Death of a 20-day-old infant in 2018. Baby Darryll was admitted to hospital and died five days later. Mother was a care leaver, had experienced a difficult childhood, and was known to Children's Social Care from the age of nine-years-old due to domestic abuse between her parents. Mother moved into care at 13-years-old, and had episodes of going missing, child sexual exploitation, and drug and alcohol use. Concerns about Mother entering abusive relationships. Pre-birth risk assessment highlighted concerns over housing arrangements and Mother's cannabis use. Coroner's Court concluded an outcome of death by misadventure, with the post-mortem stating cause of death as hypoxia. Ethnicity and nationality not stated. Learning includes: recognising adverse events that have happened in a person's earlier life can provide important context to understanding their current circumstances and behaviours; in cases where an adult is judged to have their own vulnerabilities, and they already have a named worker to support these needs it is important that for any child living in the same household there is consideration to them having their own allocated worker. Recommendations include: inform the Family Nurse Partnership National Unit to allow them to consider the learning; promote learning, as a public health message to the wider population, about the importance of avoiding co-sleeping and unsafe sleeping arrangements with babies; seek assurance about the quality and effectiveness of joint working arrangements for those services who work with care leavers who are pregnant and who require housing support.
      
    Serious Case Review No:  2020/C8534  Published by the NSPCC On behalf of an unnamed local safeguarding children board      This report was written by an independent author and is owned by the commissioning LSCB.  This report is published by the NSPCC with the agreement of the National Panel of Independent Experts.  Publication of this report by the NSPCC does not constitute endorsement of the contents. Copyright of this report remains with the commissioning LSCB.   CLASSIFIED INFORMATION – FINAL REPORT  Official    Local Authority A  Local Safeguarding Children Board  Serious Case Review Baby Darryll   Anonymised -Review report   This report is strictly confidential and must not be disclosed to third parties without prior discussion and agreement with Local Authority A Safeguarding Children Partnership. The disclosure of information (beyond that which is agreed) will be considered as a breach of the subject’s confidentiality and a breach of the confidentiality of the agencies involved.    Independent Reviewer: Kevin Ball  Anonymised version    Page 1 of 22  Final Report Submitted 21st October 2019Anonymised Report 20th August 2020CLASSIFIED INFORMATION – FINAL REPORT  Official CONTENTS  Area Page   1.Introduction to the case review   1   2. Process for conducting this review   1  3. Family structure & contribution to the review   2  4. Relevant case history   - Relevant background information prior to the timeframe under review - Relevant information during the timeframe under review   3 - 5  5. Findings & analysis  - The quality of pre-birth assessment including the use of information about known risk factors - Thresholds for intervention across services & discharge planning - The impact of transitions across Boroughs & the quality & effectiveness of support offered - Local knowledge & understanding about vulnerabilities of young babies - The quality & effectiveness of services provided to the mother as a care leaver   5 - 19   6.Good practice   19  7. Conclusion   19  8. Recommendations   20       Anonymised version    Page 2 of 22  CLASSIFIED INFORMATION – FINAL REPORT  1  Official Introduction to the case review 1.1. Following the death of a 20-day old infant in 2018 Local Authority A Safeguarding Children Board considered it appropriate to conduct a Serious Case Review, as required by statutory guidance1. For the purposes of this review, the infant will be known as Baby Darryll. In summary, the circumstance of the case concerns a young mother who had 1.2. The following findings have been made as a result of this review; - No causative link between the Mother’s cannabis usage and Baby Darryll’s death has been found; the circumstances in which the child was found may indicate unsafe sleeping arrangements. - The Mother’s parenting capacity was untested, and assumptions were made that she would be able to manage without specific support being offered. - Information sharing across agencies was disjointed and did not happen in a timely way, resulting in delays to assessments and decision making. Had information been shared effectively, and in a timely way, it may have resulted in a more coordinated offer to support to the Mother and baby, and more timely assessments and decision making.  - The impact of cannabis use on parenting capacity were not fully recognised, and bias thinking influenced professional decision making. 2. Process for conducting this review 2.1. The approach taken has adhered with the principles as set out in statutory guidance2. As such, the process has been able to capture and identify opportunities for professionals and organisations to reflect, learn and improve safeguarding practices from a whole safeguarding system perspective. 2.2. Following the decision by the Independent Chair of the Board in October 2018 to commission this Review the following steps were taken; - The Board commissioned Kevin Ball as the Independent Reviewer3. - Single agency reports and chronology were requested and submitted by those agencies and professionals who had contact with Baby Darryll and family4. This process provided each agency with the opportunity to reflect on  1 Working together to safeguard children, 2015, HM Government   2 Working together to safeguard children, 2015, HM Government.     3 Kevin Ball is an experienced & independent consultant and Scrutineer, with specific experience of chairing & authoring case reviews & with a background of working in children’s services.  4 The following agencies and bodies have contributed to this Review:  - Hospital C         - GP Practice via the CCG - Local Authority A Borough Children’s Social Care   - Metropolitan Police Service - Local Housing Trust       - Hospital C experienced a difficult childhood but was positive and looking forward to her role of being a mother. The Mother was in receipt of antenatal services for a period of time and was receiving support from other professionals during the pregnancy however due to changes in her housing arrangements complications arose. Notwithstanding those complications, following birth, Baby Darryll was discharged from hospital without concern. During the pregnancy a pre-birth risk assessment was conducted highlighting a number of concerns; specifically relating to the impact on the Mother should her housing arrangements alter, but also the extent of her cannabis use. The significance of these risk factors was not fully recognised by the professional network. In the summer of 2019, the Coroner’s Court concluded an outcome of death by misadventure. As a result of this finding, and the fact that drug toxicology testing was negative, the Police will not be taking any further action. The post-mortem has concluded the cause of death as hypoxia. CLASSIFIED INFORMATION – FINAL REPORT  2  Official their involvement by examining their records but also seeking the contributions and views of those practitioners that came into contact with the Baby Darryll and family. As a result, agencies have been able to consider actions required of themselves in order to make improvements to practice, - Review Panel meetings have interrogated information submitted and sought clarity when necessary, thereby enabling a robust and thorough examination of practice in context.   - The Independent Reviewer met with Baby Darryll’s mother to gain her perspective.  2.3. The timeframe under review was from February to October 2018. Any relevant historical information prior to this timeframe is included. 3. Family structure & contribution to the review 3.1. For the purpose of conducting this review the following individuals are relevant; 3.2. Seeking the Mother’s contribution to this review has been an important consideration in helping shape some aspects of the learning from this review. The Independent Reviewer met with the Mother on two separate occasions. Firstly, to gain her perspective about service that came into contact with her during her pregnancy and post birth of Baby Darryll, and then again to discuss the findings of the review and recommendations.  3.3. The Mother was able to express her frustrations about her contact with services and professionals whilst also balancing this was positive aspects of contact with them. Her frustrations and perceptions centred mostly on two issues; firstly the difficulties of securing housing and having to move back into Local Authority A when she had been settled in another London Borough, and secondly; the need for professionals to constantly ‘assess’ her and her situation when she had been already ‘assessed’. The Mother acknowledged that she had worked with professionals for many years, had expectations about how she should be treated as a care leaver, and conveyed greater hopes for how she might be supported when pregnant and with a new baby. When this failed to materialise, this came as a disappointment and frustration. The Mother’s perception of constant assessment and referral activity by professionals was that she was being pulled back into a system that had failed her as a child and that her hopes for what to expect with her own baby were greater than was actually on offer. She described this process as ‘… fighting the system and having to come out of a struggle with the system …’.  The Mother accepted her role and responsibility in the way in which she worked with some professionals and conveyed a hope that the review would lead to improvements and better services offered to care leavers who become young parents.  3.4. Positively, the Mother commented on the antenatal appointments being helpful and reassuring acknowledging that early in the pregnancy the Midwives had clearly alerted her to the risks of using cannabis during pregnancy, and that they took time to listen to her anxieties about the pregnancy. Despite the advice, the Mother acknowledged that she continued to use cannabis throughout the pregnancy as a way of managing anxiety. The Mother also described her Personal Adviser as being helpful and supportive, particularly in respect of getting information to her about housing related issues.    - Hospital D         - South London Maternity Service - Local Authority A Adult Social Services: Substance Misuse Team   - Other London Local Authority Children’s Services - Hospital E                          - Family Nurse Partnership National Unit  Individual:    Identified as: Subject child    Baby Darryll Mother to Baby Darryll   Mother Maternal Grandmother to Baby Darryll Maternal Grandmother Maternal Aunt to Baby Darryll  Maternal Aunt CLASSIFIED INFORMATION – FINAL REPORT  3  Official 4. Relevant case history  4.1. Relevant background information prior to the timeframe under review 4.1.1. Baby Darryll’s Mother had been known to Local Authority A Children’s Social Care from the age of nine years due to domestic abuse between her parents. Her own mother, the Maternal Grandmother, was dependent on alcohol and there was often physical and verbal conflict between the adults in the house. As a result of living in this home environment the Mother was accommodated5 at 13 years old. Whilst growing through adolescence the Mother would frequently go missing, experience sexual exploitation, and use drugs and alcohol, with cannabis use beginning at around 10 years old. Additionally, there were concerns about the Mother entering abusive relationships and being at risk from gang associations. Given these particular risks the Mother was intentionally placed by Local Authority A Borough Council in another London Borough in a residential unit away from the known risks in the Local Authority A area.  Given the length of time the Mother was in the care of the local authority this meant that she became a relevant child6, and as a care leaver benefitted from continued support from the local authority. The Mother described being very excited to be pregnant with Baby Darryll and although not involved with the Father of the child was positive about the future.   4.2. Relevant information during the timeframe under review 4.2.1. The Mother registered her pregnancy with the GP at the end of January 2018 and was appropriately referred for antenatal care. In early February she was referred to a South London  Maternity Specialist Midwifery Team due to a history of anxiety and depression; referrals were also made to the other London Borough MASH7, the Borough Perinatal Mental Health Team and the Borough Antenatal Drug Service given the Mother’s known cannabis use. Additionally, a referral was made to the Borough’s Family Nurse Partnership8.  4.2.2. During this time the Mother had submitted an application to both her current London Borough and Local Authority A Councils Housing Services to be re-housed, requesting to remain in the other London Borough. The outcome of the housing application was that the Mother was offered accommodation back in Local Authority A in July 2018 by Local Authority A Housing. The offer was reluctantly accepted by the Mother who was worried about returning to an area where there were known risks. Prior to this, and with the support of the Local Authority A Leaving Care Team and an Advocate the Mother made a complaint in May 2018 about the level of support she had been given around her housing needs. The outcome of this complaint clarified the support offered as well as finding that no further action was needed given the accommodation had been accepted in Local Authority A.   5 Section 20, Children Act 1989: the provision of accommodation for a child by the local authority, who is deemed in need (even though a person who has parental responsibility for that child is able to do so) if the local authority considers that to do so would safeguard or promote the child’s welfare.  6 Relevant child: A ‘relevant child’ is a child who is not being looked after by any local authority, but was, before last ceasing to be looked after, an eligible child, and is aged 16 or 17. It is the duty of each local authority to take reasonable steps to keep in touch with a relevant child for whom it is the responsible authority, whether he is within their area or not to appoint a personal adviser for each relevant child. An ‘eligible child’ is one aged 16 or 17, who has been looked after by a local authority for a period (13 weeks), or periods amounting in all to that period, which began after he/she reached 14 years of age and ended after he/she reached the age of 16. It is the duty of the local authority looking after an eligible child to advise, assist and befriend him/her with a view to promoting his/her welfare when they have ceased to look after him/her. For each eligible child, the local authority shall carry out an assessment of his/her needs with a view to determining what advice, assistance and support it would be appropriate for them to provide while they are still looking after him, and after they cease to look after him/her, and shall then prepare a pathway plan for him/her, Children Act 1989 & Children (Leaving Care) Act 2000.  7 MASH – Other London Borough Multi-Agency Safeguarding Hub.  8 The Family Nurse Partnership (FNP) provides a home visiting service to support young first-time mothers (aged 22 years and under) from early pregnancy until their child is two years old.  CLASSIFIED INFORMATION – FINAL REPORT  4  Official 4.2.3. Also, during this period, as a result of the earlier MASH referral the other London Borough’s Children’s Social Care completed a pre-birth assessment to explore risks to the unborn child. This concluded towards the end of June 2018, identified a number of risk factors but resulted in a decision that the Borough’s Children’s Social Care did not have a role and that the South London Specialist Midwifery Service, the Borough’s Family Nurse Partnership, and Local Authority A Leaving Care Team would be best placed to support the Mother and new baby. At this time, the involvement of the other Borough’s Family Nurse Partnership had not been secured and confirmed. Risks and concerns identified during this pre-birth assessment included current cannabis misuse, risk of postnatal depression and an insecure housing situation; with a recommendation from the other Borough’s Children’s Social Care to Local Authority A Council that they do not rehouse the Mother in Local Authority A due to the known risks.  4.2.4. Due to the Mother being rehoused back into Local Authority A in July 2018 the Mother never met anyone from the other Borough’s Family Nurse Partnership. Following assessment, the Mother had declined support from the other Borough’s Perinatal Mental Health Team as she felt she had enough support around her.  4.2.5. The Mother was seen at 29 weeks pregnancy by the South London Specialist Midwifery Service. This was their last contact with the Mother before her care being transferred out of their area. 4.2.6. During the above timeframe the Maternal Grandmother had come to the attention of Local Authority A MARAC9 due to allegations of domestic violence by her adult children. The Maternal Grandmother was also briefly known to Local Authority A Adult Social Care Substance Misuse Service.  4.2.7. Once rehoused in July back in Local Authority A the Mother was advised to transfer her maternity care to a more local hospital. Initially the Mother wanted this to be Hospital A and the South London Specialist Midwifery Team contacted this hospital to ensure the appropriate handover arrangements were made. The Mother then changed her mind and instead wanted to transfer her care to the Hospital B. The South London Specialist Midwifery Service appropriately contacted the Named Midwife for safeguarding children at the Hospital B to advise of the Mother’s background and the transfer of antenatal care. As a result of these complications the Mother was next seen at 38 weeks pregnancy at the Hospital B in August; accounting for a nine-week gap in antenatal care being available to the Mother. Given the history and concerns shared by the South London Specialist Midwifery Service, the Hospital made a referral to Local Authority A Children’s Social Care Front Door Service. This referral was processed resulting in the Hospital Social Work Team receiving information two days before Baby Darryll was born. A discharge planning meeting was then held in September three days after the birth and the day before Baby Darryll was discharged from Hospital. Local Authority A Health Visiting Service were not invited to this meeting, nor made aware of the Mother’s history or the involvement of either the other Borough or Local Authority A Children’s Social Care. 4.2.8. Three days after discharge Hospital C’s Community Midwifery Service attempted a home visit however entry was denied because the Mother had not been expecting a Midwifery visit. This refusal was communicated back to the Hospital Social Work Team. The following day the Community Midwifery Service attempted an unannounced home visit, but again access was declined as the Mother was not expecting the visit and instead was expecting a scheduled visit from the Health Visitor the next day. The following day, the Health Visitor made a successful home visit and found no concerns, stating that the Mother and Baby Darryll appeared to be doing well. Local Authority A Leaving Care Team also conducted a successful home visit and were not concerned.  4.2.9. The Mother then attended a Hospital clinic as scheduled and the assessment was that both Mother and Baby Darryll were doing well resulting in them being discharged from Midwifery care to the care of the Health Visiting Service. The Mother was reported as feeling positive but was concerned about her own mother’s health. The day after  9 MARAC – Multi Agency Risk Assessment Conference – a forum which shares information about risks due to domestic abuse and harm. CLASSIFIED INFORMATION – FINAL REPORT  5  Official the Mother attended this clinic the Maternal Grandmother died in hospital from natural causes. Two days after this Baby Darryll was admitted to hospital and died five days later. 5. Findings & analysis 1. The following section provides a commentary and analysis of professional practice. Having mapped the professional and agency contact with Baby Darryll over the timeframe under review, there are a number of features that stand out that help us understand what happened, and why events occurred as they did. These features are relevant from a multi-agency safeguarding system and practice perspective and, as such, provide us with the greatest insight into the quality and effectiveness of the response to Baby Darryll and Mother. Where possible, an explanation of why events occurred as they did, has been provided. Learning points for use by all professionals and trainers have been emphasised. The following themes are explored; - The quality of pre-birth assessment including the use of information about known risk factors - Thresholds for intervention across services & discharge planning - The impact of transitions across Boroughs and the quality & effectiveness of support offered - Local knowledge & understanding about vulnerabilities of young babies - The quality & effectiveness of services provided to the mother as a care leaver 2. By way of a summary, the findings from the analysis highlight the following issues as relevant to learning; - The circumstances in which Baby Darryll was found may indicate unsafe sleeping arrangements, with toxicology testing showing no drug use and drugs not being a contributory factor to Baby Darryll’s death.  - The Mother’s use of cannabis was known about by a range of professionals and whilst acknowledged as a risk factor, had not been assessed to be at a level to compromise the Mother’s caring abilities. Her parenting capacity had not been tested and the extent of the impact of cannabis use on parenting skills was unknown.  Curiosity about these issues was lacking, and potentially contributed to be a minimisation of the impact of cannabis. - Risk and vulnerability factors, both pre-disposing and situational, were not consistently acknowledged across all partner agencies who came into contact with the Mother. In turn, the risks to Baby Darryll’s welfare and the support needs for the Mother were not fully recognised during the final stage of pregnancy and into early parenthood. - There was insufficient weight attached to the transfer of housing accommodation for the Mother, placing her at increased risk from known associates. - Information sharing was somewhat fragmented, and not achieved in a timely manner – which inhibited timely assessment and decision making about which services could offer support to the Mother and baby.  - There were elements of professional bias by Local Authority A Children’s Social Care when assessing the Mother, complicated by case management processes, which had the effect of minimising risks to the baby.   5.1. The quality of pre-birth risk assessment including the use of information about known risks factors 5.1.1. Statutory guidance 10 states ‘… no system can fully eliminate risk. Understanding risk involves judgement and balance. To manage risks, social workers and other professionals should make decisions with the best interests of the child in mind, informed by evidence available …’ .When assessing risk from a safeguarding and child protection perspective, risk can be categorised into those factors that are currently presenting themselves as a concern, for which it may be possible to manage i.e. situational risks, and those where there is less likelihood of effecting change and which occurred prior to the current circumstances i.e. pre-disposing risks.     10 Working together to safeguard children, 2018, HM Government  CLASSIFIED INFORMATION – FINAL REPORT  6  Official 5.1.2. In this case there were a number of known pre-disposing risk factors that formed part of the Mother’s history, and which the professional network had no control or influence over; these included, - The Mother’s own childhood experiences of living with domestic abuse between her parents and witnessing parental alcohol misuse.  - The Mother’s reported use of cannabis from the age of 10 years, being in abusive relationships as an adolescent and being at risk from gang associations. - The need for the Mother to be taken into the care of the local authority aged 13 years and placed in a residential home, as opposed to foster care, which was out of the local area due to the extent of risks faced.   5.1.3. These factors are significant from a safeguarding perspective and highlight the Mother had experienced considerable adversity, abuse and neglect herself. There is a body of research evidence that supports the view that such experiences may go on to compromise their own parenting capacity and abilities11. Research12 about childhood adversity and trauma highlight maltreatment, violence, household adversity, and needing to adjust to relationships as contributory factors that can impact negatively on development and later life chances. These factors are relevant in helping us understand the likely support needs of the Mother and pathways to protection or pathways to harm for Baby Darryll.  Much of the information outlined above was known, or knowable, by all professionals involved with the Mother.  Learning point: Recognising, and exploring, adverse events that have happened in a person’s earlier life can provide important context to understanding their current circumstances and behaviours. Where the safety and welfare of an unborn child is of concern it is imperative to gather information about the parents own experiences in order to inform safety planning. 5.1.4. In addition to the pre-disposing risk factors highlighted above, the Mother was experiencing a number of situational risk factors which, either singularly or combined, had a real potential to increase risk to Baby Darryll during pregnancy and when born; these included, - The Mother’s continued use of cannabis. - The challenges faced by the Mother in securing safe and stable accommodation in the run up to, and following, the birth. - The Maternal Grandmother’s illness and death resulting in additional stress being placed on the Mother. - The risk of the Mother experiencing postnatal depression. - The Mother’s untested abilities as a first time and young parent, given her known history and vulnerabilities. 5.1.5. The South London Maternity Services have confirmed that the procedural pathway for mothers who disclose using cannabis during pregnancy was not completely followed in this case during antenatal appointments; there was no recorded curiosity about the frequency, amounts and circumstances of cannabis usage shown nor information leaflets given to the Mother about the risks to her and the unborn baby. This reflects a mind-set that normalises the use of cannabis without considering the potential risks to children13. As a result of this review the pathway and guidance will be amended to strengthen practice but also reflective supervision, encouraging greater professional curiosity.   11 i) Does the past predict the future? Reder, P., in Studies in the Assessment of Parenting, Reder, P., Duncan, S., & Lucey, C., Routledge, 2007 and ii) Analysing child deaths and serious injury through abuse and neglect: What can we learn? A biennial analysis of serious case reviews 2003 – 2005, HM Government.  12 Young Minds & NHS Health Education England: Addressing childhood adversity and trauma  13 NHS - Cannabis: the facts & NSPCC Parental substance misuse CLASSIFIED INFORMATION – FINAL REPORT  7  Official 5.1.6. The procedural pathway was followed when a urine sample was taken for toxicology testing; the results were positive for cannabis prompting a maternity safeguarding notification being completed and smoking cessation service referral offered, although this referral was declined by the Mother. Opportunities to discuss risk minimisation with the Mother were therefore not taken. This may have helped the Mother think about the risks of using cannabis and safe sleeping arrangements. The Trust is undertaking a review of this procedural guidance and plan to issue a revised pathway. 5.1.7. The other London Borough’s Perinatal Mental Health Service have reflected on their involvement and assessment, concluding that that whilst the Mother was stable and would not be eligible for their services at this stage of the pregnancy, there could have been greater curiosity about her housing situation and the impact this might have had on her. Additionally, the need to consider crisis plans at the point of discharge from their Service, and sharing these with partner agencies, is a learning point that has been highlighted; in this case, as the Mother moved through her pregnancy this may have been a useful addition to her overall ante-natal care package.  5.1.8. Evidence submitted to this review shows that the other Borough’s Children’s Social Care conducted a focused pre-birth assessment that was concluded in a timely manner. Information relating to the pre-disposing vulnerabilities and risks outlined above is mentioned, as is an assessment of the positive move for the Mother out of Local Authority A into their own Borough three years previously to create distance for her from gang associations and an abusive partner. The following positive features are also evident;  - The purpose of the pre-birth assessment was clearly defined and explained to the Mother. - It included known vulnerabilities which might impact on the Mother’s care of her baby, both currently as a care leaver and those arising from her historical experiences as a child.  - The assessment was informed by contributions from all the relevant agencies involved with the Mother and in relation to her pregnancy; this included her Personal Adviser in Local Authority A; the Specialist Midwifery Team; the other Borough’s Antenatal Drug Service; Change Grow Live (drug and alcohol services); and the Borough’s GP Practice. - The reports provided by other agencies verified the veracity of the Mother’s own account to the Social Worker (of her family history, relationships, challenges and vulnerabilities) reflective of the Mother being open and honest in the assessment and being prepared to work with professionals.  - The assessment included discussions with the Mother’s sister, who also appeared open and honest about her contact with a Children’s Social Care department. The accounts by the sister were followed up by the other Borough’s Social Worker, again demonstrating good practice in triangulating information rather than relying on first accounts.  - The assessment evidences curiosity by the other Borough’s Social Worker with the Mother about who the baby’s father might be; but without success in identifying him.  - The assessment explored the quality of the relationship between the Mother and the Maternal Grandmother.  5.1.9. The assessment concluded by identifying the current main concerns as: continued cannabis misuse; a risk of post-natal depression; and the insecure housing situation and anxiety this was causing the Mother and that she should not be rehoused back in Local Authority A. The assessment of risk in relation to the Mother’s continued use of cannabis was considered. Discussion between the South London Specialist Midwifery Team Manager and Social Worker confirmed that given the other positive aspects to the Mother’s circumstances, it was agreed that on balance the risks were not high, and they could be managed within a general support plan.  In this context the pre-birth assessment recommended that the Mother work towards stopping her cannabis due to the potential adverse impact it could have on her baby’s development.  On the basis of information submitted and known at the time this professional practice is judged as positive and reasonable given the circumstances.  The pre-birth assessment closing letter was however not shared with the Health Visiting Service or Hospital C Midwifery Service by the other Borough’s Children’s Social CLASSIFIED INFORMATION – FINAL REPORT  8  Official Care; the full assessment was also not sought by Local Authority A Children’s Social Care. The reasons given for this point to the final part of the process simply not being completed. This had led to a single agency learning point to amend procedural guidance to ensure it is a stage that is not missed in future. 5.1.10. However, there are two areas of learning from this episode. Firstly, the other Borough’s Social Worker encountered problems in getting chronological information, recent assessment work and a genogram from the Mother’s Local Authority A Personal Adviser, despite a number of attempts. Full information was not provided by the time the other Borough’s assessment was completed and the case had been closed to the other Borough’s Children’s Social Care. Sharing information in a timely manner with professionals is a core task in safeguarding work.  5.1.11. Secondly, it was felt that although there was no role for the other Borough’s Children’s Social Care, those best placed to support the Mother included the South London Specialist Midwifery Service, the South London Family Nurse Partnership, and Local Authority A Leaving Care Team. The Midwifery Service would have offered very short-term support and then transferred support over to the Family Nurse Partnership. This would have worked had the Mother remained in the other Borough and can be seen as an appropriate protective pathway for Baby Darryll. The support offered by Local Authority A Leaving Care Team would have been focused on the Mother, not Baby Darryll. Relying on this as a source of support for both mother and baby was flawed and would have placed the Local Authority A Personal Adviser in a double bind situation; conflicting priorities which may have resulted in a loss of focus on each placing the worker in a no-win situation in terms of their responsibilities. The baby, once born, would have warranted a separate worker in order to offer an objective opinion about safety and care arrangements.  Learning point: In cases where an adult is judged to have their own vulnerabilities, and they already have a named worker to support these needs it is important that for any child, or children, living in the same household there is consideration to them having their own allocated worker. This may help avoid conflicts of interest and biased thinking in assessment and decision making. 5.1.12. Hospital B have confirmed that information was shared with them about the Mother’s vulnerabilities or risk factors despite her transferring to their care late during the pregnancy (at 38 weeks). They were aware of the other Borough’s Perinatal Mental Health Team assessment of the Mother being stable and that other Borough’s Children’s Social Care had conducted a pre-birth assessment and had consequently closed their involvement with the Mother. They were also aware that the Mother had engaged well with the South London Hospital Specialist Midwifery Service, and that the Mother appeared to be prepared for the arrival of her baby.  Despite the information being given that assessments had been carried out and the case had been closed by the other Borough’s Children’s Social Care, the Midwifery Service at the Hospital  B still made a referral to Local Authority A Children’s Social Care (although not obtaining consent from Mum who said that everyone already knew about her).  This was good practice due to the Mother’s previous history and highlights recognition of the Mother’s vulnerability and risks to the baby.  5.1.13. Local Authority A Children’s Social Care have highlighted that when their Front Door Service received the Early Help referral from the Midwifery Service at Hospital B it was processed immediately for further enquiries. Importantly, the referral did not provide any detail about the most worrying features of the case or the reasons for referral. Information about cannabis use was only included in the summary section and was described as a complicating factor rather than a risk to the baby in its own right. It is noted that ‘ … there was no detail in the referral about the possible effects or consequences of using cannabis either in pregnancy or with a new born baby and it would appear that the main reason for the referral was the previous concerns of the threat of domestic abuse and gang affiliation now that Mother was back in Local Authority A …14’.  Further detail was provided in the summary section including a reference to there already being a pre-birth assessment conducted in the other Borough.   14 Local Authority A Children’s Social Care submission to the review. CLASSIFIED INFORMATION – FINAL REPORT  9  Official Learning point: For those professionals making a referral it is important to think about how the information you submit will be read and interpreted by the person reading it. You are taking the time to make a referral because you are worried. It is therefore worth investing time into making the referral clear and evidence based; and then placing yourself in the seat of the person receiving it re-reading it to ensure it is as helpful as it can be. 5.1.15. From a system thinking perspective this episode can be described as a trade-off15. Trade-offs are a system thinking concept. Work in complex systems is impossible to assign, predict and prescribe completely. Demand fluctuates, resources are often limited and goals often conflict. Frequently, the choices available to us are not ideal and we are forced to make trade-offs and choose sub-optimal courses of action. Trade-offs such as these help us understand system behaviour and system outcomes. The trade-off in this situation was that the Front Door Service practitioner experienced competing demands on their time and made a decision to not interrogate the database to see if there was further relevant information to inform the assessment of current circumstances.  Learning point: From a safeguarding system perspective, when practitioners work under pressure and struggle to manage the demand of the throughput of work, there may be value to gaining an understanding about the likely trade-offs that will be used by workers and managers to cope e.g. partial assessments, keeping records up to date, not involving all relevant partner agencies. Some trade-offs may be tolerable; others not as they compromise the welfare of children. 5.2. Thresholds for intervention across services & discharge planning 5.2.1. As stated, the other Borough’s Children’s Social Care conducted a thorough and proportionate pre-birth assessment. It concluded with a plan for protection and support which, as outlined above, was dependent on the South London Specialist Midwifery Service, South London Family Nurse Partnership and Local Authority A Leaving Care Team. Given the positive aspects noted by the assessment the decision by the other Borough’s Children’s Social Care to step down their involvement seemed rational. There was no information to warrant a step up of intervention.  5.2.2. The single complicating factor in the whole support and safety plan was that the Mother had made housing applications to two Boroughs. The advice and recommendations of the pre-birth assessment were dependent on the Mother remaining in the other Borough and receiving support from services in this area. The assessment and closing letter to Local Authority A Children’s Social Care, clearly stated that if the Mother returned to live in Local Authority A – where it was known she had previously faced risks – the situation would need re-evaluating.  Practice in the other Borough’s Children’s Social Care is that a copy of the assessment is provided to family members and a letter summarising the assessment and its outcomes is sent to all the professionals involved. The Mother confirmed that she had been given a copy of the assessment, although found it difficult to fully understand.   15 Trade-off - as cited a) Learning into Practice: improving the quality and use of serious case reviews, Masterclass 2: Systems thinking, SCIE & NSPCC, 2016 and b) Systems thinking for safety: Ten principles – A White Paper, Eurocontrol, 2014.  5.1.14. The Front Door practitioner made appropriate enquiries including speaking to Mother; the initial assessment contained all the relevant risk factors and emphasised the concerns about cannabis use. However, critically the practitioner overlooked the fact that there had been a pre-birth assessment in June 2018 in the other Borough. Having sight of this would have added considerable weight to the quality and depth of assessment completed. The closing summary from the other Borough Children’s Social Care was logged on the database case notes for the Mother, because it had been sent to Mother’s Personal Adviser, but it was not accessed at the time of the Front Door Service assessment. The reason given for this oversight has been due to work pressures to undertake tasks in a very short timeframe.  CLASSIFIED INFORMATION – FINAL REPORT  10  Official 5.2.3. At the end of June 2018, the other Borough’s Children’s Social Care closed their involvement with the Mother believing there was a sufficient support and safety plan in place. This was a reasonable course of action however the formulated plan subsequently became invalidated due to the Mother being rehoused in Local Authority A in early July. This meant in practice the other Borough’s Children’s Social Care had no reason to track and monitor arrangements once they had closed the case. It also meant that the Midwifery care transferred to Hospital B (although there was a nine week gap in handover as outlined above) and because the Mother would no longer be eligible for the services of the other Borough’s Family Nurse Partnership and any postnatal specialist care would be picked up by the D London Community Healthcare NHS Trust Health Visiting Service. The Family Nurse Partnership service in Local Authority A has different eligibility criteria to that of its counterpart in the other Borough. 5.2.4. Family Nurse Partnership (FNPs) works ‘… with parents aged 24 and under, partnering them with a specially trained family nurse who visits them regularly, from early pregnancy until their child is two …’16. To be eligible the young parent has to be living in the authority and be up to 28 weeks gestation, and the emphasis is offering a personalised model of care for each young parent. The service is not available in every local authority and capacity is limited especially when needing to prioritise the most vulnerable and complex young women. The eligibility criteria for other Borough’s FNP17 is for women aged 22 years and under with complexities and vulnerabilities. The Mother fitted this criterion, being under 22 years of age at the time and was offered the service at 29 weeks pregnancy (some discretion was applied given the stage of gestation as the other Borough’s FNP is part of the ADAPT testing programme18).  In contrast Local Authority A FNP19 offer the programme to young women aged 20 years and under (although care leavers aged 20 – 24 years are eligible). This highlights a difference in age criteria across the two Boroughs. The South London Specialist Midwifery Service ‘… did not inform Local Authority A FNP because their professional opinion was that the Local Authority A team would face limitations in regard to any action they could take because the Mother was outside of their criteria of intervention …’20 (due to her being later on in gestation).  The criteria, although different across the two Boroughs, does allow some flex; the criteria in Local Authority A FNP does explicitly permit care leavers to be eligible. On this basis it was worth making an application.  Learning point: One Service cannot make a decision or assumption on behalf of another Service about whether someone in need of support will, or will not, be eligible. This is especially so where the eligibility criteria may be similar but there are grey areas that require local interpretation and local decision making.   5.2.5. From a system thinking perspective this episode highlights a misalignment of FNP service provision across local authority areas which had the potential to create a pathway to failure21. The pathway was one that created a mismatch with Local Authority duties for care leavers potentially up to the age of 25 years. Whilst it is recognised that local delivery mechanisms need to consider funding, capacity and resource implications there is a certain logic to ensuring that offers by innovative initiatives such as the Family Nurse Partnership align with the expectations placed on other agencies targeting the most vulnerable cohort of young parents. The review has benefitted from the contribution of  16 Family Nurse Partnerships - Programme information  17 South London Family Nurse Partnership  18 Family Nurse Partnership - ADAPT  19 Local Authority A Family Nurse Partnership  20 South London Hospital Maternity Services submission to the review.   21 a) Pathways to harm, pathways to protection: a triennial analysis of serious case reviews 2011 to 2014, p. 24, University of Warwick & University of East Anglia, May 2016 & b) Learning into Practice: improving the quality and use of serious case reviews: Masterclass 2 Systems thinking, SCIE & NSPCC, 2016.  CLASSIFIED INFORMATION – FINAL REPORT  11  Official the National Unit for the FNP programme, who have confirmed that all FNP arrangements now have the flexibility and choice to offer support to young women up to the age of 25 years, and have done so since April 2016, making it more aligned to Local Authority duties. There is also a national evaluation underway which is looking at whether changing the gestation period criteria is viable. 5.2.6. The South London NHS Trust Maternity Services have also highlighted that there is ‘… no evidence of consideration by the [Specialist Midwifery Service] prior to transferring maternity care of the increase in risks following mother being placed back in Local Authority A … It would be expected that when the mother was moved back to Local Authority A a MASH referral to Local Authority A would be made by the Midwife as the risks to the unborn baby had increased ...’22.  Current Antenatal Care guidelines do not provide guidance on the transfer of care during pregnancy; as a result of this review it has prompted an action to amend and update the guidelines.  5.2.7. The South London NHS Trust has also confirmed that there is no evidence that safeguarding supervision was sought by those practitioners involved with the Mother. Having access to objective and skilled supervision which allows an opportunity to explore the more complex and vulnerable cases a practitioner may be responsible for is an important and healthy aspect of safeguarding work; it increases the likelihood that good decisions will be made about thresholds and case management. The use of safeguarding supervision is an area that is known to be of concern and there is ongoing work to remedy this, with there being an expectation that practitioners should receive supervision every 12 weeks.  5.2.8. The Hospital Social Work Team, which is part of the front-door referral & assessment service of Local Authority A Children’s Social Care, acknowledge that the ‘contact’ from the Front Door Service was not dealt with in a timely manner remaining as a ‘contact’ until after Baby Darryll had been injured and taken to hospital. This delay is confirmed by Hospital B who have reported having no response to the referral they made in September. In practice this resulted in a two-week gap of there being no action to either allocate to a worker for assessment or step down to another service. Local Authority A Children’s Social Care have noted that ‘… this practice falls short of the required standard to review the contact and make a decision in a timely way …’23.  This two-week window of time would have allowed ample time to convene a meaningful multi-agency discharge planning meeting which could have been informed by an updated assessment from the one conducted by the other Borough’s Children’s Social Care. As a consequence of this inaction, the discharge planning meeting was not sufficiently robust resulting in a limited safety plan being in place.  5.2.9. A number of risk factors are noted to have been discussed at the discharge planning meeting in September. The Mother did not think it necessary for there to be another assessment and consequently did not give her consent to one taking place. This reflects the Mother’s frustration with ‘the system’, which she felt should have known enough about her circumstances already and not need further assessments. Records examined highlight an optimistic tone concerning risks for the baby but with the Mother giving different information about her cannabis use than is contained in the original information from the Midwives i.e. she stated that she had ceased her cannabis use one month prior to the baby’s birth but in the referral the cannabis use was said to be on going. The outcome of this meeting for the Hospital Social Work Team was that a worker would not be allocated to undertake a further assessment. Those managers involved at the time have reflected on their involvement and decisions and revealed some uncertainty about the best course of action. The Mother had not agreed to an assessment, creating a dilemma for the managers who were mindful that the decision made by Local Authority A Front Door service  was that the case should proceed to an assessment. The following factors influenced the Hospital Team’s decision making;  - The concerns were historical rather than current.  22 South London Hospital Maternity Services submission to the review.  23 Local Authority A Children’s Social Care submission to the review.  CLASSIFIED INFORMATION – FINAL REPORT  12  Official - Mother had said that she had stopped smoking cannabis a month before the baby was born. - The Personal Adviser supporting Mother did not have any concerns about her ability to care for the baby.  - A risk assessment conducted by the Leaving Care Team was in place in relation to the risk of gangs and domestic abuse; the Leaving Care Team were monitoring this and working with Mother to keep her safe.  - The closing summary letter from the other Borough’s Children’s Social Care did not raise current safeguarding concerns.  - Mother had support from close family and had been back in the Local Authority A area for three months with no problem to date.  5.2.10. There are a number of factors which counter the criteria used by the Hospital Team to make their decision. These include;  - The extent of the Mother’s cannabis use was uncertain at this time. Despite the Mother stating that she had stopped smoking a month before the Baby Darryll’s birth, she gave no undertaking to stop using it when she went home. Her cannabis use was a long-standing habit and one which was likely to prove very difficult to stop altogether. The Mother advised that she did not want support in stopping and that she used it to control her anxiety and to help her sleep – highlighting a self-medicating purpose rather than as a recreational drug.  - There are two accounts of the discharge planning meeting which place a different emphasis on the risks to Baby Darryll – one from the attending Social Worker who did not know the case and one from the Personal Adviser. Differing accounts from a meeting may reflect on the quality of chairing and recording arrangements. This has prompted the creation of a report format to more accurately capture the discussion and decisions from discharge planning meetings.  - The full pre-birth assessment from the other Borough’s Children’s Social Care had not been considered at this time despite it being known about and available. One of the recommendations from the other Borough’s assessment was that child protection procedures should be considered in the event that Mother moved back to Local Authority A. Not using this assessment was a missed opportunity to build on work completed and consider next steps. This would have played into the Mother’s sense of professionals continually re-assessing her circumstances.  - The Mother had reported receiving support from extended family members. This was viewed as a positive feature however the extent of these support networks had not been fully explored and assessed; there had been a reliance on the Mother’s account of what she felt was available for her. Had this been explored it would have revealed some concerns about the extended family’s care of children and their involvement with Children’s Social Care.  5.2.11. This episode reveals a persisting challenge and dilemma for frontline practitioners who are required to form judgements about thresholds, especially those where there is a need to balance safety with, or sometimes alongside, offering support. The Hospital Team’s balancing of risk factors might be viewed as reasonable given the presenting information, however decisions were made in the absence of important information. This approach or style of thinking and decision making reflects what Munro24 refers to as an intuitive form of reasoning ‘… a cognitive process that somehow produces an answer, solution or idea without the use of a conscious, logically defensible, step-by-step process …’. In the absence of the knowable additional information a best fit decision was taken. The other style of reasoning is analytic which is characterised as ‘… a step-by-step, conscious, logically defensible process …’.  Both forms have their own merits and can be used effectively to complement decision making. In this case however, a further assessment would have been the step-by-step pathway to offering greater protections to Baby Darryll and allowing an opportunity  24 Munro, E., Common errors of reasoning in child protection work, 1999, LSE Research Articles Online.  CLASSIFIED INFORMATION – FINAL REPORT  13  Official to prove or disprove a hypothesis that the Mother was capable and coping25. Calder26 notes of intuitive reasoning that it can be heavily relied on in child protection work citing research27 which describes this form of reasoning as ‘…a hazard, a process not to be trusted … because it is … flawed by biases …’.  5.2.12. This view has been reflected by Local Authority A Children’s Social Care ‘… in reviewing the additional information … that was not considered, the threshold becomes clearer. All indications are that although Mother was upset about the possibility of another assessment, she was generally co-operative. Efforts to persuade her … might have been fruitful. … an assessment of mother and baby in situ would have been advisable, as no social worker from a child protection perspective had assessed mother’s current circumstances.   In the absence of consent, s47 enquiries would have been the option available …’  Learning point: When faced with needing to make a pivotal decision about case management and there is any question about which is the best course of action to take, there will always be benefit in seeking a fresh and impartial perspective. Seeking peer or management supervision or specialist opinion is the best option when presented with a dilemma about the safety and welfare of very young children.  5.2.13. Examination of this episode has revealed at that time there was no system for dealing with differences in opinion between Local Authority A Front Door service and the Assessment Teams when recommendations about progressing to assessments were not accepted. Therefore, there was no requirement to either follow the Front Door  Service’s recommendation or follow a process that would require further exploration of the situation. As a result of this finding, changes have been introduced to greater scrutiny of disagreements or discrepancy about threshold decisions.  5.2.14. The Housing Trust have considered their response in terms of thresholds for intervention. At the time of the six week visit the Housing Trust were not aware that the Mother was a cannabis user nor was it evident that she was smoking cannabis in her property. Signs of cannabis use at this visit would have triggered the Trust’s child safeguarding procedures. Information contained within the Local Authority A Council’s nomination form and the Mother’s application form set out that the Mother was a care leaver, was heavily pregnant and had a history of anxiety and depression. This should have prompted a vulnerability alert being placed on the Trust’s electronic case management system in accordance with procedural guidelines. As a result, an earlier three weeks visit and check as opposed to the six week check, could have been completed.  When exploring with the housing practitioner whether they recognised the vulnerability indicators it was acknowledged that with the benefit of hindsight this should have happened, but as there were no immediate presenting concerns and the Mother was receiving support from Local Authority A Leaving Care Team, the Midwifery Service and her GP, it provided a level of assurance that satisfied the practitioner that a vulnerability alert was not necessary.  Learning point: When there is a known network of professionals involved with a young parent there can be no harm done by making contact with the primary lead professional for the young parent (in this case the Personal Adviser) to advise them of your role and whether there is anything they should remain alert to.  5.2.15. A challenge for the Housing Trust, as with many housing providers is the need for them to be aware of, and interpret, threshold guidance across a large number of local authority areas. Given the high likelihood of housing staff  25 Local Authority A Children’s Social Care submission to the review.   26 Calder, M., Risk in child protection: Assessment challenges & frameworks for practice, p 112, 2016, Jessica Kingsley.  27 Hammond, C., Human Judgement and social policy: irreducible uncertainty, inevitable error, unavoidable injustice, 1996, Oxford University Press.  CLASSIFIED INFORMATION – FINAL REPORT  14  Official working with vulnerable adults and families it is worthwhile gaining this familiarity with local procedures and expectations.  Learning point: Strategic partnerships in local authority areas have a responsibility in ensuring all local services are familiar with safeguarding guidance, thresholds information and procedures.  5.2.16. The Housing Trust had no knowledge that a pre-birth assessment had been undertaken and were not invited to, or made aware of, the hospital discharge planning meeting.  D London Community NHS Trust responsible for Health Visiting were also not notified or invited to the discharge planning meeting. Consequently, the Health Visitor was not aware of the historical information and current concerns. 5.2.17. Hospital B were advised that there were no immediate concerns that should prevent the Mother from being discharged. As the Safeguarding Midwife was absent at the time there was no one to challenge this decision. The Hospital Midwife attempted to make contact with the Community Midwifery Service but did not get an answer resulting in the postnatal discharge documents being sent via email but requesting a verbal handover. The specific mention of a verbal handover suggests a level of concern sufficient to request a conversation rather than just an electronic notification. Learning point: A safeguarding system cannot rely on one person; it is the responsibility of the agency or service to ensure that there is adequate contingency planning to cover annual leave, sickness or other unexpected staff absences and that suitably qualified cover arrangements are available.  5.2.18. From the Health Visiting perspective D London Community NHS Trust has highlighted that the Health Visitor was not invited to the discharge planning meeting and as a result of this was not aware of the Mother’s vulnerabilities as no information had been shared with them previously. On review of the records it has been noted that the discharge summary birth notification had been received the same day as the new birth visit had taken place and that it had no information about the risk factors and concerns. Although the Mother was open and forthcoming about her background at the new birth visit which was completed within procedural timeframes, it meant that the Health Visitor relied on the first account from the Mother. This must have been somewhat disempowering for the Health Visitor as it prevented her from undertaking any checks beforehand by way of preparation for the visit.  The established pathway for this information exchange about cases should take place during the monthly Vulnerable Women’s Forum Meetings, where all vulnerable antenatal clients are discussed and logged on an electronic reporting system and then shared with the allocated Health Visitor. Due to the late notification this did not happen. 5.2.19. During the new birth visit the Health Visitor had queried the smell of cannabis and cigarettes in the property; this was on the back of the Mother stating that she continued to smoke cannabis outside of the home. Although the Health Visitor discussed the risks of sudden infant death, safe sleeping and other health related information, it appears that there was little enquiry about cannabis use, again reflecting a mind-set which normalises cannabis use. The conclusion of the new birth visit was positive with the Mother assessed as being calm (although tired due to visiting her own mother in hospital), confident and receptive to advice given. No concerns were observed, and the home environment was reported to be clean and tidy and very appropriate. The Health Visitor did however make contact with Local Authority A Children’s Social Care following the visit and was informed that the case was closed.  5.3. The impact of transitions across Boroughs & the quality & effectiveness of support offered 5.3.1. There are two transitions of note in this case; firstly, the transition around the Mother being re-housed from another Borough to Local Authority A, and secondly, as a result of the first handover the transition of antenatal care between different maternity services. CLASSIFIED INFORMATION – FINAL REPORT  15  Official 5.3.2. Service transitions and handovers create vulnerability in system processes; introducing new workers, differences in thresholds and procedures, have resourcing implication, and differing safety net mechanisms. When coupled with situations in which children face risk and there is a level of inherent uncertainty about case management it creates fertile ground for miscommunication and failures to occur. These are unintentional but are a key feature for professionals to be mindful of when working in complex systems, such as multi-agency partnership arrangements. It is of note that, in this case, had the Mother remained in one Borough she still would have needed to navigate three different health Trusts from the point of receiving antenatal care through to receiving community Health Visiting (Hospital B, Hospital C and D London Community Healthcare NHS Trust). Due to the transition across Boroughs this increased to five health Trusts. Such arrangements provide fertile ground for errors to occur due to organisational boundaries, different recording and databases being used, and multiple professionals requiring handovers.  5.3.3. Before considering these two key transitions, the review has highlighted some short delays in information exchange between the South London  Specialist Midwifery Service, the other Borough’s Children’s Social Care and Local Authority A Leaving Care Team at the time of the referral being made to the other Borough’s MASH and the subsequent pre-birth assessment. Whilst these delays did not have a negative impact on the next steps undertaken by the other Borough’s Children’s Social Care it does highlight added complications when working across geographical boundaries and working with multiple agencies. Delays in information sharing create further delays in decision making.  Transitions and housing provision 5.3.4. Review of this episode shows that the Mother submitted applications to two Borough Housing Services at the same time. The other Borough Housing accepted a preventative duty towards the Mother and would have offered her accommodation if she had become homeless. The Mother chose not to accept the accommodation offer, perceiving it to be an offer of shared accommodation as, at around the same time, an offer from Local Authority A Housing was forthcoming. Not wanting to be made homeless, the Mother reluctantly accepted the Local Authority A Housing offer of her own flat as this was a more attractive option.  5.3.5. The impact of the decision by Local Authority A Children’s Social Care to place the Mother in another Borough some years earlier was evidently a good one. It appears to have resulted in no further domestic abuse or gang associations for three years. The decision to then provide the Mother with housing in June 2018 is therefore at odds with the earlier decision and suggests a lack of joined up thinking from within Local Authority A Council. The safety and support plan for the Mother, and by association Baby Darryll, revolved around the Mother remaining outside of Local Authority A. By all accounts the Mother was settled in the other Borough, engaged with services, and received continuity of care from her local GP Practice who knew about her alcohol and drug use and were supporting her. The closure letter from the other Borough’s Children’s Services to all involved clearly recommended that ‘… Local Authority A continue to find appropriate accommodation as a duty to her as a care leaver within an alternative Borough to Local Authority A due to the risks …’28.  5.3.5. The Housing Trust have reflected that no contact was made by any agencies working with the Mother once she had moved back into Local Authority A accommodation. As stated in section 5.2, the Trust were not made aware of the full extent of the Mother’s background or support needs during the first six weeks of her tenancy. Care Leavers are acknowledged as a vulnerable client group by the Trust and are offered 1:1 support. This offer of support was made by the Trust at the six-week welcome visit but was declined by the Mother who felt she had a sufficient support network already.    28 Other Borough’s Children’s Social Care submission to the review.  CLASSIFIED INFORMATION – FINAL REPORT  16  Official Transitions and antenatal care 5.3.6. The second transition to be examined concerns the handover of antenatal care between maternity services. As highlighted the Mother changed her mind about where she wished to receive antenatal care. Women are able to choose where they wish to access antenatal care and the South London Specialist Midwifery Service were consistent in their practice of sharing information with both Hospital A’s and then Hospital B. This is good practice and clearly demonstrates a focus on the needs and wishes of the Mother but also consideration of the needs of the unborn child. From this aspect, the South London Specialist Midwifery Service made attempts to support a protective pathway. There is however a possible learning point from this episode. In order to support better practice the South London Specialist Midwifery Service might have also considered making a referral to Local Authority A MASH at the point they became aware that the Mother was going to be rehoused in Local Authority A. At the time (June 2018) they were the only Midwifery Service that had had contact with the Mother and their insights into the Mother’s situation could have added a useful perspective to any further assessment work undertaken. This referral would however need to be balanced with gaining the consent from the Mother and given the Mother’s view about not needing additional support this would likely have prompted a threshold dilemma for the Specialist Midwifery Service. A consultation with the Maternity Safeguarding Team might have given the Midwife an opportunity to reflect on, and take action in regard to the increase in risks for the unborn baby, by mother moving back to Local Authority A. The Mother’s Personal Adviser and the Midwifery Service were the only two consistent professionals working with the Mother.  5.3.7. As highlighted in section 5.1. Hospital B were provided with background information from the South London Specialist Midwifery Service, although had not had sight of the pre-birth assessment from the other Borough’s Children’s Social Care. They appropriately made a referral to Local Authority A Children’s Social Care because from their perspective there was no current social care involvement. This impacted on the quality of the discharge planning meeting.  Learning point: Sharing pre-birth assessments, which have been conducted due to likely risks to the infant, with all relevant health care professionals is an important, and necessary, task. Failure to share this assessment disadvantages those professionals making their best decisions, reduces the impact of conducting a pre-birth assessment and potentially places the infant at risk. 5.4. Local knowledge & understanding about the vulnerabilities of young babies 5.4.1. Research29 into other Serious Case Reviews highlights the largest proportion of cases subject to review relate to children under one year of age with a significant percentage being children under three months. Given this knowledge it is helpful for this review to explore the extent of professional knowledge and understanding about this particularly vulnerable group of children, especially in the context of known information about both pre-disposing and situational risk factors in this case.  5.4.2. From the other Borough’s Children’s Social Care perspective, the pre-birth assessment was conducted by a Social Worker in their assessed and support year of employment (ASYE) and supported by an experienced Manager. Additional support was also available from an experienced Senior Social Worker. Relevant guidance about conducting pre-birth assessments was accessed. Records indicate just one supervision session taking place.  An awareness of the risks to the unborn child are clearly evident. 5.4.3. Local Authority A Leaving Care Team and the Personal Adviser for the Mother had a key role in bridging services and acting as a facilitator to promote joined up working arrangements, especially given the transitions discussed above in section 5.3. They were aware of the Mother’s history, had worked with her a long time and had regular contact with  29 Pathways to harm, pathways to protection: a triennial analysis of serious case reviews 2011 to 2014, p. 35, University of Warwick & University of East Anglia, May 2016. CLASSIFIED INFORMATION – FINAL REPORT  17  Official her supporting her through the pregnancy. They were well placed to assess the strengths and difficulties of the situation, although as articulated in section 5.1., it is arguable they were placed in a double bind situation during the pregnancy due to a potential conflict of interest. Records and discussions confirm that they were mindful of the baby’s needs, in its own rights, and conversations took place between the Manager and Personal Adviser about whether they should make a referral to the MASH. A decision was reached that they should make such a referral, and this was also a recorded action in the Mother’s Pathway Plan in August 2018, only a few weeks before the birth. However, a referral was not then made for the following reasons:  - The pre-birth assessment by the other Borough’s Children’s Social Care was relatively positive. - The risks associated with gangs were considered to be negligible because the Mother had ceased contact with these individuals. The Mother had confirmed that she was actively avoiding them and had a contingency plan in place should she meet them. - Risks associated with domestic incidents were considered; although a legal intervention via a Non-Molestation Order was an option, on balance it was felt best not to alert the perpetrator about her return to the area.  - An evaluation that the Mother had matured in recent months, was in control of her alcohol and cannabis use and generally she appeared to be having a positive outlook on life.  This was supported by the fact that the Mother was also seeing a counsellor, and this was seen as a positive relationship.  5.4.4. Whilst the above list of situational factors is positive, there is little recognition about; - The weight of the Mother’s earlier life experiences and how this may impact on her parenting capacity.  - The fact that she was not disclosing to anyone who the baby’s father was; something that ordinarily may be a cause for considerable curiosity but also concern.  - The extent and reliance on her cannabis use as a self-medicating habit rather than recreational usage; which is likely to have some impact on parenting capacity. - The possibility of the decision to not make a referral being overly optimistic in terms of the pathway for the Mother and baby once born, and the likelihood of additional support being needed sooner rather than later.   5.4.5. It is arguable that the revised decision by the Local Authority A Leaving Care Team to not make a referral to the MASH further reflects an intuitive form of reasoning, as discussed in section 5.2, highlighting a possible bias that was favourable towards the Mother, and which left Baby Darryll vulnerable. Learning point: It is important to remain open and receptive to having to re-evaluate your assessment and relationship with the parents you work with, being mindful of any undue bias or influence about someone’s character or situation or convincing information.  5.4.6. From the perspective of the Housing Trust staff have completed training with a specific focus on the vulnerability of both young and unborn babies where there are known risks and vulnerability factors and the importance of reporting concerns, early intervention and inter-agency working.   5.4.7. The Midwife who saw the Mother and Baby Darryll at home had attended the appropriate level of safeguarding training, where a session is devoted to the vulnerability of babies even without extra risk factors.  The Midwife was aware of the mother’s cannabis smoking and asked for reassurance that the mother would try to give up. 5.4.8. The South London Specialist Midwifery Services have reflected that there is room for improvement in terms of their specialist service evidencing in recording understanding and curiosity about the vulnerabilities of young babies, especially where there are known risk and vulnerability factors. These risks and vulnerabilities include known cannabis use and the impact on parenting plus the transfer of housing back to an area where there were known risks. This expectation will form part of the revised pathway referred to in section 5.1. CLASSIFIED INFORMATION – FINAL REPORT  18  Official 5.4.9. The D London Community NHS Healthcare Trust responsible for Health Visiting Services in the Local Authority A area have confirmed that the allocated Health Visitor had completed the appropriate level of safeguarding training, in line with expectations30, which included risk and vulnerabilities for young babies when known vulnerability factors. 5.4.10. The practitioner involved with the Mother and Baby Darryll from Hospital B took appropriate actions thereby demonstrating knowledge and understanding about the risks to Baby Darryll in the circumstances.  5.4.11. There is learning for Local Authority A Adult Substance Misuse Service who were involved briefly with the Maternal Grandmother. Their initial assessment of her provided them with an opportunity to be more curious about the disclosure by the Maternal Grandmother about her daughter’s pregnancy. She had shared some concern about the father of the unborn child and that he was ‘… involved with people with guns …’. This information was correctly shared via email in early September with the Leaving Care Team. As the worker was on annual leave an out of office message was received but the information was not followed up with a phone call.  It was only on the Leaving Care practitioners return from leave some 10 days later was the information received. Although this information may not have been critical to the assessment and case management at the time, it could have added useful contextual detail to the knowledge held by the Personal Adviser and the Midwifery Services.  Learning point: Safeguarding children is everyone’s responsibility. When information emerges from your interactions with service users, irrespective of your role and agency remit, that indicates someone has a worry about a child it is important to be curious with the service user about the information being shared. This may then require you to seek advice about whether it is appropriate to share this information with either the Police or Children’s Social Care.  5.5. The quality & effectiveness of services provided to the mother as a care leaver 5.5.1. Local Authority A Children’s Social Care have confirmed that the Mother had benefited from a Personal Adviser for over three years having been allocated a worker when she became 18 years old. Reports indicate the relationship was positive and that other members of the team knew the Mother and she genuinely found their support helpful. The team in which the Personal Advisers work is multi-disciplinary. The Mother was also engaged with a counsellor. The Mother had a Pathway Plan, and this has been judged as of a good standard and relevant to her circumstances, having been reviewed just prior to Baby Darryll’s birth.  There are two areas of interest in terms of the quality and effectiveness of services provided to the mother as a care leaver. When care leavers become parents:  5.5.2. The review has considered areas for learning and improvements in relation to the work that Personal Advisers and the Leaving Care Team undertake with care leavers who then become parents. These areas include; - The Leaving Care Team primary purpose is to support care leavers and as such this is their focus; not that of any children of the individual care leaver.  In this case, there are some signs that the focus on the mother as a care leaver obscured a shift in attention, or equal attention, on to Baby Darryll. - The Pathway Plan does not contain a section to assess the needs of care leavers who are, or about to become, parents. In this case, the Mother’s Plan contained information about a range of practical tasks such as preparing her accommodation for the baby, liaising with housing about access with a pushchair, and exploring the correct State benefits. Whilst the focus on practical tasks is entirely appropriate and necessary there is little mention about the need and capacity to develop parenting skills. Reflections by the Leaving Care Team, and with the benefit of hindsight highlight that there were services such as playgroups and young parenting groups that were available but were not considered for the Mother or Baby Darryll. Similarly, a referral to Local Authority A Family Nurse Partnership would have been an entirely appropriate step to take, however this was not considered.    30 Royal College of Nursing - Safeguarding children & young people: Roles & competencies for healthcare staff CLASSIFIED INFORMATION – FINAL REPORT  19  Official 5.5.3. It is possible that other professionals involved with the Mother once back in Local Authority A, for example the Midwifery Services, saw the Personal Adviser as the conduit to action in respect of Baby Darryll’s welfare. Records indicate liaison between these services may have resulted in unwittingly blurring the boundaries between the Leaving Care Team meeting the support needs of the Mother against meeting the safety and welfare needs of Baby Darryll. This issue has also been touched on in section 5.1.  Learning point: When there is a significant event or change in a young person’s life as a care leaver, such as becoming a parent or a very close bereavement, and there is a professional network involved it will important for the network to reflect on their roles and responsibilities and whether changes are needed to the support being offered.  Supporting care leavers with accommodation and housing:  5.5.4. The Mother’s hope was to continue living in the other London Borough as she felt safe and had developed local connections e.g. friends and college. It would appear that her application was treated as a general homeless application rather than considering her as a care leaver and assessing her other vulnerabilities. Under the Homelessness Reduction Act (2018) Care Leaver’s should be able to apply to any local authority where they have a local connection and to be assessed for housing; multiple applications can also be made to different housing authorities. The involvement of advocacy support with the Mother’s case did not result in any change in decision. The weight and level of support provided to the Mother during this process may be an area that Local Authority A Children’s Social Care may wish to examine in greater detail to ensure that the offer of advocacy and support to care leavers is in line with expectations and promotes good outcomes. 6. Good practice 6.1. This Review has identified a number of areas which can be highlighted as good practice. It is important that good practice is recognised and shared. Examples include; - The pre-birth assessment and closing summary conducted by the other Borough’s Children’s Social Care is a well thought through and proportionate piece of work. - The Community Midwifery Service from Hospital C acted appropriately in contacting Local Authority A Children’s Social Care to escalate their concerns about the Mother’s refusal to grant entry to them when they visited.  - The Community Midwifery Service from Hospital C achieved meaningful engagement with the Mother in a postnatal clinic resulting in the Mother being open about her difficulties and family issues.  - The South London Specialist Midwifery Service applied professional judgement in ensuring antenatal care was transferred despite there being no guidelines to do so.  - Hospital B Midwifery Service made a referral to Local Authority A Children’s Social Care despite being told that the previous social work department had closed the case.  - The support offered by the Mother’s Personal Adviser following Baby Darryll being admitted to hospital and after the death has been commended. 7. Conclusion 7.1. This case review has examined the circumstances around the death of a 20-day old infant in October 2018. It has examined multi-agency contact and involvement with the Mother during the pregnancy and benefitted from the contribution of some of the professionals involved at the time. The review has also captured the views and perspective of the Mother.  7.2. The review has highlighted that there were a number of pre-disposing and situational risk factors identified, but which were assessed to not be at a level that justified statutory intervention. Investigations and enquiries by the Police and Coroner have concluded that the cause of Baby Darryll’s death is a case of misadventure. The circumstances may indicate unsafe sleeping arrangements.  CLASSIFIED INFORMATION – FINAL REPORT  20  Official 7.3. A number of factors contributed to the multi-agency response not being as effective as they might have been; these include a minimisation of risk from parental cannabis use, biased professional judgements informing decision making, disjointed information sharing that was not timely, and untested assumptions about the Mother’s parenting capacity. The review has highlighted points for learning and improvement within single agencies but also across safeguarding partnerships.  The review concludes with recommendations. 8. Recommendations  Those agencies that have contributed to the review have submitted action plans to make improvements alongside the reports submitted at the beginning of this review process. As such, agencies have been able to progress learning and improvement activity without the need to wait for the overview process to conclude. Much of the learning identified in this review has been captured as areas for improvement by those agencies represented and is reflected in their action plans. The following recommendations are for the Local Authority A Safeguarding Partnership to take forward. 1. To ensure the learning from this review is disseminated across the multi-agency safeguarding partnership to practitioners and managers.  2. To seek assurance that the actions identified by each partner agency, as a result of this review, have been managed, implemented and embedded in a timely manner.  3. To inform the Family Nurse Partnership National Unit of the findings of this review to allow them to consider the learning and shared with local partnership arrangements and supervisors.  4. To promote learning, as a public health message to the wider population, about the importance of avoiding co-sleeping and unsafe sleeping arrangements with babies.   5. To seek assurance about the quality and effectiveness of joint working arrangements for those services who work with care leavers who are pregnant and who require housing support.  6. To review the information sharing protocol and practice around sharing of pre-birth assessments (closing summaries and full assessments) to confirm that they are provided to the relevant professionals and agencies that are involved with the mother/father; consent to share by mothers/fathers should not be seen as a barrier to the professional network and guidance should include advice about how to overcome any barriers which may arise as a result of consent issues.  7. All organisations across the partnership to ensure all agencies use of the threshold document is proactively considered, especially when consent is withheld and there may be a need to re-evaluate decisions taken on individual cases.  8. To seek assurance that all multi-agency safeguarding training courses and relevant resources relating to risk assessment include explicit reference to the risks associated with cannabis use and the potential impact during the antenatal period and on parenting capacity.   