further work which are linked to the circumstances of Child D’s death 1 The LSCB should share the findings of the SCR with Camden LSCB. Both LSCBs should monitor the action being taken to implement the findings and disseminate the lessons of the review to professionals (while ensuring that discussion of the case does not prejudice the criminal prosecution). 2 Luton LSCB should give detailed consideration to the messages about the vulnerability of babies and the risks associated with even momentary shaking that emerge from the SCR. Member agencies commissioning or providing services to potential parents and parents of small children should take action to improve the safeguarding of children in relation to this. Recent initiatives such as the NSPCC ‘Coping with crying’ and ‘Preventing non-accidental head injury’ programmes should be considered. 3 Luton LSCB should review present guidance for professionals on the pathway for the identification and referral of concerns about bruising. It should consider the value of adding a specific bruising ‘protocol’ to the multi-agency procedures, in consultation with the other LSCBs that share those procedures. 4 Luton LSCB should undertake a review of current approaches to the assessment of learning difficulty as a factor that may influence parenting and consider how best to improve the availability of such assessments at targeted service level and child in need level.    54 5 Great Ormond Street Hospital should ensure that consultants (including honorary members of staff) have up to date safeguarding training and provide leadership to their multi-disciplinary teams on this issue, as they do in other areas of clinical practice. 6 Great Ormond Street Hospital should ensure that gaps in safeguarding training are consistently identified in all staff appraisals, regardless of the seniority or role of the staff member  7 Luton LSCB, commissioners of health services in Luton, Cambridge Community Services NHS Trust, Luton and Dunstable University Hospital NHS Trust and Great Ormond Street Hospital NHS Foundation Trust, should consider further how they can improve the ability of staff to transfer the lessons of training about the recognition of child abuse and neglect into their normal working environment. Recommendations and proposals for further work on wider services for children identified in the course of the SCR 8 Luton GPs, the NHS England Area Team (which commissions their services), the CCG and Luton and Dunstable Hospital should review the current arrangements for information sharing between GPs and LDUH at the point of referral for antenatal booking and during pregnancy. The aim should be to find ways of increasing the identification and sharing of relevant background social information about pregnant women and their partners. 9 As part of the current review of the school nursing service the Director of Public Health for Luton and Cambridge Community Services NHS Trust should consider how to improve transfer of cases from health visitors to school nurses. 10 NHS England, Luton CCG, GPs and Cambridge Community Services NHS Trust should review the current delivery of the Healthy Child Programme in order to explore:  1) whether there are better ways of sharing information between GPs and health visitors (including the use of electronic systems) and  2) whether more tasks in the Healthy Child Programme can be a shared responsibility for health visitors and GPs in cases when the child has been identified as being vulnerable. 11 Luton CCG, the Luton and Dunstable University Hospital (LDUH) and the provider of the GP Urgent Care Clinic should review the safety and the quality of provision made under the current streaming arrangement at LDUH in relation to children under the age of 12 months.   55 Appendix I  REVIEW TEAM MEMBERSHIP Agency Designation Luton Clinical Commissioning Group Consultant Paediatrician and Designated Doctor for Safeguarding Children Assistant Director / Designated Nurse  Safeguarding Children Named GP for Safeguarding Children and Adults Luton Borough Council Children and Learning Department Head of Specialist Family Support Services Luton and Dunstable University Hospital Lead Nurse for Safeguarding Children  Great Ormond Street Hospital and NHS Foundation Trust Head of Safeguarding and Named Nurse  Cambridgeshire Community Services NHS Trust Named Nurse Safeguarding Children Luton Safeguarding Children Board Business Manager Administrator Independent Lead Reviewer     56 Appendix II  List of documents and material considered by the SCR review team and roles of professionals who have contributed Chronologies of contact with family members from participating agencies Copies of selected original patient records Notes of interviews and discussions conducted with the following professionals: Luton and Dunstable University Hospital NHS Trust Midwives Emergency Department Screening Nurse Paediatrician Safeguarding Midwife Cambridge Community Health Services NHS Trust Health Visitors  Luton Borough Council Social Worker   Great Ormond Street Hospital NHS Foundation Trust Social Worker Family Support Worker Clinic Assistant Honorary Consultant Surgeon  GP Urgent Care Clinic  General Practitioner  GP practice General Practitioners  Schools and nursery schools Teachers, Nursery Worker, Nursery Manager, Teaching Assistant (taped interview) reviewed by the Principal Educational Psychologist Luton Borough Council     57 Appendix III Principles from statutory guidance informing the SCR methodology 1. The approach taken to reviews should be proportionate according to the scale and level of complexity of the issues being examined. 2. Reviews of serious cases should be led by individuals who are independent of the case under review and of the organisations whose actions are being reviewed 3. Professionals must be involved fully in reviews and invited to contribute their perspectives without fear of being blamed for actions they took in good faith.  In addition Serious Case Reviews should:  Recognise the complex circumstances in which professionals work together to safeguard children.  Seek to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did.  Seek to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight.  Be transparent about the way data is collected and analysed.  Make use of relevant research and case evidence to inform the findings.  Working Together to Safeguard Children 2013 (Sections 4.9 and 4.10)     58  Appendix IV References  HM Government, Working Together to Safeguard Children – 2013 HM Government, LSCB Regulations 2006 M Brandon et al (2008) Analysing Child Deaths and serious injury through abuse and neglect: what can we learn? (England, 2003-2005) M Brandon et al (2011) Child and family practitioners’ understanding of child development: Lessons learnt from a small sample of serious case reviews University of East Anglia K Broadhurst et al (2010), Ten pitfalls and how to avoid them - What research tells us www.nspcc.org.uk/inform  E Hollhangel, J Braithwaite and R Wears (2013) Resilient Health Care; Ashgate National Collaborating Centre for Women’s and Children’s Health - Commissioned by the National Institute for Health and Clinical Excellence (July 2009) When to suspect child maltreatment OFSTED, (2011) Ages of Concern: Learning Lessons from Serious Case Reviews a thematic report. E Rowley and J Waring (eds) (2013), A Socio-Cultural Perspective on Patient Safety, Ashgate Royal Colleges of Paediatrics and Child Health, (September 2010) Safeguarding Children and Young people: roles and competences for health care staff, Intercollegiate Document  S Shribman and K Billingham / Department of Health (October 2009) Healthy Child Programme – Pregnancy and the First Five Years of Life Charles Vincent (2010) Patient Safety (second edition) Wiley-Blackwell BMJ Books      L S  C B  Serious Case Review in relation to the death in January 2013 of Child D  Response from Luton Safeguarding Children Board In March 2013 Luton Safeguarding Children Board began a Serious Case Review (SCR) in relation to the services that were provided to Child D and her family. The review scrutinised the work of the following agencies: • Cambridge Community Services NHS Trust – which provides community health care for children in Luton, including health visiting services • Luton and Dunstable University Hospital NHS Trust (LDUH) – which provided midwifery, child health and emergency department services • GP surgeries and the GP Urgent Care Clinic (located at the LDUH) • Great Ormond Street Hospital NHS Foundation Trust – which undertook surgery on Child D • East of England Ambulance Trust  • Cambridge University Hospitals NHS Foundation Trust – which provided a specialist ambulance service. • A playgroup; a nursery and a school (all in Luton) attended by the older half sibling of Child D The full findings of the SCR are set out in the overview report which has been published alongside this response. The publication of this report was delayed in order to ensure that it did not prejudice the criminal investigation into Child D’s death. The table below sets out the main points of learning from the Serious Case Review and the action that has been taken to improve services and make children safer, both in Luton and at Great Ormond Street Hospital. With a small number of exceptions the case review highlighted problems that are not amenable to simple solutions, so that the work to implement the recommendations and to monitor their impact on practice will become part of the long term work of the safeguarding boards and their member agencies. In relation to its previous Serious Case Reviews the safeguarding board has asked member agencies for periodic updates to understand whether the work that has been undertaken have made a positive impact on services and on the lives of children. The board will continue that practice and publish the responses of agencies on its website.   Professor Michael Preston-Shoot Independent Chair  Luton Safeguarding Children Board October 2015          Luton Safeguarding Children Board Town Hall Extension Gordon Street Town Hall Luton LU1 2BQ Business - 01582 547624 Training - 01582 547555     Learning from the Serious Case Review Action that has been taken since January 2013 and the impact of those measures Continuing work to make children safer and improve the quality of services 1. The case history underlined the high level of vulnerability of small infants and the dangers of shaking them, even momentarily.  Luton LSCB decided that agencies that commission or provide services to potential parents and parents of small children should take action to improve parental understanding of this. Luton LSCB and member agencies have implemented this in two ways.  Luton LSCB and agencies that work with parents and infants have been working with the NSPCC in an initiative entitled ‘Coping with Crying’. This includes publicity materials, including a DVD, designed to be shown to new parents, and training materials for professionals. The initiative underlines very strongly the dangers of shaking infants and small children. Training materials have been incorporated into the training programmes of Luton LSCB and member agencies. Luton Clinical Commissioning Group (CCG) is also exploring how best to adapt the content of the parent held child health record the ‘Red Book’, to ensure that it provides very clear information on this and that professionals who issue and use the red book draw the attention parents to this information. The first phase of ‘Coping with Crying’ is being evaluated nationally with a view to it being made available in a wider range of hospital and community health settings. Luton agencies will implement the ‘Coping with Crying’ initiative when revised materials become available. Lessons from the current evaluation of the project will be taken into account to improve the dissemination of information to parents.  A revised ‘red book’ will be in use in Luton from September 2015. Luton LSCB will continue to challenge member agencies to demonstrate that they are explaining the dangers of shaking a baby to parents, especially those who are vulnerable or under stress. 2. Two health professionals in Luton saw small bruises on an immobile infant, but for different reasons were unable to challenge the accounts given by a parent as to how this had happened. In hindsight it became apparent that the mother herself was looking for answers and would not have been alienated if she had been challenged. Luton LSCB agreed that it would review its guidance for professionals on the pathway for the identification and referral of concerns about bruising and add a specific bruising ‘protocol’ to the multi-agency procedures because that was an Luton LSCB and its member agencies have adopted a specific procedure on bruising (the bruising protocol) which sets out the actions that all professionals are expected to take when they recognise that a child has been bruised. The bruising protocol was adapted from one that had been working successfully in a neighbouring local authority area. It explicitly addresses the action needed in relation to the bruising of a non-mobile baby. This work was completed in 2014. Given the importance of GPs and practice staff in caring for infants particular emphasis has been placed on the protocol in safeguarding training for GPs. A template for The implementation of the bruising protocol will continue to be monitored through audit and reports on local single and multi-agency reviews.  Any incident in which bruising in an immobile infant is not dealt with in line with the protocol will be reviewed in detail to understand why that has happened so that there is continual learning on this topic.    Learning from the Serious Case Review Action that has been taken since January 2013 and the impact of those measures Continuing work to make children safer and improve the quality of services approach which had been successfully adopted in other areas. recording bruises on children has been added to the version of the SystmOne medical records used by GPs. GPs that do not use this system have received a specific briefing from the named GP. 3. The mother of Child D had a degree of learning disability which was not recognised during the various professional assessments and which is believed to have impaired her ability to protect her child from harm. Luton LSCB agreed to undertake a review of current approaches to the assessment of learning difficulty as a factor that may influence parenting and consider how best to improve the availability of such assessments when parents and children are being assessed and supported A working group drawn from health professionals, social care and early help services has devised a brief assessment format to be used when professional judgement indicates that a parent may need additional support as a result of a learning disability. This will be available to staff in antenatal care, paediatrics, health visiting, social care and early help to assist in identifying the need for additional support and advice. The LDUH antenatal service will seek to identify women who have a degree of learning disability at the antenatal booking appointment. Where specific additional needs are identified a specialist assessment can be commissioned. The LSCB will require agencies to monitor and report back on the effectiveness of this new tool and other changes to improve practice.  The Safeguarding Adult Board will also continue to monitor the experience of adults with learning disability who are parents and to challenge agencies where there are gaps in services. Luton’s Adult and Children’s Safeguarding Boards will work towards agreement of a protocol setting out roles and responsibilities in relation to the assessment and support of parents with a learning difficulty 4. Child D attended an outpatient appointment at Great Ormond Street Hospital (GOSH) where a record of a small bruise was made, but the infant was not referred under the hospital’s safeguarding procedures. GOSH agreed that it needed to ensure that consultants (including honorary members of staff) have up to date safeguarding training and provide leadership to their multi-disciplinary teams on this issue, as they do in other areas of clinical practice.  The hospital also agreed to ensure that gaps in safeguarding training are consistently identified in all staff appraisals, regardless of the seniority or Level 3 Safeguarding training compliance of medical staff (including Consultants) has substantially improved since the time of this incident. It now stands at 94.2% (an increase from 91.2% in the previous year).  The Co-Medical Director circulated an email to consultants confirming with them their responsibilities as the responsible consultant. The leadership responsibilities are clearly defined within individual job descriptions.  Level 3 Safeguarding compliance for Honorary Consultants who have a joint GOSH/Institute of Child Health contract and require Level 3 for their role is 90% (an increase from 45% in the previous year).  Given its nature as a specialist regional centre the hospital continues to have a large number of honorary members of staff. Arrangements are in place to ensure that the training department can check safeguarding training records of individuals to ascertain compliance rates.  Development of key actions for specific situations including bruising are being developed to ensure that best practice is followed at all times.  Camden LSCB will continue to monitor and challenge the performance of GOSH in relation to safeguarding.     Learning from the Serious Case Review Action that has been taken since January 2013 and the impact of those measures Continuing work to make children safer and improve the quality of services role of the staff member The GOSH Human Resources (HR) Director has contacted all HR Directors from host organisations requesting assurance that staff are compliant at each level and this has increased the trust’s figures by 10%. 5. The SCR identified that as well as receiving relevant training on the identification of symptoms of child abuse, there was a need to improve the ability of staff in all agencies to implement the lessons of training about the recognition of child abuse and neglect in their normal working environment. Luton LSCB and all of the agencies involved in the review agreed to act on this recommendation. Luton LSCB seeks to assure the effectiveness of its training programmes by following up participants by phone and email.  It remains the responsibility of professionals, supervisors and managers to test whether staff training is having a positive impact on professional practice. The board’s member agencies are expected to report on this through the periodic assurance reports on safeguarding activity to the LSCB executive and the audits that the board carries out under Section 11 of the Children Act 2004. As part of its training strategy the LSCB is developing a tool to evaluate the impact of training on practice. Section 11 audits and assurance reports will continue to test the impact of training on professional practice      At GOSH mandatory training compliance is now assessed at all staff appraisals. In addition managers can access real time reports to check the current compliance status of any member of staff. GOSH safeguarding training now includes specific messages about bruising and specific resources for staff.  The Safeguarding Newsletter was sent to all staff, and included in the Trust briefing which was disseminated across the organisation. GOSH has introduced a post training evaluation to identify the impact of training and how staff have incorporated that learning into their practice. The outcomes of these evaluations will inform future training.  The Trust continues to work to ensure that best practice is followed by all employees.  There is regular engagement with speciality meetings to ensure on-going dissemination of learning to all grades of staff, and random spot check audits will be conducted. The analysis of the impact of training will be reported through the Trust’s internal governance structure. and will inform future training needs.  The Trust provided a verbal update to Camden Safeguarding Children Board in June 2015 as part of    Learning from the Serious Case Review Action that has been taken since January 2013 and the impact of those measures Continuing work to make children safer and improve the quality of services its Section 11 Audit response.   6. The SCR identified that it is critical that as much information about relevant background factors (such as childhood adversity, domestic abuse and mental health problems) about parents is identified in GP records and shared with antenatal services during the early stages of a woman’s pregnancy.  The safeguarding board asked Luton’s GPs and the Luton and Dunstable University Hospital to find ways of increasing the identification and sharing of relevant background social information about pregnant women and their partners when referrals for antenatal care are made. Considerable reliance is placed on the fact that during the antenatal period midwives from the Luton and Dunstable Hospital access mothers’ GP records during the normal course of antenatal care under normal arrangements. This enables a high rate of identification of information about medical and psycho-social concerns contained in medical records The Named GP for Luton has prepared a briefing note for GPs underlining the importance of providing background  information to the antenatal service when making referrals  A format has been developed for antenatal referrals. The paper system was completed in May 2015. The target date for the completion of the electronic system is December 2015.  The board expects the Luton and Dunstable Hospital to continue to monitor any incidents which arise as a result of gaps in background information about parents. Training of GPs will continue to emphasise the importance of providing information about all risk factors in antenatal referrals 7. The review identified the need for more reliable transfer of records to school nurses when a child has received additional support from the health visiting service. The public health service and the provider of the service agreed to include this in the specification for the service The school nursing service is now commissioned by the Public Health section of the local authority. The service specification now makes explicit reference to the need for records of vulnerable children to be identified and brought to the attention of the school nursing service when cases transfer.  This will be monitored as part of normal contract compliance 8. Although Child D had complex health needs and her mother had a difficult social background there was very limited sharing of information and no direct contact between the GPs and health visitors involved.  It was identified that the electronic patient record database used by most Luton GPs was hindering the sharing of information between GPs and health visitors because its default setting was to not allow health visitors access to information.  Luton CCG and NHS England have been working with The LSCB, the CCG and the trust which provides the health visiting service all recognise that closer collaborative working between GPs and health visitors does not rely solely on electronic means of sharing information. Further case reviews conducted in Luton have    Learning from the Serious Case Review Action that has been taken since January 2013 and the impact of those measures Continuing work to make children safer and improve the quality of services NHS England, Luton CCG, GPs and Cambridge Community Services NHS Trust agreed to review the current delivery of the Healthy Child Programme in order to explore:  1) whether there are better ways of sharing information between GPs and health visitors (including the use of electronic systems) and  2) whether more tasks in the Healthy Child Programme can be a shared responsibility for health visitors and GPs in cases when the child has been identified as being vulnerable. Luton GPs to enable the default position to be altered allowing health visitors the right to access information in GP records. This has led to a number of developments. Health visitors can now view GP records should they have safeguarding concerns. The named GP introduced a safeguarding template for GP practices which structures the recording of all safeguarding concerns about children in May 2015. A further developed version of this will be available in December 2015   demonstrated the need to promote ways of health visitors and GPs working closely together over the welfare of vulnerable children.  The Director of Public Health Luton Borough Council and Luton LSCB will continue to monitor and challenge the effectiveness of health visiting services.  NHS England continues to oversee the effectiveness of GP services for children.   9. Luton CCG, the Luton and Dunstable University Hospital (LDUH) and the provider of the GP Urgent Care Clinic agreed to review the streaming arrangement at LDUH Emergency Department in relation to children under the age of 12 months. With effect from September 2014 the arrangements for streaming children at LDUH were changed so that every child under the age of 6 months and every child who is reported or believed to have suffered a head injury is seen at the LDUH Emergency Department, rather than at the Urgent Care Clinic Luton CCG, the Luton and Dunstable University Hospital (LDUH) and the provider of the GP Urgent Care Clinic will continue to monitor the operation of the clinic and the streaming mechanism. Any adverse or concerning incident will be reported and investigated under the normal clinical governance arrangements.  