Summary of a review into the death of an 11-week-old girl in December 2012. Mother found Baby E dead after falling asleep on the sofa with her; both parents had been drinking at home prior to the death. Parents' two oldest children had been subjects of child protection plans under the category of emotional abuse, and later for child sexual abuse, before being taken in to care. The younger children were on plans under the category of emotional abuse and neglect. Parents had a history of: moving house, alcohol misuse, domestic abuse and lack of engagement with professionals. Issues identified include: lack of pre-birth assessment; challenges of managing the different and complex needs of different children in the family; failure to share information about the family between agencies; poor recording standards; failure to make parental alcohol misuse and domestic abuse care elements of the children's child protection plans and professional over-optimism about family functioning. Uses the Social Care Institute for Excellence (SCIE) systems model to pose questions to Bury Safeguarding Children Board (BSCB) and put forward recommendations. Recommendations for BSCB include: an audit of recording practices; a review of how safe-sleeping arrangements are built in to child protection plans; and a review of compliance with procedures for pre-birth assessments.
      
 Title:  Serious case review: executive summary: Baby E (Case E12) LSCB: Bury Safeguarding Children Board Author: Dennis Charlton Date of publication: 2013  This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC.  This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above.                          1    Bury Safeguarding Children Board  Serious Case Review  EXECUTIVE SUMMARY  Baby E (Case E12)    Report Author:  Dennis Charlton Date:    19th September 2013    Commissioned by: Bury Safeguarding Children Board 2    CONTENTS CONTENTS .............................................................................................. 2 SECTION 1 - INTRODUCTION ................................................................. 3 SECTION 2 – TERMS OF REFERENCE ....................................................... 3 SECTION 3 – INDEPENDENCE OF THE SERIOUS CASE REVIEW ............... 5 SECTION 4 – MEMBERSHIP OF THE SCR PANEL ...................................... 6 SECTION 5 – METHODOLOGY ................................................................. 6 SECTION 6 – FAMILY STRUCTURE .......................................................... 7 SECTION 7 – CONTEXTUAL INFORMATION ............................................. 7 SECTION 8 – NARRATIVE ....................................................................... 9 SECTION 9 - CASE ANALYSIS ................................................................21 SECTION 10 – SUMMARY AND RECOMMENDATIONS .............................45 Research Sources ..................................................................................58 APPENDIX 1 ..........................................................................................59 APPENDIX 2 - MULTI AGENCY ACTION PLAN – CASE E12 (Baby E) .......61  3  SECTION 1 - INTRODUCTION  1.1 This Serious Case Review Executive Summary is produced in accordance with the Bury Safeguarding Children Board procedure for conducting a Serious Case Review (SCR).   1.2 The reason for this Serious Case Review is because of the death of an eleven week old baby girl (Baby E). It was reported that her parents had been drinking at home and both fell asleep, the mother on one sofa with the baby and the father on another sofa by himself.  1.3 Bury Safeguarding Children Board Serious Case Review Sub-Group met on the 12th January 2013 and made a recommendation to the Chair of Bury Safeguarding Children Board that the case met the criteria for a Serious Case Review. The Chair of Bury Safeguarding Children Board confirmed the decision to undertake a Serious Case Review on the 21st January 2013. The Serious Case Review findings were discussed at Bury Safeguarding Children Board on the 8th July 2013 and recommendations agreed. Because of the strong possibility that members of the family would be identified if the Overview Report was published in full, an Executive Summary was commissioned.  SECTION 2 – TERMS OF REFERENCE 2.1 The time period over which events have been reviewed is the 1st January 2012 to the 21st December 2012. This time period covers the pregnancy of Baby E until her death on 21st December 2012.  2.2 The Specific Terms of Reference for the Serious Case Review are as follows:  1. What were the key relevant points/opportunities for assessment and decision making in this case in relation to the child and family? Do 4  assessments and decisions appear to have been reached in an informed and professional way?  2. Did assessments in relation to Baby E take into account the previous family history (e.g. alcohol and domestic violence) and any other known risk factors?  3.   Did assessments in relation to the other siblings take into account the impact of a new baby?  4.  To what extent were the individual needs of each child identified, considered and addressed?  5. What was the basis of professional assessment of parental change and how was that used in decision making in the child protection planning and decision making processes?  6. When and in what way were the children’s wishes and feelings ascertained and taken into account when making decisions about the provision of children’s services? Was this information recorded? What were the individual children’s experiences?  7. Were there any issues, in communication, information sharing or service delivery within agencies and with partner agencies?  8. Were appropriate child protection or care plans in place and child protection or care plans complied with?  9. When it was agreed to cease the child protection plan, what systems were in place to monitor/support the family prior to first child in need meeting?  10. Was the work consistent with your agency and the BSCB policy and procedures for safeguarding and promoting the welfare of children, and with wider professional standards? 5   11. Was practice sensitive to the racial, cultural linguistic and religious identity and any issues of disability of the child and family, and were they explored and recorded?  12. Was there sufficient management oversight?  SECTION 3 – INDEPENDENCE OF THE SERIOUS CASE REVIEW  3.1 The author of the SCR Overview Report was Dennis Charlton. He is an Independent Consultant in Child Protection with substantial experience in safeguarding children. Mr Charlton is a former Assistant Director of a local authority Children’s Service. He has undertaken a number of Serious Case Reviews both as an Overview Report author and also Chair of SCR Panels. He is accredited to undertake SCR’s using the Social Care Institute of Excellence (SCIE) systems approach.   3.2 The Chair of the Serious Case Review Panel was Jane Davies. She has had extensive experience in Children and Families Social Work.  Most of her social care experience has been in safeguarding work with children and families and she has offered a range of independent social work services, including Interim Management posts, Independent court work, and risk management training for Local Safeguarding Children Boards. Additionally she chairs adoption and fostering panels for four Local Authorities. She is not currently employed by Bury Council and had never had any prior involvement in any capacity with Baby E and family.  3.3 All of the Individual Management Reviews were undertaken by experienced managers, who had no direct management responsibility for the case.    6  SECTION 4 – MEMBERSHIP OF THE SCR PANEL  Jane Davies Independent Chair SCR Panel  Service Manager, Safeguarding Unit Children’s Services, Bury Council  Acting Operations Manager, Greater Manchester Probation Trust  Acting Strategic Lead for Early Intervention, Children’s Services, Bury Council  Lead Officer, Safeguarding for Schools & Extended Services  Detective Chief Inspector, Serious and Organised Crime Group, Greater Manchester Police  Designated Nurse Safeguarding, NHS Bury Clinical Commissioning Group  Health Improvement Services Coordinator, Community Services, Bury, Pennine Care Foundation NHS Trust  Designated Doctor NHS Bury Clinical Commissioning Group  4.1 The Chair of Bury Safeguarding Children Board is Ms Gill Rigg.  4.2 The Overview Report author attended the SCR Panel meetings as an observer and to clarify any issues arising from the Individual Management Review Reports.  4.3 The SCR Panel received administrative support from a Senior Administrative Support Worker.  SECTION 5 – METHODOLOGY 5.1 The Overview Report was undertaken following a systems approach. There was detailed analysis of the Individual Management Reviews and an examination of significant events, for themes, that indicated either strengths or weaknesses in multi-agency safeguarding systems.  7  5.2 Child Protection Conference minutes were examined in order to support information from the Individual Management Reviews.   5.3 Both Baby E’s parents were informed about the decision to undertake a Serious Case Review. They did not wish to contribute but asked to be informed about the findings of the Serious Case Review. At the conclusion of the Serious Case Review both parents were informed of the findings.  SECTION 6 – FAMILY STRUCTURE  6.1    The family composition was of mother, father, two adolescent children and younger children. SECTION 7 – CONTEXTUAL INFORMATION 7.1  The family was first known to agencies in Bury in 2009.  Prior to that, they had been known to a neighbouring authority in the North West.  The first referral was made to Bury Children Social Care in July 2009.  7.2  Since that time there have been numerous concerns about the family, including: • Frequency of house moves • Alcohol misuse • Domestic violence • Inconsistent parenting • Poor engagement with agencies  7.3  There were particular concerns about the oldest two children. These concerns included: • Sexualised behaviours • Challenging emotional and behavioural presentations • Missing from home • Substance misuse • Poor school attendance 8   7.4  These concerns led to an Initial Child Protection Conference held in March 2011 when all of the children were made the subjects of Child Protection Plans, the two eldest children (S1 and S2) under the category of emotional abuse. The younger children under the category of Likelihood of Emotional Abuse and Likelihood of Neglect. Some of the key themes discussed were, domestic violence and alcohol misuse by parents.  7.5  S2 was accommodated by the local authority, as a voluntary arrangement under Section 20 of the Children Act 1989, in July 2011 and was initially placed in a foster placement. There were particular concerns about her frequent “missing from home” and the possibility of sexual exploitation.  7.6  S1 moved out of the family home to live with Maternal Grandmother on a temporary basis.   7.7  There were further Child Protection Reviews held throughout 2011 and 2012, in line with statutory requirements. The eldest two children, S1 and S2 remained the subjects of Child Protection Plans under the category of Likelihood of Emotional Abuse, although the category of Likelihood of Sexual Abuse was added for S2, until her Child Protection Plan was discontinued in May 2012. S1’s Child Protection Plan was discontinued when he moved to a foster care placement in July 2012.  The other children remained the subjects of Child Protection plans under the category of Likelihood of Emotional Abuse and Likelihood of Neglect.  7.8  At the start of the timeframe for this Serious Case Review, S2 was accommodated in a foster placement and maintaining contact with the family. S1 was living with Maternal Grandmother. S2 was later made the subject of a Care Order and placed in residential care. S1 became looked after by the local authority and was placed in a foster care setting. The other siblings were living with parents in the family home.    7.9 The author of the Serious Case Review Overview Report alerted Senior Managers to information suggesting that there were still serious issues of 9  child sexual exploitation in relation to S2. In the light of this information the Serious Case Review Panel recommended that a Critical Case Review be undertaken in relation to S2. This process has now commenced and satisfies the specific recommendation of the Overview Report focusing upon child sexual exploitation. SECTION 8 – NARRATIVE 8.1  Throughout January 2012 there were seen regularly by health and social care agencies. Overall there was a view that the health needs of the children were being met, although there were concerns about the sexualized behaviour of a younger sibling and also the cause of an intimate personal injury to S1.   8.2    It was also felt that considerable pressure had been lifted from the family because of the placement of S2 in foster care. This was confirmed at a Child Protection Review Conference held in late January 2012. It was also noted that there had been some improvements in parental engagement with agencies and that the children’s mother had completed a parenting programme. It was also felt that a recent house move had improved the sleeping arrangements for the children.  The minutes of the Review Conference also indicate that the Chair hoped that discussion could take place at the next Review (to be held early at four months instead of the statutory six months) about “removing the children’s names from the Plan”.  8.3  There was a significant change in the level of co-operation shown by the parents towards the school following the Child Protection Review held in January 2012, when the children’s father stated that he intended to  remove the children from school 1. This was apparently because the parents were unhappy about some of the comments made by school at the Child Protection Review Conference. The change of school was not supported by agencies working with the family.    10  8.4  In late February 2012 there was a Strategy Meeting between the Police (Public Protection Investigation Unit) and Children’s Social Care about concerns of sexualised behaviour shown by some of the children in the family home. There was also a specific allegation that S1 had touched S2 inappropriately.  Key issues that emerged from this meeting were: • Concerns about the siblings having poor attendance and homework completion records • Concern about S1 spending time in the company of an adult male who was known to the family and the intimate injury that had occurred to S1 • The generally sexualised behaviour of the siblings.   8.5  Mother (ME) attended the antenatal clinic in early March 2012. She was seen by a Midwife. The Midwife did have some prior knowledge of the family circumstances from a telephone conversation with the family Health Visitor. There was also information on the GP records indicating that there was problematic alcohol use. Hand held maternity records were issued and mother was referred to hospital to book in for maternity care.  8.6  There was a statutory Child Protection visit on the 19th March 2012 by the allocated social worker. This visit was two days outside the guidance for time intervals between Child Protection visits.  8.7  The Family Court made an Order for the local authority to undertake a Section 37 Report in March 2012 in relation to the children within the family. This seems to have been because of concerns identified by the Children’s Guardian during care proceedings with S2. An Interim Care Order was granted in relation to S2.  8.8  A Core Group meeting took place on the 27th March 2012. There were some concerns expressed about the behaviour and development of some of the younger children. It was also noted that attendance at school had improved with the younger children.    11   8.9  Sibling 2’s foster placement broke down in early April 2012 and she was moved to a residential Children’s Home. Difficulties in the placement had been caused by S2 going “missing from home” on several occasions and consequently being at risk of sexual exploitation.  8.10  In April 2012 the allocated social worker contacted school to say that they had recently undertaken a home visit and both parents were drunk. Observations from Children’s Social Care records say that the household was chaotic. There were parental relationship concerns and father claimed he had commenced drinking vodka at 10am that day. A Health Visitor home visit in April 2012 described the children as clean and appropriately dressed.  8.11  S2 went missing again on the 12th May 2012. In all, she was recorded by the Police as “missing from home” on 17 occasions during May 2012. There were clearly Police concerns about the possibility of sexual exploitation and a Strategy Meeting with The Police Public Protection Investigation Unit; Children’s Social Care and Barnardo’s Safe Accommodation Project representatives took place on the 16th May 2012. Steps were taken in seeking an alternative placement for a young person living at the same Children’s Home. It was thought that it would be less likely that S2 would go missing if she were separated from her placement associate.   8.12  In mid May 2012 there was a referral to the Police Protection Investigation Unit (PPIU). S2 had been missing for three days from her placement address. She was said to have been “chilling with friends”. She returned to her placement by taxi but refused to say where she had been.  8.13  S2 was reported as “Missing From Home” on the 20th May 2012. She was later found at the family home. Police called at the family home and returned S2 to the Residential Unit. Because she appeared disorientated she was taken to the local hospital Accident and Emergency Dept by Residential staff where she tested positive for cannabis. 12   8.14  On the 23rd May 2012 there was information given to Children’s Social Care from the Police Public Protection Unit that an adult male had disclosed to his mental health worker that he had been in a sexual relationship with S2. This was later retracted. The same male spoke of other adult males sexually exploiting S2.  8.15  Midwife 2 contacted Midwife 1 from North Manchester General Hospital to share information about the children’s mother and the family.  Relevant information was shared about the Child Protection status of the children, the concerns about domestic violence and mother’s alcohol problem. Information was also given about the two oldest children S1 and S2. Midwife 1 was also informed about a due Core Group Meeting and was invited to that meeting. The exact date of this communication was unclear but is understood to have taken place prior to the 29th May 2012.  8.16  On 25th May 2012, in late evening, the Police were called out to a domestic incident at the family home. There had been an argument between the children’s parents. The argument was temporarily resolved through the children’s father agreeing to stay at his brother’s house overnight. The children were not viewed as being at risk of harm.  8.17  There was a Child Protection statutory home visit on the 25th May 2012 by the allocated social worker. This visit was significantly outside the minimum requirement for contact with children subject to Child Protection Plans.  8.18   During May 2012 there were increased concerns that S2 was actively involved in age inappropriate relationships with adult males. The Police spoke to S2 in late May 2012. She denied any knowledge of relationships with adults. There was also a reported domestic violence incident at the family home in late May 2012.   13  8.19  The next Child Protection Review Conference was held on the 29th May 2012. A number of concerns were expressed about the children, including behavioural problems, dietary maintenance and developmental delays. There were also concerns expressed about the use of alcohol by the children’s mother even though she was pregnant.  8.20 This Child Protection Review Conference did not cover S2. Because of her status, of being looked after by the local authority, and having a LAC Plan, it was felt unnecessary for her to be also the subject of a Child Protection Plan. Her Child Protection Plan had therefore been discontinued formally at the Child Protection Review in May 2012. There were significant concerns expressed about S2 at this Looked After Child Review including that S2 had been associating with adult males There was no indication from the minutes about any further actions in relation to S2.  8.21 On the 30th May 2012, S2 was again reported as missing from her residential placement and was discovered at her family home. There were allegations from another young person in the residential placement that S2 had been sexually assaulted by a number of adult males the previous evening. S2 declined to be interviewed by Police/Children’s Social Care. There is no indication that this matter was further investigated.  8.22 In mid June 2012, the Police were called to the family home. Neighbours had complained that there were arguments that had been going on all day. When the Police arrived the house was quiet, although the children’s mother acknowledged there had been an argument earlier. Police records show that the house appeared clean and tidy; the children were eating and appeared well cared for. Father had been drinking but seemed “ok”.   8.23  A home visit by the Family Support Worker (FS1) on the 19th June 2012. Key themes that emerged were: • Mother said she had only consumed alcohol on a couple of occasions during this pregnancy. • The issue of harbouring S2 when she went “missing” was discussed.  14  8.24  S2 was reported missing from home on a further 11 occasions during June 2012 before being moved to a residential placement outside of the geographical locality. This placement appears to have offered considerable stability.  8.25 On the 22nd June 2012 there was a visit to a potential new foster placement for S1 accompanied by his social worker. This was viewed as a positive development. S1 was later moved to a new placement in early July 2012.  8.26  Medication for depression was discussed with the children’s father when he attended GP at Practice 2 in early July 2012. It was noted that alcohol continued to be a problem.  8.27  A Core Group Meeting took place on the 10th July 2012. This meeting was approximately four weeks over the timescale when it should have taken place.  8.28  There was a LAC Review in relation to S1 on the 19th July 2012.   8.29 The Health Visitor made a home visit on 23rd July 2012. The  youngest children were seen. They were described as being clean and appropriately dressed.  8.30  There was a home visit on the 26th July 2012 by the allocated social worker (SW1). The youngest child was seen to have a shaved head. Discussions with mother suggested that Maternal Grandmother had cut the child’s hair because there was chewing gum stuck in it. There were queries about whether Grandmother had been intoxicated when cutting the hair. The possibility that this may have been the case was acknowledged by mother.  8.31  There was a home visit by the Family Support Worker on the 30th July 2012.   15  8.32  A Child Protection statutory visit took place on the 7th August 2012. There were further planned home visits by the Family Support Worker on 17th August 2012. The family was not at home and a further home visit on the 22nd August 2012 took place.   8.33  Identified by the School Nurse that one of the children had changed GP Practices. A note on the School Nurse records dated 29th August 2012, says that the School Nurse was to inform the social worker. There is no indication that this information was given to the social worker.  8.34  The Core Assessment undertaken by Children’s Social Care was finalised as an updated document on the 31st August 2012.  8.35  A Core Group Meeting took place on the 6th September 2012, followed by home visits by the Family Support Worker on the 11th September 2012 and 18th September 2012. The family was not home for this latter visit.  8.36  Health assessments were undertaken by the School Nurse on the younger children on the 7th September 2012, with parents present. No concerns were recorded but it is not clear what views the children expressed, if any.  8.37  There was a home visit by the Health Visitor on the 20th September 2012 to share Child Protection Conference Reports with parents. It was recorded that parents were in agreement with the recommendations.  8.38  At this point all of the children were attending school 2. Reports from the school about the attendance of the children and their general demeanor were very positive.  8.39  A Child Protection Review Conference took place in late September 2012. The decision of the Conference was that the children living at home should continue to be the subjects of Child Protection Plans.  • There was some discussion about the IFIT assessment and work with the parents. This is covered in more detail in the Analysis section. 16  • The Family Support Worker reported concerns that the family did not always engage. • There was some disappointment expressed that mother would not attend SureStart’s antenatal classes. • Home conditions were reported to be immaculate. • There was no discussion about a pre-birth assessment.  8.40  Midwife 1 telephoned the hospital on the 26th September 2012 to inform them of a Child Protection Conference held the same day. Unfortunately details of the discussions taken place at the meeting, the decisions from the meeting, and planned actions were not recorded by Midwife 1.  8.41 The Special Circumstances Form, held on mother’s hospital records, indicates that staff were informed that unborn Baby E was made the subject of a Child Protection Plan and that the social worker was to be informed when Baby E was born. The information also stated that mother and baby could go home after delivery as long as the social worker was aware of this.  8.42 On the 30th September 2012 Baby E was born at hospital, following a normal delivery. She was small with a low birth weight. She was discharged home the following day.  8.43  The children’s father attended GP Practice 2 on the 1st October 2012 for a review of his depression. It was noted that there was non-compliance with the drug and alcohol team. It was noted that there was a very high intake of alcohol - up to 20 units daily. The GP Practice was unaware of any safeguarding concerns.  8.44 A post-natal visit was made to the family home by Midwife 3 on the 2nd October 2012. Midwife 3 was unaware of the Special Circumstances Form held on mother’s records but did review the hand held post-natal records that indicated there were ongoing safeguarding concerns in respect of the family.  No concerns were noted, although there is no record of other children or adult family members who were present during the post-natal 17  visit. The Individual Management Review covering this contact suggests that good practice, given these particular circumstances would have recorded such information.  8.45  This post-natal visit suggests that Midwife 3 had no concerns regarding mother and baby’s physical or emotional wellbeing.  8.46 One of the standard assessments undertaken by midwives during the early post-natal stage is a Safe Sleeping Assessment and Action Plan contained within the Parent Held Child Health Record. Once completed, a copy remains in the Hand Held Record and a copy is sent to the Health Visitor with one copy retained in the Midwifery notes. Essentially, the Safe Sleeping Assessment and Action Plan contain a number of questions for parents that act as a cue to discuss various sleeping arrangements.  8.47 One specific question “do you have a plan to manage safe sleeping away from home after drinking alcohol” was not completed. The relevant Individual Management Review points out that given the particular concerns in this case this question would have been particularly important.  8.48  The Individual Management Review makes the observation that there is no further evidence that, following the home visit on the 2nd October 2012, that enquiries were made about the family background or information about other professionals previous and ongoing involvement. The need for all practitioners to ensure that there is effective liaison between professionals and good quality information sharing is addressed in more detail in the analysis section.  8.49  The assessment with ME in all probability left Midwife 3 with a false impression of the professional concerns about the family and also future risks.  For example ME had indicated in the assessment that she would not consider placing her baby in her bed or on a sofa/beanbag to sleep, and that she does not share a bed with her baby and that she does not drink alcohol in the house or come home to baby after drinking.  18   8.50  A Core Group Meeting took place on the 5th October 2012 and a statutory Child Protection home visit on the 17th October 2012.   8.51  There was a post-natal visit to ME by Midwife 3 on the 6th October 2012. The entry on records states “all well no concerns”. There was no specific reference within the records that covered an assessment of parenting capacity.  8.52 A further post-natal visit took place, by the Midwife, on the 9th October 2012. Again there was no specific reference to parenting capacity. The primary purpose of this visit was to re-weigh Baby E because although she had gained weight since the last time she was weighed, she still had not regained her birth weight. There had been a slight gain in weight at this visit and Midwife 3 also gave advice on feeding.  It is unclear, because of the lack of recording what information Midwife 3 had about domestic violence, alcohol misuse and mother’s history of depression.  8.53  There was a further post-natal visit on the 14th October 2012. Again there was no clear indication that an assessment of parenting capacity had taken place. Baby E had regained her birth weight.  8.54  Another post-natal visit took place on the 18th October 2012. There was no specific reference in Midwife 3’s records that reflected an assessment of parenting capacity. There was also a pre-arranged home visit by the Health Visitor who was unable to gain access so this was re-arranged for the 29th October 2012.  8.55  A home visit by the Family Support Worker took place on the 29th October 2012. There was also a Primary Birth Visit by the Health Visitor. Baby E was presented as clean and appropriately dressed.  8.56 Specific issues discussed with ME by the Health Visitor were. • Feeding • Cot Death Prevention/bed sharing 19  • Immunisations and 6-8 week check • Care of Newborn • Contact details for Health Visitor and Clinics. • Smoking cessation support also offered but declined  8.57 A post-natal visit took place on the 1st November 2012. The recorded entry stated that the mother was well with no concerns. The entry in Midwife 3’s records does give a clear indication that the Health Visitor and social services are involved and have made visits. A reference also to Baby E’s father attending parenting classes does confirm that Midwife 3 was aware of other agencies being involved and possibly that there was a Child Protection Plan.  8.58  On the 1st November 2012 Baby E was seen at GP Practice1. She was accompanied by her mother and the nursery nurse. Baby E was feeding well and there was nothing of note in the clinical examination. It was noted that Baby E was “snuffley” with a congested nose. A diagnosis of viral respiratory tract infection was made. The GP was aware of the safeguarding issues and the GP practice had a policy to particularly support high-risk babies.  8.59  Baby E was seen on the 5th November 2012 at hospital. Baby E was described as doing well apart from mild bronchitis.   8.60 Father (FE) attended a Parenting course first session on the 5th November 2012 at the Children’s Centre 1. He was reported to have engaged well.  8.61 Further Core Group Meetings took place on the 5th November 2012 and the 4th December 2012 supported by Family Support Worker visits to the family home on the 19th November 2012. The meeting in December was crucial in that it led to a recommendation for Child Protection Plans to be discontinued. This issue is addressed in detail in the Analysis section.  8.62  An outreach worker from the Children’s Centre 1 visited the family home by prior appointment on the 8th November 2012. There was no reply; 20  although a phone conversation between the children’s mother and the outreach worker clarified that mother had forgotten about the appointment.  8.63 Father attended second session of the Parenting course on the 8th November 2012.   8.64 Mother and Baby E attended Children’s Centre 2. Baby E and both parents also seen by the Health Visitor on a home visit on the 12th November 2012. No problems recorded.  8.65 On 19th November 2011 S2 was reported as missing from her residential unit. Returned later that evening.  8.66 An outreach worker from the Children’s Centre 1 visited the family home on the 22nd November 2012. ME was described as being welcoming. Baby E was seen and looked well cared for. It was noted on this visit “the house looked pristine”. FE also attended fourth session of Parenting at Children’s Centre 1.  8.67  There was a Core Group Meeting on the 4th December 2012. There was a view that the criteria for discontinuing Child Protection Plans in relation to the children were met.   8.68  At the Child Protection Review Conference held on 13th December 2012, Child Protection Plans in respect of all of the children were discontinued. They would continue to receive support through a child in need plan.  There appears to have been a difference of view between the Chair of the Review and the allocated social worker. The Chair took the view that the family could receive universal services as required now that the Child Protection Plan was discontinued. The allocated social worker was adamant that a child in need plan was required. This is discussed in more detail in the Analysis section.  21  8.69 On the 29th November 2012 FE attended the fifth Parenting session at the Children’s Centre 1.  8.70 FE attended the sixth Parenting session at the Children’s Centre. It was noted by the outreach worker (OR 1) who was one of the co-presenters of the course that FE ‘s compliance was “overdone” and did not feel natural.  8.71 On 21st December 2012, Baby E died. Mother had fallen asleep with her on a sofa. Father had fallen asleep on another sofa. ME had woken and found Baby E “white”. She had woken Baby E’s father who called an ambulance and started CPR without ambulance control guidance. The ambulance arrived at 01.57 hours and found Baby E with no sign of life. She was pronounced dead at hospital at 02.55 hours.   SECTION 9 - CASE ANALYSIS 9.1  Issues in Relation to S1 and S2 – During the course of undertaking this Serious Case Review, it became clear that there were unresolved safeguarding issues in relation to S1 and S2 and decisions about earlier interventions with them would need to be formally reviewed.   A theme that emerged very strongly was the concern expressed by professionals about the likelihood that S2, a sibling of Baby E had experienced sexual exploitation. There were also concerns about sexualised behaviour from S1 and the impact of that on other children.   9.2  The Serious Case Review Panel was made aware of concerns about S1 and S2 immediately they became apparent. At the time of completion of this Overview Report the Serious Case Review Panel had made a decision to undertake a Critical Case Review in relation to those two children (S1 and S2).      What were the key relevant points/opportunities for assessment and decision making in this case in relation to the child and family? Do 22  assessments and decisions appear to have been reached in an informed and professional way?  9.3  There were a number of key points for assessment and decision making in this case. The first point was the pre-birth assessment. There had been an early professional acknowledgement when ME’s pregnancy was first known of that there would be a need for a pre-birth assessment.   9.4 This was a logical step in safeguarding the, then, unborn baby. At the Child Protection Review Conference held on the 29th May 2012, there was an agreement that the pre-birth assessment would commence at twenty-four weeks gestation (this has now changed to fifteen weeks gestation).  9.5  There were additional opportunities to reaffirm the need to undertake a pre-birth assessment and to firm up arrangements for the assessment process. Several Core Group meetings were held between May 2012 and the birth of Baby E, when these arrangements could have been finalised as well as the Child Protection Review Conference in September 2012.  9.6  The fact that a pre-birth assessment was not undertaken demonstrates a lack of coordination by agencies, which is worrying. This was an essential piece of work that had the potential to consider the current dynamics within the family in the context of a new baby. It would have allowed agencies to make an appraisal of current identified parental problems, notably, alcohol misuse and domestic violence, and also consider the overall impact on both the other children and the baby.  9.7  There seem to be two main themes. First, the primary responsibility to drive through the pre-birth assessment is shared by the operational social care team and the Independent Reviewing Service, through the Child Protection Plan. In this case a key element of the Child Protection Plan, was never completed. There was clearly a failure from the operational side to manage the pre-birth assessment and also a lack of challenge by the reviewing process to ensure this work was completed satisfactorily.  23  9.8 There is, however, a responsibility of other allied agencies to challenge the lack of action in relation to the pre-birth assessment. There should, for example, have been a challenge from other agencies about the contribution they wished to make to the pre-birth assessment.  The implications, from a systems approach perspective, are that mechanisms in place to ensure essential work is undertaken and completed may have insufficient rigour.  If this were the case, remedial action would be required to strengthen quality assurance mechanisms and compliance requirements. This is addressed within the recommendations.  9.9  As well as the core assessment, all other agencies involved with the family were undertaking, as part of their professional practice, individual agency assessments. There are some weaknesses that have been identified within the Individual Management Reviews.  9.10  In relation to maternity services.  There was clearly a good deal of positive work undertaken with ME and Baby E, and generally appropriate actions were taken.  There is, however, an absence of key recorded information that limits the value of assessments and decision-making processes.  This means that many of the records relating to midwifery involvement are not compliant with policies and guidance for the service.  9.11  There do appear to be some inbuilt problems in encouraging systematic recording. It would be normal practice for safeguarding information to be recorded on a Special Circumstances Form, contained within the client’s hospital record. This form would be updated as key events occurred. This depends however upon hospital Midwives initiating the Special Circumstances Form and Community Midwives’ telephoning the hospital to give new information. This information would then be recorded on the Special Circumstances Form by hospital staff. Potential problems in relaying information are enhanced, if, as in this case, the client/patient is not booked in at a specific hospital, at the point of contact by the initial Community Midwife. In order for a Special Circumstances Form to be generated, the client/patient has to be booked into a named hospital.  24  9.12  The problems of communication are compounded by the possibility that Community Midwives employed by Bolton NHS Foundation Trust (as they were in this case), may have clients on their caseloads, who are booked in at different hospitals, with each hospital having different documentation for recording information.  9.13 There were key opportunities for assessment during Midwife 3’s initial contact with ME. There is an acknowledgement within the Individual Management Review, covering midwifery services, that had Midwife 3 been in possession of all of the relevant information known to professionals this would have influenced the assessment.  9.14  There are undoubtedly some information communication systems between hospital and community midwifery services that need to be improved.  The most obvious problem, however, was that the pre-birth assessment, planned through multi-agency safeguarding procedures, and led by Children’s Social Care, was never undertaken, and, as such, there was an absence of coordinated pre-birth assessment between agencies. Had the pre-birth assessment taken place it may well have encouraged links and more information sharing between social care, midwifery and health visiting services.  9.15  Assessments of S1 and his possible risk to the other children were not undertaken satisfactorily. The AIM assessment designed to provide an assessment of risk in relation to children who sexually offend was seriously delayed. It took from June 2011 to May 2012 to complete this work, largely because of problems in allocating the work.  9.16  The findings as outlined in the Child Protection Conference minutes are that the AIM assessment concluded that S1 was a “low risk” and is “predicted on a lack of corroborating evidence” for the allegations. This seems to lack a sense of caution and is not consistent with S1’s presentation and reports of behavioural difficulties. It did however have implications for the safety of the other children in the family, as S1 25  returned to the family home for a period of time in June 2012 prior to being placed in foster care.  9.17  The recommendation by the Court that S1 should live outside the family home, whilst an assessment was being undertaken, was sensible in these circumstances, although the assessment was delayed excessively.   9.18  The IFIT assessment attempted with parents was not a successful intervention. The aim of the programme is to support families in crisis, using solution based motivational techniques, to help families make positive change. In this particular case, before the programme was fully under way the allocated practitioner became sick and the case was not re-allocated for several months. This may have had a significant de-motivating impact on the parents. When the case was re-allocated the parents missed the first four appointments and it appears that the motivation to engage only became effective when the Section 37 Welfare Report was submitted to the Court.    Did assessments in relation to Baby E take into account the previous family history (e.g. alcohol and domestic violence) and any other known risk factors?  9.19  As indicated, there was no pre-birth assessment and this limited the likelihood of information being comprehensively shared between agencies. There were, however, a number of forums where key historical information, including that relating to alcohol misuse and domestic violence, could have been shared, including Child Protection Reviews. Whilst these issues were discussed in those multi-agency forums there is no indication that a full picture based on historical information was ever developed.  9.20  Prior to the Initial Child Protection Conference, held in March 2011 there was involvement with the family, by Police and Children’s Social Care due to domestic violence. There were numerous referrals to the Police because 26  of domestic violence and awareness by both Police and Children’s Social Care that alcohol misuse was a key factor in parental conflict. Although these were known factors, alcohol misuse was barely mentioned at the Initial Conference and did not form part of a Child Protection plan in relation to parenting capacity. There was a stated intention to address domestic violence issues through specialist support for ME, but little evidence that this was progressed.  9.21  Child Protection Reviews during 2012 focused on key identified risk factors. These were seen as: • Frequency of house moves • Alcohol Misuse • Domestic Abuse • Inconsistent Parenting • Inconsistent engagement with professionals  9.22 This was an accurate understanding of concerns about the family, based on a reasonably good understanding of the immediate family history. Good attendance by most key agencies at the Child Protection Reviews meant that concerns about the family were common knowledge.   Although alcohol misuse was referred to, particularly in relation to being a contributing factor in domestic violence, there was no plan for treatment suggested in the Child Protection Plans.   9.23  There were some initial gaps in awareness about historical concerns. In particular Midwife 3 was not aware of the family history prior to the first post-natal visit in early October 2012. Once Midwife 3 became aware that there was Children’s Social Care involvement, she took this into account in her assessments and observations in relation to Baby E and her mother.  9.24  GP Practice 1 was aware of alcohol misuse and domestic violence within the family and these issues were highlighted in the child safeguarding review notes held in GP Practice 1. There was also information from midwifery notes that made reference to ME being intoxicated before an antenatal meeting. 27   9.25  There was no indication however that GP Practice 1 had used the information to seek services for Mother (ME) for alcohol misuse. The Individual Management Review covering GP services says, for example, alcohol issues for ME have never been highlighted in the Practice notes. There was clearly a need for the assessment processes to include the GP in sharing information and planning interventions.  9.26  Father (FE) attended a different GP Practice. Notes, from that Practice, highlight long-standing alcohol problems, going back to the year 2000. He had been appropriately referred to Drug and Alcohol Services on two occasions, but had failed to engage with those services. GP Practice 2 was not aware of Child Protection concerns or that any of the children in the family were the subjects of Child Protection Plans. This exposes a serious weakness in information sharing systems. It is likely that there were professional assumptions, without checking out the information, that the same GP Practice would be applicable to all family members. In fact as well as father, there was also one child, in the family who was also registered at GP Practice 2.   9.27  Overall the Core Assessment used as a basis for the Child Protection Plan was not adequate. There were key areas that were not addressed as fully as they should have been. • Historical patterns of behaviour were not analysed adequately. • Key information about parental depression, alcohol misuse and domestic violence was not explored in enough depth. • The wishes and feelings of the children were not adequately sought. • The assessment was too static and did not build on new information.   9.28  The impact on children of both domestic violence and alcohol misuse are well established in research literature (Cleaver et al 2010). There are particular associations between violence and alcohol misuse. There are also likely to be more severe adverse effects of parental alcohol misuse if associated with violence and family discord. This is particularly relevant if both parents have alcohol problems. There are also potential issues of the 28  effects of alcohol on the developing foetus and the risk of Fetal Alcohol Syndrome, with associated features such as growth deficiency Given the level of evidence based concerns, there should have been a specific focus on both domestic violence and alcohol misuse within the Child Protection Plans.  9.29  There were also important historical issues about the parenting and care of S1 and S2 that were not explored in any detail. At the time of the Initial Child Protection Conference in March 2011, both S1 and S2 were displaying indications of disturbed behaviour. This included sexualised behaviour, both children going missing from home, drug use and conflict between the two siblings. Both children were described as vulnerable children.  9.30  The information should really have led to Section 47 enquiries, exploring the background of the family and any historical parenting issues. The information may have helped to make sense of S1 and S2’s behaviour as well as safeguard the younger children. This emphasises the need for detailed historical information in planning child safeguarding interventions.  Did assessments in relation to the other siblings take into account the impact of a new baby?  9.31  The lack of a pre-birth assessment for baby E had, as outlined earlier, had a significant impact on the consideration of the impact of a new baby.   9.32  There were additional mechanisms for consideration of the impact of a new baby, notably at Child Protection Reviews and Core Groups. There is no evidence from the minutes of those meetings that specific consideration was given to the impact of a new baby on the family, although there was a general acknowledgement that the children had many needs both in health and educational terms.  9.33 There is some evidence in the minutes of the Child Protection Review of the 26th September 2012 that ME was viewed as an experienced mother. 29  The focus of discussions was on the pregnancy and ME’s attendance at antenatal classes. Whilst this was important the focus should have extended beyond these appointments and the pregnancy in order to consider evidence of earlier parenting capacity.  9.34  All of the relevant Individual Management Reviews share concerns that there was no real consideration of the impact of a new baby.  There were for example health assessments undertaken by a school nurse on some of the siblings and the concerns were focused on parents ensuring that the children attended all of their health appointments.   9.35  Similarly although an updated core assessment was completed by Children’s Social Care in early September 2012, it did not address the potential impact of a new baby on the other children.   To what extent were the individual needs of each child identified, considered and addressed?  9.36  Overall there is some evidence that consideration of the other children was taken into account. There is some evidence from both the Core Group meetings and the Child Protection Reviews that individual children’s needs were considered and acted on. This did relate primarily however to health and educational needs. This was particularly apparent with the input by schools 1 and 2, where detailed consideration was made about each individual child.   9.37  All of the Child Protection Reviews did spend time looking at the needs of each individual child. Again, however, these discussions were largely limited to health needs and educational progress with only limited discussion about parental capacity to meet those needs.  9.38 The exchanges of information between the two schools and the careful documentation of each individual child’s needs were examples of very good practice and undoubtedly had a positive contribution to the children’s quality of life. 30   9.39 The focus, when it moved from the children’s health and education needs, however remained, for most agencies, very much on parental behaviour. There were for example concerns expressed at the Child Protection Review held in May 2012 that mother (ME) was continuing to drink alcohol excessively through pregnancy. Evidence was given of a recent domestic violence incident where both parents were thought to be under the influence of alcohol. There was also an occasion, in April 2012, when parents attended IFIT that ME was under the influence of alcohol.  The residential unit where S2 was staying had also had suspicions that ME was under the influence of alcohol. By September 2012 ME was self-reporting that she was drinking very little. This account appears to have been accepted by professionals working with the family without any challenge or firm evidence.  9.40  There were also significant concerns during May 2012 - June 2012 with S2 going missing from her residential unit and being found at the family home. There was no evidence of any analysis of the impact of this on the other children.  What was the basis of professional assessment of parental change and how was that used in decision making in the child protection planning and decision making processes?  9.41  The Child Protection Review held in September 2012 noted a number of positive factors in relation to the family. At this time both parents were said to have engaged fully with the family intervention programme. Attainment, punctuality and attendance at school had improved significantly and health appointments had been consistently kept. There were some positive examples given of improved parenting, such as improved care of one child’s health needs, through parents following dietary guidance. It was also felt that as the children were all in education now they would be able to manage the baby more effectively.   31  9.42  Although there were some remaining concerns such as the levels of supervision and stimulation for the children, there appeared from a professional perspective to be substantial positive change in parenting capacity, with a good impact on the children.  9.43 The younger children, for example were described as responding well to boundaries, not as over familiar with strangers, and the speech of the children, which had always been a concern, was making progress. Punctuality and attendance was also reported as being much improved.  9.44 The fact that S1 and S2 were no longer living at the family home also appeared to professionals to have had a major impact on the family dynamics in terms of the parental ability to cope and also the behaviour of the younger siblings. The Child Protection Conference of the 13th December 2012, when Child Protection Plans for all the children were discontinued, was clear that S1 and S2 had taken up a great deal of time when they lived in the family home and must have impacted on family life.   9.45 This view of improved family functioning, from September 2012, was maintained throughout the next few months and by the core group meeting of the 4th December 2012, there was a unanimous view that the criteria for discontinuing child protection plans had been met.  This view prevailed at the Child Protection Review held on the 13th December 2012. It was felt that parents were far more effectively meeting their younger children’s needs, school attendance was 98% and the children’s medical appointments had been kept.  9.46  There were very positive reports from school 2, in terms of the children’s academic progress, emotional presentation and physical appearance and each of the children’s medical appointments had been maintained.  9.47 There were also positive reports about Baby E who was said, by the health visitor, to be in a good routine, eating and sleeping well. There were good 32  bonds observed between parents and Baby E and the immunisation programme was up to date.  9.48 Although it is not stated explicitly, there was probably a belief based on the evidence that mother (ME) had successfully managed to raise a number of children and although there were a number of concerns, they had all survived their infancy. This previous history did not suggest there would be major concerns about Baby E in terms of life threatening events.  9.49 There was also an absence of any reported domestic violence incidents between July 2012 and December 2012. This again may have been a contributory factor in professional thinking that the family was functioning better. There are a number of potential hazards in forming judgments about family functioning based on an apparent absence of critical events such as domestic violence episodes. If they have not been reported, it does not necessarily mean that they have not happened.  9.50  Overall the decision to discontinue Child Protection Plans seemed at first sight reasonable, in terms of the interpretation of the evidence by professionals. On closer examination, however, the evidence for sustained change however should have been challenged more robustly. There should have been more caution and key issues such as alcohol consumption and domestic violence should have been addressed much more directly and been a cornerstone of the Child Protection Plan. Had they been, it is unlikely that the Child Protection Plans would have been discontinued.   9.51 There are a number of factors that were not properly addressed. • Baby E had only been born on the 30th September 2012. As such there was very little time to assess the parental capacity to sustain a reasonable level of care. • The pre-birth assessment had not been undertaken. • Father (FE) had recently been reviewed by his GP in terms of depression and alcohol misuse. Other professionals working with the family did not know this important piece of information.  33  • There seems to have been very little consideration of risks by FE in caring for a baby. • There was, in all probability, a level of naivety in the belief that ME’s use of alcohol had decreased. There was no active monitoring of FE’s alcohol consumption. • The concern expressed in the IMR covering the Children’s Centre, that FE’s participation in the parenting programme was not entirely genuine does not appear to have fed into wider considerations about child protection planning.  9.52  There was also an element of understating the parental motivation for compliance with interventions.  The Family Intervention Programme aimed at supporting families in a crisis, for example, was only successful in engaging the parents after their lack of participation was raised in a Welfare Report for Court. Thereafter, parental engagement was exemplary but it did suggest that there was a need to maintain a level of control over activities in order to assure parental participation.  When and in what way were the children’s wishes and feelings ascertained and taken into account when making decisions about the provision of children’s services? Was this information recorded? What were the individual children’s experiences?  9.53  There was evidence particularly in the AIM intervention that the views of S1 were an important aspect of the assessment process. S1 for example had an important say in determining his living arrangements in foster care. Similarly the views of S1 and S2 were sought as part of the Section 37 Welfare Report for Court in considering whether thresholds had been met for legal proceedings in relation to the children.  9.54  There is also evidence from Core Group meetings and Child Protection Review Meetings that professionals attending had a very good understanding of the children, their individual problems and individual needs. This familiarity with detailed information about the children comes 34  over particularly strongly in the Individual Management Review undertaken in relation to the schools.  9.55  One of the younger children had a statement of educational needs and was supported in contributing to that process. There is also good evidence from School1 and School2 that teaching staff were very familiar with the children’s needs and the schools frequently advocated on behalf of the children.  9.56  A Family Support Worker was also allocated specifically to work with the younger children. An important aspect of that work was to engage directly with the children and in doing so determine their wishes and feelings. This was an important step in that it acknowledged that in order to work more effectively with the family, additional workers would be required to have an input specifically with the younger children.  There are some indications from the Children’s Social Care Individual Management Review that the allocated social worker had felt overwhelmed and felt unable to offer the children the individual attention they required.   9.57  There is very little evidence that work was undertaken with the children to obtain their views on either the issues of domestic violence or alcohol misuse. This was disappointing, as it is well established that parental alcohol problems can have a significant impact on children, particularly if both parents are misusing alcohol. Additionally the co-morbidity of alcohol misuse and domestic violence is known to compound the difficulties parents experience in meeting the needs of their children.  It was important that the children had an opportunity to ventilate their feelings about these issues. In turn, this may have offered more insight into how the family was functioning.    Were there any issues, in communication, information sharing or service delivery within agencies and with partner agencies?  9.58  There are significant issues of information sharing both within and between agencies. At the stage when ME’s pregnancy was first known 35  about, all of the children were subject to Child Protection plans. It would have been reasonable, in these circumstances, to expect a heightened level of communication between agencies.  9.59  There were some serious communication deficits within midwifery services that were compounded by a failure to record information. This effectively means that the available information does not adequately reflect the communications between different professionals within health agencies and with external partner agencies.  9.60  A number of examples of this poor communication are contained within the relevant Individual Management Review. There was, for example, from recalled accounts, a telephone conversation between the Health Visitor and Midwife 1, in March 2012, about ME being pregnant and that there were “safeguarding meetings”. This conversation took place prior to Midwife 1 first seeing ME. As the details of the conversation were not recorded, it is not possible to know if key issues such as alcohol misuse and domestic violence were discussed.  9.61  Similarly, Midwife 3 had no prior knowledge of the family before the post- natal visit on the 2nd October 2012. She was not aware that there was a Special Circumstances Form or that there had been ongoing concerns about the children and that they were the subjects (including Baby E) of Child Protection Plans.   9.62  When Midwife 3 did become aware of safeguarding concerns in relation to the family, there were opportunities to establish contact and share information with the allocated social worker, Community Midwife 1 or the Health Visitor. This would have enhanced any ongoing work with the family.  9.63  Overall due to the poor standard of recording the NHS standards for the policy on “Safeguarding Children-Roles and Responsibilities” were not met within the midwifery service. This issue is likely to extend beyond individual workers and there are some indications that the lack of 36  recording, in particular, may be systemic. This is a weakness that is addressed in the Individual Management Review and appropriate remedial action is recommended.  9.64  There was evidence of some good communication between the school nurse and social worker and also between the health visitor and social worker. This does seem to have broken down in relation to the pre-birth assessment and there was no indication on file that there was communication between Children’s Social Care and health professionals about progressing the pre-birth assessment process.   9.65  There was no communication between school nurse and health visitor outside of the core groups and Child Protection Conference Reviews. This is an area covered in the health related IMRs and training and supervision plans are in place to address this. These communication issues are equally relevant for General Practices and similar action is planned to improve communication.  Were appropriate child protection or care plans in place and child protection or care plans complied with?  9.66  The children became the subjects of Child Protection Plans in March 2011. There were some significant deficits in the Child Protection Plans. It had been identified that domestic violence and alcohol misuse were key features of family problems yet neither were adequately addressed within Child Protection Plans. There should have been consideration about treatment plans for alcohol misuse for ME and FE and more clear input on domestic violence.   9.67  There were opportunities for Child Protection Plans to address the need for intervention with regard to domestic violence. There is reference, in March 2011, to the possibility of a referral for ME to a local programme for preventing domestic violence. This referral, however, did not take place. There is also a similar reference to work needing to be undertaken with FE 37  about the impact of domestic violence on the family. There is no indication that such work was ever undertaken.   9.68  There were two reported incidents of domestic violence (May 2012 and June 2012). There is no evidence that any contact was made with the family by Children’s Social Care with regard to these incidents or that they were discussed in Child Protection Conference Reviews. There is particular significance with the domestic violence incident in June 2012 in that alcohol use was described as a feature of the incident and also that mother admitted that she had used alcohol throughout the pregnancy.  9.69  At this time ME was pregnant and the reported parental conflict linked to historical knowledge about alcohol misuse by the parents should have led to intervention by Children’s Social Care and partner agencies.  9.70  There was also the opportunity to address issues of alcohol misuse within the context of the Child Protection Plan. The lack of awareness by some professionals that the children’s father had a different family GP to the rest of the family and was consuming very dangerous levels of alcohol was in part due to not enough attention being paid to the use of alcohol within the family as well as a failure to engage the children’s father properly. Similarly there should have been much more discussion in Core Groups and Child Protection Reviews about the possible impact of alcohol misuse on Baby E and the other children, ensuring that key information such as the change of GP was shared.  9.71  The fact that the issues of alcohol misuse and domestic violence were not core and active elements of Child Protection Plans that were routinely monitored and rigorously addressed illustrates the weakness of the Child Protection Plans in this case. Both alcohol misuse and domestic violence were long-term historical issues within the family, dating back to at least 2005. Serious concerns had been noted from that time about family dysfunction and the impact of domestic violence and alcohol misuse. Treatment proposals and plans for both mother and father should have been a key element of the Child Protection Plan. 38   9.72  This should have led to much clearer thinking in the Child Protection Plan about the possible impact of alcohol misuse by both parents on a new baby. There was historical information available that showed ME had used alcohol throughout her pregnancy with her last child, particularly in the later stages. This should have alerted all agencies to build this information into the Child Protection Plan in consideration of parental capacity to care for a baby (as well as the other children).  9.73  Department of Health guidance (2005) is very clear that there is an increased risk of “cot death” if parents have recently drunk any alcohol. Similar guidance about co-sleeping advised parents “never to sleep on a sofa or armchair with their babies”.  A very recent British Medical Journal publication (May 2013) builds on the consensus of expert opinion about the dangers of co-sleeping and offers credible findings that suggest that it multiplies the risks of sudden infant death.  9.74  These issues should have been explicit within the Child Protection Plan. There was also an absence of consideration of these risks in relation to FE. There would presumably have been occasions when the children’s mother, would have been unable to offer direct hands on care of Baby E, the primary care being taken on by FE. The information on FE’s level of alcohol consumption should have led to serious questions about his parenting capacity.  9.75  There was a marked inconsistency about how the levels of risk within the Child Protection Plan were ascertained and also how judgments about ongoing risk were determined. In January 2012 the Child Protection Review Conference noted that there had been some improvements in parental compliance. The Chair of the Review commented that consideration should be given at the next Child Protection Review to terminating the child protection plans if similar progress was reported.   9.76  Concerns were reported at the next Child Protection Review in May 2012, including an incident of domestic violence where alcohol misuse had been 39  a factor, and there were concerns expressed about the lack of progress and the lack of cooperation from parents.  By December 2012, however, the Core Group felt confident enough that progress had been maintained to recommend discontinuation of the Child Protection Plans. This was agreed at the subsequent Child Protection Review.     9.77  The fact that there were different Chairs of the Child Protection Reviews in May 2012 and September 2012 does not alone explain the dramatic change in perception about the family. It does, however, suggest that there was a professional aspiration for family functioning to be identified as improving, thus allowing the Child Protection plans to be discontinued.  9.78  One factor that may be pertinent is the length of time that the children had been subject to Child Protection Plans (16 months at the time of the May 2012 Child Protection Review). There is an implication, from the Government Performance Assessment Framework, that if children are the subjects of Child Protection Plans for more than two years, there are elements of “drift” with the Plans and more robust action, such as Care Proceedings may be required.  9.79  The possible need for such intervention as Care Proceedings was very clearly stated at the Child Protection Review in May 2012. This may have led to professional thinking that the few positive changes they were seeing with the family, in September 2012 and December 2012, such as FE’s attendance at the parenting programme, had more significance than it merited. There is in fact some evidence, from earlier involvement with the family, that the changes being identified by professionals were limited and may have been indicative of false compliance. This is particularly relevant to FE’s attendance at the parenting programme.  9.80  There are clearly some problems in determining whether families are resistant or whether services are inappropriate or ineffective. In this specific case there were some clear examples of essential elements of a Child Protection Plan that were never adequately tested. This relates in particular to monitoring and treatment for misuse of alcohol. 40   9.81  There are some indications that suggest a mindset had formed in the belief that significant progress was being made with the family. There are references in the minutes of the Child Protection Reviews to alcohol not being a problem any more and being only one reported incident of domestic violence (although it was never properly investigated). In fact the only basis for assuming that alcohol was not a problem any more was the self-reporting of ME.  Issues of alcohol misuse were not addressed directly with FE and there was no monitoring arrangements or treatment plan for either despite a long history of alcohol misuse.  9.82  As previously stated, the alcohol issues had never been fully explored and the Review Conference was essentially forming a view based on weak evidence and self-reporting by the parents.  9.83  It is likely that some of these views about progress were shaped around two main factors. A belief that many of the family problems and stresses lay with the behaviour of S1 and S2 had gone, now they were no longer living at the family home. This belief does not fully take into account the poor parental management of S1 and S2 when they were younger. The second factor seems to be an inappropriate optimism, based on very little evidence that change had occurred and was now sustainable. In fact the evidence for change was limited and the potential for sustainability had never been assessed.  9.84  A number of research studies have commented on the views and reactions developed by practitioners when working with resistant families. Bostock et al 2005: Rose and Barnes, 2008) These studies note the tendency for unjustified optimism after families make small steps in complying with agencies. This case echoes those findings.   9.85  Overall Child Protection Plans were not managed robustly enough and failed to address the significant problem areas within the family. Although procedurally Child Protection Plans were made, they were not used as working plans for practitioner and family input. There is a sense of “drift” 41  in these plans, with little real progress being made. When progress did seem to take place, it was given more significant status than it merited and led to collective professional over-optimism.  When it was agreed to cease the child protection plan, what systems were in place to monitor/support the family prior to first child in need meeting?  9.86  The rationale for discontinuing the Child Protection Plans was so flawed that the plans to monitor and support the family through children in need processes and meetings would have struggled to be effective.  9.87  The strongest likelihood is that “drift” would have continued with a series of crises being responded to, on various levels, as individual events. There were clearly agencies, such as school, which were firmly committed to the children and no doubt they would have been vigilant in bringing known concerns to the attention of agencies. It would, however, be reasonable to predict that the children would present with more behavioural problems, as they grew older.  9.88  It is of some concern that the Chair of the last Child Protection Review proposed both a cessation of the Child Protection Plan and also the sole use of universal services. For a family facing such a scale of problems, this would have been inappropriate. It is to the allocated social worker’s credit that they strongly opposed this proposal.  9.89  Following the tragic death of Baby E there should have been an immediate reconsideration of Plans for intervention with the family. It is not rational to argue the threshold for the criteria for a Serious Case Review has been met and then not taking urgent protective action in relation to the other children. Section 47 Enquiries should have commenced and consideration made as to whether a Child Protection Conference was required in order to help safeguard the children. It is a significant oversight that such action has not been taken.  42  Was the work consistent with your agency and the BSCB policy and procedures for safeguarding and promoting the welfare of children, and with wider professional standards?  9.90  There were a number of elements of work in Children’s Social Care that were not consistent with agency policy and procedure. There were for example a number of recorded child protection statutory visits that were outside the guidance for frequency. Although the allocated social worker stated that they made additional visits that were not recorded, it is impossible to corroborate this and it does leave concerns that at a time, nearing the birth of Baby E visits was less frequent than they should have been.  9.91  It is equally of concern that this issue was apparently not picked up in supervision or examined in the Core Groups or Child Protection Reviews.  9.92  Core Group meetings were also outside of the prescribed time limits. Again this was not addressed in the Child Protection Reviews. Child Protection Reviews were held within the timescales for Child Protection procedures.  9.93  Within the work undertaken by the maternity services there are significant shortfalls in compliance with procedural requirements, notably in the recording of information. The Individual Management Review highlights evidence that records were not felt to be compliant with the health “Safeguarding Children Roles and Responsibilities Policy”, and the “Health Record Keeping Standards Policy”. Given the circumstances of this case, there should have been much more emphasis on safe sleeping and the use of alcohol.  9.94  There were concerns about FE’s engagement with the parenting course. It would have been good practice for the workers running this course to have alerted Children’s Social Care, and partner agencies, about these concerns and also to have informed Children’s Social Care about FE declining outreach services from the Children’s Centre. This information 43  was relevant to discussions about Child Protection Plans and may have helped place discussions about progress with the family in a more realistic context.  9.95  In relation to other agencies, there was evidence of compliance with safeguarding policies and standards.   Was practice sensitive to the racial, cultural linguistic and religious identity and any issues of disability of the child and family, and were they explored and recorded?  9.96  Different agencies hold very different information about the religious and ethnic heritage and background to the family.  There is no information from any of the records from core groups, Child Protection Conferences or Child Protection plans that religion or ethnic identity were issues to be considered.  The GP Practice was particularly sensitive to issues of diversity and Baby E had her BCG in line with her requirements.   9.97  The information on diversity recorded by midwifery services was inadequate and follows a pattern, in this case, of recording of information not being given sufficient importance.   9.98  Similarly the religion of FE was noted on the Children’s Centre registration form but not his ethnicity.   9.99  Overall there was no indication from the core group minutes or the Child Protection Reviews that issues relating to religion or racial heritage were considered or addressed. This was clearly a weakness.       44   Was there sufficient management oversight?  9.100  There was some evidence of management involvement and oversight in this case. The Police Individual Management Review details the process of management supervision for each investigation that took place.  9.101 Both of the GP practices had access to resources in terms of managing the safeguarding issues, including named and designated doctors. There is an issue in relation to GP Practice 2 (The GP Practice for FE). It was known that he was consuming very large amounts of alcohol and also that he was the father of young children. It may have been assumed that this in all probability would have a negative impact on his parenting capacity. It would have been appropriate in these circumstances to seek advice about safeguarding matters from the designated doctor.  9.102 Although there is evidence from Children’s Social Care records that there was supervision by a Team Manager, records of this supervision suggest that the process was more functional and pragmatic with little reflective emphasis. Evidence from the Munro Review suggests that the opportunity for reflective thinking is a central plank for learning and case analysis. Such reflective practice may have facilitated a different way of looking at the case and questioned whether perceived change was really evidence based.  9.103 There were clearly issues about the allocated social worker feeling overwhelmed by the complexities within the family. This should have been addressed at an earlier stage, although it was good practice when a Family Support Worker was also allocated to work with the family.  9.104 Within the Children’s Centres, there has been an identified need to review procedures for the supervision of outreach workers and this is taking place at present. A pilot is also due to commence where there is mentoring advice from a social worker for children’s centre staff in relation to more complex cases.  45  9.105  In relation to Midwifery Services, provision of formal safeguarding supervision was not in place at the time of the events described in this Serious Case Review. Since February 2013 formal safeguarding supervision has been introduced for the Outreach Midwifery Service at Bolton NHS Foundation Trust. Plans are in progress to extend this formal arrangement for other midwives covering different geographical areas (Bury and Salford).  9.106  As well as formal management oversight, there is a specific issue about working with families where there is resistance to change. The Overview Report has already noted the tendency of practitioners to interpret small changes in compliance in an over-optimistic way. The potential for this weakness in safeguarding systems can be compensated for, in part, through active reflective supervision allowing a realistic and objective view of the case to be maintained.  9.107  There are some suggestions that individual management supervision needs to be replaced by a more strategic approach of the use of facilitators across teams, clinical supervisors and regular case audits to help create a culture committed to reducing child maltreatment (Gardner 2008). This is addressed in the Recommendations.   SECTION 10 – SUMMARY AND RECOMMENDATIONS 10.1  There are several interacting factors that exposed flaws in safeguarding systems in this tragic case. Identification of these factors suggests that there may be a number of inherent weaknesses that agencies need to address in order to minimise the possibility of similar problems re-occurring.  10.2  This was a complex case with a number of different themes, including behavioural problems and issues of possible sexual exploitation. This family had children with different needs and this was a strain on resources. It was for example extremely difficult, in the early stages, for 46  the allocated social worker to see each child individually. As such, the children’s wishes and feelings were never fully determined. The Child Protection Review Conference should be a forum where the wishes and feelings of the children are made explicit and challenge is made if those views are not known. This issue is addressed in the Recommendations.  10.3  The picture was further complicated by established patterns of domestic violence and alcohol misuse that were identified by professionals but never addressed fully. The domestic violence incidents in May and June of 2012, for example, were never properly investigated or addressed within the context of ongoing child protection concerns. The need to review agency compliance with domestic violence procedures is addressed in the Recommendations.  10.4  Assessments across the board were poor. There was no pre-birth assessment and as such no assessment of the likely impact of Baby E on the family or the risks to Baby E. A good quality core assessment should have identified what the risks to Baby E were, and the interventions necessary to minimise those risks. Had a detailed pre-birth assessment taken place it may have examined the family history in much more detail and uncovered some pathological themes that offered insight into present and future family functioning. Compliance with procedures for pre-birth assessment is addressed in the Recommendations.  10.5  Given the history of alcohol misuse it should have been clear to all professionals that there was a heightened risk to Baby E. Although the health visitor and midwives addressed safe sleeping, with the children’s mother, it should have been a more significant area for consideration within the Child Protection Plan. Where there is very young child and a history of parental alcohol/drugs misuse and domestic violence, co-sleeping and safe sleeping should be a core element of the Child Protection Plan. This is addressed in the Recommendations.  47  10.6  There were key communication deficits that meant vital information was not shared by all professionals in the safeguarding network. It was essential, for example, that all agencies had common information about GP Practice 2’s involvement with father and attempts at treating his alcohol misuse and depression. Similarly the Children’s Centre Outreach Worker’s perception of father’s involvement with the Parenting Programme was an important consideration in forming a view about the co-operation of parents.  10.7  There are other examples of poor or only partial communication between agencies, particularly between health related agencies and also between Children’s Social Care and health agencies. This was particularly marked around the time of Baby E’s birth when the Midwife made an initial visit without being aware that the children and Baby E were the subjects of child protection plans. The case illustrates the need for agencies to be constantly communicating with each other and sharing updated information at every opportunity. At the very least the formal mechanisms of core groups and Child Protection Review Conferences need to ensure all information is updated and current. This is addressed in the Recommendations.  10.8  These deficits were disappointing because throughout this case there are countless examples of very effective inter agency communication. Both of the schools alerted agencies to any concerns they had about the children. They were also committed to multi-agency meetings. Similarly there were examples of good liaison between the health visitor, school nurse and the social worker.   One of the key lessons from this Serious Case Review is that even in circumstances where there is multi-agency commitment, the pathways for information being generated and circulated need to be constantly reviewed and checked.  10.9  There were also some examples of poor recording standards that meant important information could not be corroborated and was dependent on practitioner re-call. This again is an inherent weakness commonly seen in 48  Serious Case Reviews. This issue is addressed in the Recommendations.  10.10  There was generally, from the summer of 2012, an overoptimistic view of family functioning. This appears to be based on a number of factors. • The erroneous belief that alcohol was no longer an issue. This seemed based on mother’s self-reporting. In fact the domestic violence incident in June was linked to alcohol misuse.  • The belief that domestic violence incidents had diminished. Domestic violence had been a feature for so long in the family history that it was very unlikely to spontaneously cease. There had been two incidents in May and June 2012, neither of which was properly followed up. • The belief that parents were co-operating. The only real evidence for this was father’s attendance at the Parenting Programme, and the worker’s facilitating the programme had doubts about father’s motivation.   10.11  Practitioner optimism is a relatively common feature of professional thinking particularly when cases are stuck or there are minimal changes. The lesson from this Serious Case Review is that there must be an evidence-based approach that allows as much reflective thinking and professional challenge as possible. The Child Protection Review Conference should be a central forum where evidence should be tested and subject to professional challenge. There is no evidence of sufficient challenge in this case. This issue is addressed in the Recommendations   10.12 This very sad case has illustrated some of the complexities of multi-agency safeguarding work and identified key themes for learning and future practice. There was evidence of considerable commitment and care across all of the professional groups and although there were significantly increased risks to Baby E, because of domestic violence, alcohol misuse and parental smoking, it was not possible to predict the death of Baby E. Preventative measures would have been enhanced had there been better assessments, better communication and a more active Child Protection 49  Plan. Even with those measures, however there could not have been any certainty about the outcome for Baby E.  10.13  The purpose of this Serious Case Review is essentially to provide information that can be used to learn lessons from this case, and to improve multi-agency safeguarding practice. A final recommendation is therefore offered to assist in the process of learning.  RECOMMENDATIONS FROM THE OVERVIEW REPORT  1.   The Local Safeguarding Children Board should request all constituent agencies to undertake an audit of recording practices.  2. The Local Safeguarding Children Board should review how safe-sleeping arrangements are built into Child Protection Plans   3. The Local Safeguarding Children Board should review compliance with procedures for pre-birth assessments, with the aim of ensuring that in each identified case a pre-birth assessment is undertaken to a satisfactory standard within timescales.  4. The Local Safeguarding Children Board should review procedures in order to ensure that all Child Protection Initial and Review Conferences address issues of changes in core information about families.  5. The Local Safeguarding Children Board should review current practice in order to ensure that there is sufficient professional challenge in decision-making forums such as Child Protection Review Conferences, and that the wishes and feelings of children are addressed. This review should include live observation of CP Review Conferences.  6. The Local Safeguarding Children Board should audit agency compliance with domestic violence procedures.  50  7. The Local Safeguarding Children Board should ensure that all appropriate front line practitioners and their managers have the opportunity of learning lessons from this Serious Case Review.  8. The Local Safeguarding Children Board should consider strategies to introduce a culture of practice improvement through reflective supervision.   51  RECOMMENDATIONS FROM INDIVIDUAL AGENCY MANAGEMENT REVIEWS  NHS Bury Clinical Commissioning Group  1. Develop a communication pathway for safeguarding between agencies and intra agency for health which will overlay the health child programme.  2. Assurance is sought that a process is in place to ensure prompt notifications of birth between maternity services at Pennine Acute Hospital Trust and Community Services Bury.   Bolton NHS Foundation Trust  3. Improvements in Record Keeping The way in which Community Midwives record their interactions with clients where there are safeguarding concerns needs to reflect recording of what are the identified concerns in the case, what assessments/observations have been made in relation to such concerns, what actions have been taken and what are the Midwife’s planned future actions. Community Midwives records should also reflect any incidences where they have liaised with other professionals in order to share or gather information about the family. Record keeping in this way is in-keeping with Trust policy on record keeping practice and safeguarding practice and is also in line with national guidance around working together to safeguard and promote the welfare of vulnerable children and their families. It is important that trust documentation facilitates recording in this way and as such it is proposed that new documentation be introduced for use by all Community Midwives.   Community Midwives must also ensure that they prepare a report to be submitted during any Initial Child Protection Case Conferences that they attend and that a copy of this report is filed in the client’s records (Mother and Baby). Following attendance at a safeguarding meeting of any kind the Midwife must record details of what was discussed and agreed during such meetings and once official minutes are received a copy of these should be filed in the client’s records (Mother and Baby).  4. Improvements in Information Sharing Practice Community Midwives must ensure that they share/gather any key information with/from relevant professionals in a timely manner and that they record such activity in their records. This must happen in order that 52  appropriate decisions can be made which are based on sound professional judgement, being in possession of all of the relevant information about the family at the time decisions are made.  Good information sharing practice also needs to take place between Midwives themselves. In this case midwife 3 was not aware of the relevant information prior to her first post-natal visit to the family (despite Midwife 1 and 2 being aware of concerns).   5. Review of the Existing Safeguarding Children Supervision Policy and Ensure the Revised Policy Reflects the Arrangements for Safeguarding Supervision for All Staff Groups Within the Organisation (hospital and community).   There is already a Safeguarding Children Supervision Policy in place for Bolton NHS Foundation Trust staff. This policy was developed prior to the integration of hospital and community services in Bolton (and was developed for use by community practitioners). This policy is currently under review (was planned for review anyway in July 2013). In-keeping with this policy, currently safeguarding supervision is provided for the Outreach Midwives (Outreach Midwives cover Bolton postcodes and provide midwifery care for clients residing in Bolton where there have been concerns raised of a safeguarding nature). The supervision provided to the Outreach Midwives falls under the categories of both ‘management supervision’ and ‘specialist supervision’ (within the policy management supervision ‘is required for staff that have continuing responsibility for children subject to a Child Protection Plan and who are members of the Core Group’ and is provided by the practitioners Manager or Team Leader. Specialist supervision ‘is available to any member of staff within the trust who has a concern about a child’. This supervision will be provided by a member of the Safeguarding Team, ‘either as telephone advice and guidance or by an appointment arranged by the staff member. Staff with concerns may be seen individually or with others who are working with the child/family’. There are complex and exceptional cases whereby it would be expected that specialist supervision would take place’).  For Team Community Midwives employed by Bolton NHS Foundation Trust (who are not Outreach Midwives), each area has a Team Leader whom staff can call upon for support and guidance regarding the management of vulnerable cases and also they have access to the Named Midwife Safeguarding and the divisional Safeguarding Children Specialist Nurse (and the wider Safeguarding Children Team). Despite Community Midwives accessing their Team Leaders currently for support and advice there is no formal arrangement in place whereby this ‘management supervision’ is recorded as per the Safeguarding Supervision Policy. It is recommended a review take place of how each Team Leader operates in terms of their oversight of vulnerable cases being managed on their team. It is also recommended that arrangements are put in place for the provision of a more formal means of safeguarding supervision to take place (in-keeping with the Safeguarding Supervision Policy).   53  Greater Manchester Police  There were no recommendations from the Greater Manchester Police Individual Management Review.  Bury Council Children’s Services- Children’s Centres, Child Care and Early Years   6. Parenting assessments carried out before and after individuals attendance on evidence based parenting courses should be shared with the children’s centre outreach worker, in cases where the latter are involved with the family, to inform future action plans.  7. Training in the use of an agreed evidence based capacity assessment should be given to children’s centre staff.  8. A briefing for social work staff to be prepared, detailing the types of support that children’s centre outreach workers as part of a child in need or child protection plan.  9. A formal request to be made to Bolton Trust Midwifery Service for them to send all birth discharge information to Children’s Services for distribution to children’s centres, who will then engage with the families.  10. The use of a casework module on the current database to be reviewed and implemented across all children’s centres in Bury if it is found to be an effective means of securely storing case notes.  11. Further guidance on the completion of children’s centre registration forms to be developed, including instructions to note where individuals decline to provide information.  54  12. Partner agencies to be asked to register families with the children’s centre when they bring families in for appointments and to complete session attendance so that the database can be updated.  13. Outreach worker procedures to include guidance for notification of social workers about families’ non attendance, or non engagement with children’s centre staff.  14. Children’s centre registration forms to be revised to include a question regarding the sexual orientation/sexuality of the individual.  Pennine Care Foundation Trust GP Services, Bury  15. All GPs actively seek out information about maternal mental health, parental smoking, drug and alcohol use when they have contact with women during pregnancy and in the first 6 months after the birth and consider the impact on the children in the family, providing advice to families on the risks to their child.  16. GPs to ensure that they actively share information with social care when they know that a child is subject to a child protection plan.  17. GPs to ensure they consider the impact of adult health concerns on the safety of the child and to refer onto social care if they consider the threshold for possible significant harm is reached.  Children’s Social Care  18. Children’s Social Care Senior Management to review management and social work capacity within the service by end of May 2013.  19. Children’s Social Care to re-launch the Quality Assurance Framework which includes regular auditing of case files and thematic audits.  Thematic audits to be timetabled for the forthcoming year and to include timeliness of statutory visits and core groups by end of July 2013. 55   20. Children’s Social Care to put systems in place to ensure that managers receive appropriate management information to quality assure practice by end of July 2013.  21. Children’s Social Care to review the functioning and capacity of the safeguarding unit to ensure that IROs are able to carry out the functions outlined in the IRO handbook, that they are of sufficient seniority and that they are able to carry out a scrutiny and challenge role which has a clear audit trail by the end of October 2013.  22. Children’s Social Care review the current supervision policy to ensure that it enables reflective practice and that there are mechanisms to reflect on whether or not children and young people on workers’ caseloads are suffering from significant harm by end of August 2013.  23. Children’s Social Care to put in place a participation strategy, which supports and enables the voice of children and young people to be central to the planning on their case, and to contribute to the service in general, and includes the training of workers by the end of September 2013.  24. Children’s Social Care to deliver training with regard to evidence based tools that can be used to inform assessment by end of October 2013.  25. Children’s Social Care to complete a critical learning review in respect of S2 by end of July 2013.   Pennine Care NHS Foundation Trust, Community Services, Bury  26. To ensure better communication between Health Visiting and School Nursing Teams when they are working with the same family with children on a Child Protection Plan.  27. To ensure Health Visitors and School Nurses are more confident and competent with challenging decision making in core groups and Child Protection Conferences. 56   28. To ensure Health Visitors and School Nurses access Safeguarding Supervision 3 x per year over a 12-month period as per Pennine Care Safeguarding Supervision Policy.  29. To establish better links between Health Visitors and GPs when children are made subject to a Child protection plan. To review how robust links can be established between health professionals and the GP Practices.  30. To ensure health professionals receive targeted supervision in relation to the practice issues identified in this report, particularly in relation to communication with key professionals who are involved in the health care needs of the family.  29.   All the health professionals in this case to be informed of the mechanisms in place within the organisation to escalate concerns in relation to the multi-agency care and decision making.  Schools 30. School staff prior to attending child in need and child protection meetings meet individually with each child in a sensitive age-appropriate manner to ascertain what life is like at home and what changes they wish to see. This would enable a true representation of a child’s wishes and feelings. These should then be written into reports provided to meetings  31.  Foetal alcohol awareness to be provided to designated persons for safeguarding and SENCOs in Bury schools.  32.   A reminder to schools that the CAF process needs to be adhered to. This could be done by a presentation at a meeting, which all Headteachers attend.  33.   The issue of school staff being asked to vote on children not known to them within the child protection process be explored further and guidance training be considered if this is found to be a particular issue. 57   34.  That it becomes standard practice that when families move from one school to another and there are child in need or child protection plans that face–to–face meetings are held and recorded between the schools.       58  Research Sources  Bostock, L et al (2005) Managing risk and minimising mistakes in services to children and families. Social Care Institute of Excellence. London.  Carpenter, Robin et al (2013)Bed sharing when parents do not smoke. Is there a risk of SIDS: An individual level analysis of five major control studies. BMJ. London  Cleaver, H. Unell, I and Aldgate, A ((2010) Children’s Needs- Parenting Capacity; The impact of parental mental illness, learning disability, problem alcohol and drug use, and domestic violence on children’s safety and development. The Stationery Office, London.  Gardner, R (2008) Developing an effective response to neglect and emotional harm to children. NSPCC. London  Klonowski, Anna (2013) Report of Child Sexual Exploitation Issues in Relation to Rochdale Metropolitan Borough Council During the Period 2006 to 2013  Munro E (2011) Munro Review of Child Protection- Final Report. Department of Education, London  National Institute for Health and Clinical Guidance 2005) NICE Guidance 37  Rose, W and Barnes, J (2008) Improving Safeguarding Practice, Study of Serious Case Reviews. Research Report. DCSF. London                                  