Death of a 13-month-old girl of Somalian heritage in February 2013. Post mortem identified evidence of fractures, judged to be strongly indicative of a non-accidental injury. Parents were both convicted of neglect. Family were known to universal services only. Mother arrived in the UK seeking asylum whilst pregnant with Child S. Father and Child Ss siblings joined at a later date. All injuries to Child S occurred after the family were reunited. Issues identified include: professionals had only limited information about the familys history in Somalia; family moved regularly between local authorities making it harder for agencies to share information and provide them with consistent support; and mothers family were sometimes used to interpret for her rather than providing an independent interpreter. Recommendations include: a single system is needed in London to ensure health visiting services are notified by GPs when new children move into an area and an effective notification system is needed across London for informing universal health and childrens services when housing services move vulnerable families.
      
 Title:  Serious case review: Child S. LSCB: Greenwich Safeguarding Children Board Author:  Date of publication: 2016  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.                               Greenwich Safeguarding Children Board          Serious Case Review   Conducted Under  Working Together to Safeguard Children 2013    Child S   The Overview Report               Lead Reviewer Amy Weir MA MBA CQSW   December 12th 2015 Final Version 12th December 2015 2 | P a g e     GREENWICH SAFEGUARDING CHILDREN BOARD  SERIOUS CASE REVIEW  RELATING TO Child S Date of birth: January 2012 Date of death: February 2013 Ethnic origin: Black African  OVERVIEW REPORT   CONTENTS  PAGE    Executive Summary  3 1.   Introduction 4  2.   Serious Case Review Process  5  3.   Family Composition and Cultural Issues  10  4.   The Facts - Background and Summary of Agency Involvement  11  5.   Child S's Experience    12  6.   Analysis of Practice and the Lessons Learnt  13  7.   Conclusions and Terms of Reference  16  8.   Recommendations for Greenwich Safeguarding Children Board                18  9.   Recommendations for individual agencies  19  10. Learning from the review   19 Appendices Appendix A - Family and Significant others and Genogram  Appendix B - Scope and Full Terms of Reference  Appendix C. Membership of the Greenwich LSCB Serious Case Review Panel  Appendix D - LSCB action plan and progress.  Appendix F - List of References     Final Version 12th December 2015 3 | P a g e   Summary of the Findings of this SCR  What happened in this case?  This young child of a newly arrived family from a war-torn area suffered multiple fractures. Expert medical opinion found that physical abuse and the injuries contributed to her death. The family had only been in the UK since mid-2011. They were supported by other family members and used universal health services and appeared to seek medical advice until the child received these injuries. Prior to the death of this child, there had been no concerns about the care the child was given or her mother’s parenting. The family were not known to any targeted services.  It is unlikely that the death of this child could have been predicted from the history as it was known or from the information which each agency had. The parents have been convicted of neglect for failing to access appropriate medical intervention for the child - under Sec 1 (1) Child and Young Person’s Act 1933 neglecting a child in a manner likely to cause him/her unnecessary suffering. The trial took place at the end of 2014 and the parents were sentenced in January 2015; father received a custodial sentence and mother was given a suspended custodial sentence.   What might have reduced the risk of this child’s death?  Some system issues for consideration have emerged from this review. There appear to have been some areas for improvement in the universal, early help system. It is important to note, however, that Child S’s injuries and physical abuse seem to date from only the last 2 months of life and after father and the other siblings were reunited with this child and her mother.  High mobility / universal health service in several areas involved. In 18 months, the family moved on four occasions and lived in four different London Boroughs. It is clear from this review that there are several obstacles to ensuring that continuity of universal service provision is achieved for vulnerable families with young children across London. This family, which was mother alone with one child for most of this period, was potentially vulnerable as asylum seekers; the mother and child may have been vulnerable as they moved further from extended family members. Although mother registered with GPs, Child S did not consistently get the access needed to universal health care surveillance and support provided for under 5s through the health visiting service. Missed opportunity to identify and address needs of a family who sought asylum & was given leave to remain Mother was thought to be suffering from post-traumatic stress during her first few months in the UK– though she apparently did not want support for this. There may have been a better understanding of mother’s needs if interpretation services had been used all the time – particularly during her pregnancy and the early months of Child S’s life; her family were used to interpret on some occasions rather than seeking additional support for her. However, there are indications that mother was reluctant to seek help. There may be hidden vulnerabilities and risks as far as families who have recently sought asylum and have been granted leave to remain are concerned. The need in the current high demand on housing to move families to other areas away from the host Borough increases the likelihood that vulnerabilities may not be identified.  Although this Serious Case Review was commissioned by Greenwich Safeguarding Children Board, the family had only been living in Greenwich for a few weeks prior to the child’s death. Therefore, the findings and recommendations are mainly for wider consideration beyond Greenwich across London and for the other areas in which the family lived. Final Version 12th December 2015 4 | P a g e    1.  Introduction  In order to ensure confidentiality and out of respect to family members, all names are anonymised throughout this report.    1.1  Background to this Review This Serious Case Review (SCR) was commissioned following the death of a 13 month old child referred to as Child S in this review. It considers the circumstances of the death and whether the services, which were received from a range of professionals across several different London local authority areas, responded appropriately to address the child’s needs.  1.2 Child S was born in January 2012. The child died aged thirteen months old in February 2013.  Two days after Child S's death the initial post mortem identified that there was evidence of fractures. As a result of this, a specialist paediatric post mortem was undertaken. This revealed that there were severe multiple fractures of different ages which were judged to be strongly indicative of non-accidental injury. These factors led to the decision on 6th March 2013 by the Greenwich Safeguarding Children Board (GSCB) Chair to undertake a serious case review.   1.3 Child S was the youngest child of the S family. Child S was born in January 2012 and was reportedly in good health but died unexpectedly in February 2013. The immediate cause of death according to the post mortem was inhalation of stomach contents; multiple healing and recent bone fractures caused by a “forceful event” (ribs, long bones and scapula) were also found. The pathologist dated the child’s injuries to two main time periods – two to four days and two to four weeks prior to death. All of these injuries occurred after father and siblings came to the UK in December 2012.  1.4 At the time of her death in February 2013, Child S was in the care of mother and father and she was living with them and four other siblings.  1.5  Summary of Circumstances Leading to the Review  1.5.1 A Review was regarded as necessary because of the unexplained fractures which were identified during the post mortem. The family were for the most part only known to universal health services in the various London Boroughs where they had lived. No particular concerns about the parenting of Child S or the child’s siblings had apparently been identified. However, the death is believed to have resulted from physical abuse and the parents were arrested in relation to the child’s death, were charged and were subsequently found guilty Final Version 12th December 2015 5 | P a g e   of child neglect at the end of November 2014; they were sentenced in January 2015. For these reasons, it was decided by the Greenwich Safeguarding Children Board in 2013 that this case met the criteria for undertaking a Serious Case Review - as set out in Working Together 2013.  2.  Serious Case Review Process   2.1 The Statutory Basis for Conducting this Serious Case Review   This Serious Case Review (SCR) was formally commissioned on 6th March 2013 when the Independent Chair of the Greenwich Safeguarding Children Board endorsed the recommendation from the Serious Case Review Panel that a review should be carried out.   Ofsted and the Department for Education were notified of Child S's death and that the decision to conduct a SCR had been made.   The decision was based on the criteria from Working Together to Safeguard Children 2013 which identify the factors which should be taken into account when deciding whether a SCR should be undertaken.   2.2  Terms of Reference   2.2.1  The full terms of reference are appended to this overview report. The Individual Management Review authors were asked to consider the issues listed in Working Together as well as the particular issues set out in the terms of reference.  SCR Criteria from Working Together to Safeguard Children 2013 The statutory guidance requires LSCBs to undertake an SCR when the criteria are met (regulation 5 of the LSCB guidance 2006). Regulation 5 of the Local Safeguarding Children Boards Regulations 2006 sets out the functions of LSCBs. This includes the requirement for  LSCBs are to undertake reviews of serious cases in specified circumstances. Regulation 5(1) (e) and (2) set out an LSCB’s function in relation to serious case reviews, namely: 5 (1) (e) undertaking reviews of serious cases and advising the authority and their Board partners on lessons to be learned.  (2) For the purposes of paragraph (1)(e) a serious case is one where: (a) abuse or neglect of a child is known or suspected; and  (b) either Final Version 12th December 2015 6 | P a g e   (i) the child has died; or (ii) the child has been seriously harmed and there is cause for concern as to the way in which the authority, their Board partners or other relevant persons have worked together to safeguard the child.  In addition the guidance requires that SCRs address the following:   providing a sound analysis of what happened in the case, and why, and what needs to happen in order to reduce the risk of recurrence  advising the Greenwich Safeguarding Children Board, relevant local authorities and other agencies on lessons to be learned.  agreeing with GSCB partners and other relevant agencies what action they need to take in light of the SCR findings.  be written in plain English and in a way that can be easily understood by professionals and the public alike; and  be suitable for publication without needing to be amended or redacted.  Key Issues to consider in the SCR - Specific issues which have been identified as requiring particular analysis in this case are:  There was no previous indication that Child S was at risk of significant harm and the family were never referred to a Children’s Social Care department. Given this, the SCR focused on the role of universal services:  did professionals have an understanding of the family history prior to their asylum application?  should any additional needs arising from the family circumstances have been identified by professionals in contact with the family particularly given that the family were recently arrived in the UK,  had sought asylum and had been granted leave to remain?  were the family offered the opportunity to access relevant advice and support from appropriate agencies (i.e. refugee support organisations)?  are there specific issues around ethnicity, language or religion?  whether and what sort of vulnerability assessment might have been undertaken  consider the impact of the family’s mobility in terms of their homeless application and opportunity to access appropriate support  were there any issues, in communication, information sharing or service delivery particularly in relation to the placing authority (RBK&C) and the host local authorities?  was any consideration given to any needs of the other children and the father at the point of their arrival in December 2012?   were there any organisational difficulties being experienced within or between agencies? Final Version 12th December 2015 7 | P a g e    2.2.2  The Time Period for this Serious Case Review is from May 2011 – when the mother arrived in the UK – to the outcome of Child S’s post mortem in February 2013. This review considers all the information which has been ascertained from that period.   2.2.3  Other Review processes  The Coroner decided not to hold an inquest in relation to Child S's death. There was a criminal trial which concluded in January 2015.  The minutes and papers from the Greenwich Rapid Response Meeting held on 6th February 2013 have also been shared and considered in the review.  As part of the review process, Child S's parents were contacted to inform them that a review had been taking place. This contact was initiated following the ending of the trial. Mother was written to but there was no response from her. It has not been possible to contact father who is serving a custodial sentence as his whereabouts have not been received from the Prison Service. Every effort has been made to make contact with the parents up until the final date of publication as there are many questions remaining about what happened in the family. It is still planned to share and discuss the findings of this review with the parents.  2.3 Timing of the Review  There has been no delay in the decision making in the arrangements for undertaking this review. The independent SCR Panel Chair, the Overview Author and the Individual Management Reviews were commissioned promptly. The review was completed in a timely way.   There was some delay in finalising the overview report. The criminal trial did not conclude till January 2015. It only became known in mid-2015 that the Coroner had decided not to hold an inquest.  2.4 The Serious Case Review Panel and Overview Report - independence and process  2.4.1  The SCR Panel Chair and the Lead Reviewer are appropriately independent, qualified and experienced professionals.  2.4.3  The overview report has been written from the evidence set out in the Individual Management Reviews and agency statements as well as from document reading and from further conversations with IMR authors to Final Version 12th December 2015 8 | P a g e   clarify the details and findings. The author has also considered whether there are any relevant research findings to apply to the case.  2.4.4  The membership of the Serious Case Review Panel is set out in Appendix C.  2.4.5  The Serious Case Review Panel met on four occasions prior to the first presentation of the Overview Report to the LSCB. The Independent Chair encouraged adherence to timescales, and the general management of the Serious Case Review Panel meetings and the process was efficient and effective to ensure maximum learning from the Review. The Independent Chair was provided with professional business management and administrative support.  The Serious Case Review Panel provided the Lead Reviewer with good advice and constructive comments about this Report and they effectively challenged each of the Individual Management Reviews. The Panel was proactive in identifying points of concern as well as areas for learning which have been incorporated into this overview report.   2.5 Individual Management Reviews  The family have lived in four local authorities across London; the following organisations have been identified as ‘participating organisations’ which had important information to contribute to the review.   NHS Greenwich Clinical Commissioning Group submitted an overarching Individual Management review based on submitted IMR’s from health services (GP, Health Visitor and Midwifery) in Greenwich, Wandsworth, Hackney and Kensington and Chelsea.   NHS West London Clinical Commissioning Group  NHS City and Hackney Clinical Commissioning Group  NHS Kingston Clinical Commissioning Group  NHS Wandsworth Clinical Commissioning Group  Kingston Hospital  Royal Borough of Kensington and Chelsea (RBKC) Housing Needs Services  Metropolitan Police Service  Royal Borough of Greenwich Children’s Services  2.5.1  In accordance with Working Together 2013, Individual Management Review authors were advised of the need to look openly and critically at individual and organisational practice. They were asked to judge whether the case indicated that improvements to practice could and should be made, and if so, to identify how those changes will be brought about. (Working Together to Safeguard Children 2013). The Individual Management Final Version 12th December 2015 9 | P a g e   Review Report authors were briefed as to their responsibilities by the Independent Chair and Overview Report Author at the beginning of the process. The LSCB Manager also supported the authors and she was available throughout the process to give advice.  2.5.2 All those who conducted the Individual Management Reviews were identified by the Serious Case Review Panel and the Independent Author, as being either completely independent of the area, or senior personnel within each agency who were completely independent of any direct involvement or line management responsibilities concerning the case.   2.5.3  The Serious Case Review Panel decided that the following agencies and organisations would be asked to contribute to the Review.   Individual Management Reviews were provided by:   Homerton University Hospital NHS Foundation Trust  Kingston Hospital NHS Foundation Trust  Primary Care in City and Hackney – the Nightingale Practice  NHS Greenwich Clinical Commissioning Group  Royal Borough of Kensington and Chelsea  Housing Needs Service  Statements of Information by:  Royal Greenwich Children’s Services  Oxleas NHS Foundation Trust  St George’s NHS Health Care Trust (Community Division)  Metropolitan Police  London Probation Service  London Ambulance Service  UKBA  2.6 The Voice of the Young Person, Family and Significant Others  2.6.1  Throughout the course of this review, all those involved have kept the circumstances and interests of Child S in mind. Child S has been the central focus of all the enquiries made.   2.6.2  As stated above, the criminal proceedings against Child S’s parents concluded in January 2015. Mother has been written to but there has been no response. Father is still serving a prison sentence. The parents had Final Version 12th December 2015 10 | P a g e   previously been informed that a review was being undertaken. They will be contacted when the report is published so that the findings of the review can be shared with them.  2.6.3  It is clear from the evidence of medical experts in this case for the court proceedings that Child S had suffered considerable pain and discomfort following the more than 70 fractures inflicted upon her – on at least 2 occasions. The fractures have been dated as having occurred at two to four days and two to four prior to her death. It was stated that she would have been very distressed and in a lot of pain. It is of serious concern that her parents apparently did not seek medical help for her when she would clearly have been in considerable pain.   2.6.4  Evidence given in the trial has been that mother had told a friend she was concerned about the pain Child S was experiencing; she told her friend that she was worried and wanted to take the child to see the GP. On one occasion, the mother took the child to see the GP but she did not mention the child’s arm injury but only mentioned chest problems. In her own statement, mother told Police that father prevented her from taking the child to see the GP and she was frightened to challenge him about this. Father has made no statement about what happened to Child S.  3.0  Family History and Cultural Issues  3.1 Details of the family composition and of significant others are set out in the appendices to this report. All names have been anonymised.  3.2 The family originate from Somalia. All members of the family are Black African Somalis. The family composition includes the parents and four living siblings; Child S, the subject of this review died in February 2013; the family reported that another child of the family had died in Somalia. The mother moved to the United Kingdom in May 2011 leaving her four children in Somalia and she made an application for asylum. At that point, she was in the early stages of pregnancy. It is reported that the family were issued with a ‘reunion’ visa and her husband and children joined her in December 2012.   3.3  The family were placed in the Royal Borough of Greenwich on the 7th December 2012 by the Royal Borough of Kensington and Chelsea (RBKC) which had accepted the family as homeless. Prior to the move to Greenwich, the mother had lived in Hackney in accommodation provided by RBKC, and had lived in Wandsworth and Kensington and Chelsea with relatives and extended family members. She had also lived for some of the time with extended family members.   Final Version 12th December 2015 11 | P a g e   3.4 The panel has considered the lifestyle, culture and identity of Child S and her birth family.  There is comparatively little information about this family since they have only been living in the UK for a short time. They observe the Muslim faith. Their main language is Somali.   3.5 Mother and father both had some contact with the Somali Parents’ Network after they moved to Greenwich. The Network supported the parents with advice about how to meet their cultural needs locally and about financial support and access to schools for the older children. As part of this review, the author of this report met with a representative of the network to gain an understanding of what its involvement had been.   4.  Background and summary of agency involvement  4.1   The family – were in contact with universal health services in each of the London Boroughs that they lived in. There was no contact with Children’s Social Care services in any of the London boroughs that the family lived in.    4.2  When she claimed asylum from UKBA on arrival in the UK in May 2011, Child S’s mother went to live with her sister in Wandsworth. Child S’s mother used her sister’s papers to travel to the UK and her sister received a custodial sentence for this immigration offence.   4.3  Child’s S’s mother registered for maternity services at 11 weeks of pregnancy. From the symptoms she described, it was suspected that she was suffering from post-traumatic stress. The UKBA was informed by the St George’s Healthcare Trust in September 2011 that mother showed some symptoms of trauma and depression and that she was feeling anxious whilst the future remained uncertain. An interpreter was used so that her needs could be assessed and the health visitor, as part of her support, gave her advice about her asylum claim and about benefits. Mother said that she had good family support and the health visitor had no significant concerns about her well-being.   4.4 Child S was born In January 2012 while mother was still living with her sister’s family. She appears to have coped well with the new baby and was well supported by health staff. She was reported to be missing her husband and other children but was able to speak to them by telephone.   4.5  In August 2012, Child S’s mother approached the RBKC Housing Needs Service for housing under the homelessness legislation. The mother and child S were given temporary accommodation in a flat in Hackney in September 2012. In October 2012, RBKC accepted responsibility for securing suitable accommodation for the household including father and the four other children if or when they should come to the UK. Mother had Final Version 12th December 2015 12 | P a g e   advised that she had applied for the rest of her family to re-join her under a family re-union visa. RBKC Housing did not identify any other specific support needs other than that the family needed accommodation.   4.6 Mother registered herself and Child S with a GP in Hackney in November 2012. However, they were not known to the health visiting service as the information from the GP practice did not inform the health visiting service that this young child was registered with the practice and living in the local area. Child S was never examined or seen by the GP during the stay in Hackney.   4.7 In December 2012, the father and the other four children arrived in the UK. They approached RBKC for larger accommodation and they were allocated alternative four-bedroomed accommodation in Greenwich.   4.8 The family registered with a GP in Greenwich in December 2012. However, although mother tried to register Child S with the GP this was not actioned and Child S remained registered with the GP in Hackney.   4.9 Child S died in February 2013. The father reported that the Child had had breathing difficulties and he rang 999. The child was found to be unresponsive. A specialist post mortem subsequently showed that Child S had healing fractures, multiple fractures with high energy fractures on the collar bone. The parents were interviewed, arrested, are currently on bail having been charged  under Sec 1 (1) Child and Young Person’s Act 1933 relating to neglecting a child in a manner likely to cause her unnecessary suffering and the trial is set to begin on September 2nd 2014.   4.10  Timeline for the family 2011 -14  May 2011  Mother entered UK pregnant May 11 to July 12   Mother lived with her sister in Wandsworth Jan 12   Child S was born July to Nov 12  Mother lived with her sister in RBKC Nov to Dec 12  Mother moved to Hackney (placed by RKBC Council) Dec 5th 12  Father and other 4 children entered UK Dec 7th onwards Family moved to Greenwich (placed by RKBC Council) February 13  Death of Child S February 13  Both parents were arrested February 13 Four siblings taken into care and legal proceedings initiated and since completed. November 14   Trial of both parents. Found guilty of neglect.  Final Version 12th December 2015 13 | P a g e   5. Child S’s Experience – January 2012 to February 2013  5.1 Throughout this review, there has been a strong emphasis on ensuring that Child S’s experience is appreciated. In his 2009 report Lord Laming stressed the importance of attending to and understanding the direct experience of children and young people and said:  “Professionals can find it very difficult to take the time to assess the family environment through the eyes of a child or young person..... Staff across frontline services need appropriate support and training to ensure that as far as possible they put themselves in the place of the child or young person and consider first and foremost how the situation must feel for them.”  5.2  The Biennial Analysis of Serious Case Reviews 2005-07 (Marian Brandon et al) identified how children who had died were able “to slip from view”. The review stressed the importance of “seeing the world from the child’s point of view and understanding the risks of harm he or she faces”. It stressed that this depends on front line staff really focusing on the child.  5.3 Child S had several different addresses in just over a year. Child S’s mother had family support while she was living with her sister and brother-in-law. When they moved to Hackney, it is likely they would have been more isolated living at a considerable distance across London from the rest of the extended family. They were registered with a GP and therefore could access support from the practice. Overall most of the information we have about Child S’s mother suggests that she coped well with Child S and provide good care.  5.4  When father and the other children joined mother and Child S in December 2012, this must have been a very significant change for Child S. Her father and four siblings had had no contact with this child until then.   6.  Analysis of Practice and the Lessons Learnt  This overview report does not repeat the analysis included in all the Individual Management Reviews, but highlights those issues the SCR panel thought were most significant. It also adds additional analysis drawing on relevant research to consider what lessons can be learned. Several areas for improvement and lessons have been identified within the review process.    6.1 The analysis included in a number of the Individual Management Reviews and the Health Overview Report was helpful and of good quality.   Final Version 12th December 2015 14 | P a g e   6.2 Mother had only been in the UK for less than two years when Child S died. Mother had relatives here and she decided that it would be better for her family to seek asylum in the UK with the help of her sister. The family had already experienced the trauma of one of their children having been killed in Somalia. There is very little other information about the family’s history and it was likely to have been very difficult for services to get to know them well as they were living in four different London Boroughs during the period.    6.3 However, the IMRs show that universal services – particularly in health and housing - addressed mother’s needs. She was well supported during her pregnancy and post the birth of Child S. The health visiting service before she moved to Hackney supported mother in her care of Child S. Mother was given advice about her asylum status and about the financial benefits she could receive. Interpretation services were used and it is clear that Child S’s mother was able to get appropriate responses to the needs she identified for herself and the family. On the face of it, there is no reason to believe that mother did not receive the help and support that she needed; help and support were offered and mother decided not to take up everything which was offered and that was her choice.  6.4 The high mobility of this family undoubtedly affected the way that services were delivered to the family. Although, arrangements and handovers across different areas appear to have worked well until Child S and mother moved to Hackney, Health care was still provided via the GP in Hackney. Unfortunately, there was no contact with a health visitor as that service did not know that Child S and her mother were now in Hackney. When they moved to Greenwich Child S remained registered with the Hackney GP through an administrative error so again the Greenwich health visiting service was not put in contact with her immediately.   6.5  At the time of Child S’s death, there was a system in place in London - NOTIFY - which was intended to ensure that information is shared about homeless families as set out below:  NOTIFY is a web-based notification and information system, designed to improve homeless households' access to services. Its primary role is to notify relevant services of the placement or movement of homeless households placed in temporary accommodation by London boroughs under homelessness legislation. It will also produce comprehensive information on homelessness and temporary accommodation in London. The system uses information provided by London borough housing departments to notify housing, education, social care, and health services about homeless households placed in, moving between or leaving temporary accommodation. Information is contained in a database and updated weekly.  The following link - http://www.notifylondon.gov.uk. – provides an outline of how the system was supposed to operate at the time these events occurred.  Final Version 12th December 2015 15 | P a g e   However, local intelligence suggests that despite the appearance that Notify has London-wide coverage, it appears that only about two-thirds of London Boroughs actually use it regularly and reliably. It also appears that neither universal health nor children’s services are linked in through authorised users as the Notify website would suggest. It cannot be relied upon that universal health or children’s services are linked in through authorised users as the Notify website would suggest.   6.6 The only agency which provided any overall linkage with the family through the geographical moves from West London to Hackney and then to Greenwich was RBKC Housing between November 2012 to the death of Child S in February 2013. RBKC Housing Needs used the Notify system both when the family was moved to Hackney and also when they moved to Greenwich. The housing provider appropriately provided accommodation for the family and responded quickly to those needs. For the RBKC Housing Needs Service, there were no particularly outstanding concerns about mother’s vulnerability and this family’s application was seen as similar to many others. Generally, as families are moved to different Boroughs by housing providers, there is no effective system where there are children in the family, to notify either health or children’s services that these families have moved in or out. In this case, RKBC did use the Notify system and took the appropriate action to inform Hackney and Greenwich Local Authorities of the family’s placement in the respective Boroughs. However, since the family was not known to Children’s Social Care and since no concerns had been identified about the care of Child S, neither Hackney or Greenwich children’s services would have had cause to assess the family. There would clearly be real advantages for all concerned and particularly for children if there was a clear and more effective notification system in place across London – particularly in relation to children under 5 years.  6.7  During the course of this review, London Councils decided to undertake a review of the Notify system; this commenced in March 2014 and the Chair of this SCR panel was directly involved. A report was published in December 2014. The report has made some recommendations for improvement but it is not clear that they fully address the issues raised in this review and some members of this SCR panel believe that it does not give sufficient regard to safeguarding.   6.8 Mother was able to register with GPs and to access basic medical care for herself and Child S when this was required. However, the gaps in communication across universal health provision resulted in Child S not receiving the full range of health promotion and surveillance which should have been in place as set out in the Healthy Child Programme (2009). If mother was under additional stress this would also have been assessed more comprehensively through the programme.  The HCP is the early intervention and prevention public health programme that lies at the heart of our universal service for children and families. At a crucial stage of life, the HCP’s universal reach provides an invaluable Final Version 12th December 2015 16 | P a g e   opportunity to identify families that are in need of additional support and children who are at risk of poor outcomes.  DH Healthy Child Programme (2009)  6.9   There was a significant change within the family from December 2012 after father and the other four children re-joined mother and Child S. It is known now that Child S was being injured at home during the last two months of her life and that the child would have been suffering considerably having had multiple fractures inflicted. In addition, neither parent sought appropriate medical intervention for Child S after she was injured – even though it was clear to other family members that she was hurt when she cried and showed she was in pain. It appears that when she was picked up she cried and she struggled to crawl or move. Neither parent has accepted this picture of how impaired Child S was.   6.10  Mother took Child S to see the GP in mid-January 2013, just a few weeks before the death. The child was presented with an upper respiratory tract infection. Although mother originally stated that she told the GP about the child’s sore arm, the GP does not recall this and noted nothing about this. In a subsequent statement, mother admitted that she did not take the child to the GP about her sore arm. The GP was very clear in evidence in court about what she would have done if the arm had been mentioned.   6.11  Although mother eventually made a statement admitting that she was aware that Child S was in pain and needed medical treatment, she alleged that she was too frightened of father to take the child for medical attention. Father has said nothing about events except that Child S suddenly became unwell on the day that she died.  7. Conclusions  7.1 It is unlikely from all the information which has been gathered, that Child S’s death was either predictable or preventable. There was no previous indication that Child S was at risk of significant harm and the family were never referred to a Children’s Social Care Department. There had been no concerns about the well-being or safety of Child S at any point.   7.2 Mother seemed to be well able to care for Child S and there had been no concerns about her parenting of the child. Mother appeared to have followed health advice and ensured that Child S received appropriate immunisations.  7.3 However, after December 2012, there was a significant change in the family and it appears that, after that time, the care of Child S deteriorated and she was subjected to physical abuse causing multiple, severe Final Version 12th December 2015 17 | P a g e   fractures. Although it is not clear which parent inflicted these injuries, it is as concerning that neither parent sought medical treatment for Child S to relieve the suffering which was being experienced.  7.4 Addressing the Terms of Reference   Did professionals have an understanding of the family history prior to their asylum application? It is clear that there was only limited information about the family’s history in Somalia. This all came from mother’s self-report, via a family member or, on some occasions, through an interpreter as her English was limited. Professionals are described as having had some understanding of this background which seems to have enabled mother to be provided with the services they needed. However, there is mention in early health records that mother may have been suffering from post-traumatic stress, which had been identified on her arrival in the UK, but it is not clear that this was sufficiently identified or pursued as vulnerability. We do not know whether this condition persisted in mother but it is clear that professionals did not see her or her child as vulnerable.   Should any additional needs arising from the family circumstances have been identified by professionals in contact with the family particularly given that the family were recently arrived in the UK and seeking asylum and subsequently were granted leave to remain?  The panel has found no evidence in the enquiries made which indicate that most of the needs of mother and this child were not addressed. However, some concerns have emerged about whether sufficient use was always made of interpreting services to ensure that mother’s wishes and feelings were fully ascertained. Mother also had family in the UK to support her so she was not totally isolated. It appears that when Child S was in her mother’s sole care, she flourished and was making good progress.   Was the family offered the opportunity to access relevant advice and support from appropriate agencies (i.e. refugee support organisations)? Mother was living within her extended family for much of this period and was clearly able to access benefits, housing and health services. In the last few weeks before Child S’s death, the health visiting service was not in touch with or visiting the family. This might have provided additional support to the family but it is clear too that the family were in touch with the GP and the local Somali Family Network so there was some support available.  Were there specific issues around ethnicity, language or religion?  As far as language is concerned, mother has limited use of English. It is well evidenced that interpretation services were provided for her when she was in contact with most services and that, even when these were offered, she did not always take up what was available. There is no indication that there were any problems for services in responding appropriately to the family’s cultural or religious needs.  What sort of vulnerability assessment might have been undertaken?  The health services in contact with the family were seeking to respond to the needs presented by mother and to assess whether there were additional needs. The records show that a range of different responses were provided. There is evidence that she was reluctant to discuss what had happened in Somalia and that she preferred to depend on the support from her extended family. It is possible Final Version 12th December 2015 18 | P a g e   therefore that it would have been difficult to elicit from mother more about her circumstances. The RBKC housing needs assessment did not identify any specialist needs and also there was awareness that she had family support. The Housing Needs Service would not make any specific assumptions about the vulnerability of someone who had previously sought asylum, as they would assess a household’s vulnerability on a case by case basis. If there had been any concerns about the mother’s parenting or the child’s welfare this would have been noted and considered.  What was the impact of the family’s mobility in terms of their homeless application and opportunity to access appropriate support?  The family’s mobility is one of the most significant issues in this case. As set out above, there is a gap in current arrangements for ensuring that health and children’s services are notified when children move across London Boroughs. Although is also clear that RKBC is very diligent in using the Notify system when it is responsible for families.  Were there any issues, in communication, information sharing or service delivery particularly in relation to the placing authority (RBKC) and the host local authorities?  There are some legislative provisions about the responsibility of housing authorities to share information when a family moves. The Housing Act 1996 requires local authority housing need services to notify each other when placing a homeless housing in temporary accommodation in another local authority area (s.208 of the Act). Further, the Homelessness Code of Guidance that accompanies the Housing Act states that when homeless household are placed in another borough, the placing housing needs service should take positive steps to ensure effective liaison and co-operation between the relevant service departments of both local authorities, including housing, social services, environmental health and education. The Homelessness Code of Guidance also states that local authorities should ensure that all babies and young children placed in temporary accommodation have the opportunity to receive health and developmental checks from health visitors and / or other primary care professionals.  The Notify system was designed to fulfil the above requirements for information sharing. It is noted that RBKC Housing Needs used the Notify system correctly and according to its purpose. In common with many other London authorities, the London Borough of Greenwich did not use the Notify system. Evidence has emerged to indicate that the Notify system is not being used effectively and consistently across the whole of London.  There would need to be a pan London policy change, if an effective system to ensure that health and children’s services were informed of the movements of families between areas, was to be put in place. In this case, it would have provided an additional mechanism beyond GP registration to  inform other local services that Child S had moved into the area.  Was any consideration given to any needs of the other children and the father at the point of their arrival in December 2012?   The only agencies which would have known immediately about father’s and the other children’s arrival in December 2012 were the UKBA and the RBKC Housing Needs Service. UKBA did not have any specified responsibility to consider the needs of the newly arrived other members of the family. Given the information available to RKBC, no specific needs could be identified concerning the newly arrived members of the family in Greenwich. If the Notify system was more regularly used then local health services and education services in Greenwich could have been alerted.  Final Version 12th December 2015 19 | P a g e    Were there any organisational difficulties being experienced within or between agencies?  As stated above, this review has highlighted concerns about whether information about children is being adequately transferred when their families move across Borough boundaries and from one GP to another. The pick- up of information by health visiting services when families move and register with a new GP appears to be problematic. The application of “corporate caseloads” for health visiting which are not aligned to GP practice may also militate against efficient and speedy identification of new children in the area.     8.  Recommendations for Greenwich Safeguarding Children Board  In addition to the Individual Management Review recommendations, this Serious Case Review has highlighted a number of areas requiring attention. These are detailed in the Action Plan along with the specific actions required. These recommendations should be read in conjunction with the Action Plan which provides detail about methods of implementation and timescales.  The Greenwich Safeguarding Children Board recommendations are set out below:  There was limited involvement with this family by Greenwich services. Therefore, the recommendations listed below are for wider resolution on a wider London basis with GSCB needing to work with the London LSCB and other local LSCBS to progress them.  8.1  GSCB should link with the London LSCB and NHS England and the local CCG to raise awareness across London that a more consistent and single system is required to ensure health visiting services are notified by GPs that new children have moved in.  8.2 Following the London Councils’ Notify system review, the Chair of the GSCB SCR review group to take to the London LSCB and London Councils the continuing concerns raised in this review about how vulnerable families with children are moved around London by Local Authority Housing Services without an effective notification system for informing universal health or children’s services being made.   9.  Recommendations for individual agencies The Individual Management Reviews provided in support of this Serious Case Review contain recommendations which have been considered and endorsed by the LSCB, which if robustly implemented, will enhance safeguarding arrangements across the partner agencies of this LSCB and the other LSCB areas concerned. The GSCB has been tracking and monitoring the completion of these actions.  10.  Learning from the Review – next steps  Final Version 12th December 2015 20 | P a g e   The learning from this review is being taken forward within each agency and by the LSCB. Findings will be discussed with those staff who were directly involved. It is still hoped to share the review report with the parents but this may not be possible.   There is a communications strategy and timetable in place for the publication of the Overview Report. The Chair is mindful of the need to proceed with sensitivity about this given the high visibility of this case in relation to the criminal proceedings.  This is the final SCR report as at 12th December 2015. It had been planned to publish early in 2015 after the conclusion of the criminal trail and after the inquest. However the LSCB was not informed for many months about the Coroner’s decision not to hold an inquest and this resulted in the delay in publication.         Amy Weir MA MBA CQSW  Lead Reviewer  Child S Serious Case Review Final Version 12th December 2015 21 | P a g e   Recommendations to GSCB – Progress Report and Update  Recommendation Action Planned Progress  1. GSCB should link with the London LSCB and NHS England and the local CCG to raise awareness across London that a more consistent and single system is required to ensure health visiting services are notified by GPs that new children have moved in.   Panel Chair (JN) to write to NHS England and ask for issue to be raised with London LSCB.  JN also to write directly to London LSCB to check out response. Completed.   Completed. 2. Following the London Councils’ Notify system review, the Chair of the GSCB SCR review group to clarify the outcome of the Review. If necessary, take to the London LSCB and London Councils the continuing concerns raised in this review about how vulnerable families with children are moved around London by Local Authority Housing Services without an effective notification system for informing universal health or children’s services being made.   Panel Chair (JN) to meet with lead for Notify.     JN to join group reviewing Notify from 27/3/14 and to be completed by Sept 14.   SCR Panel Chair to take forward further concerns re Notify review and its recommendations after end of review.   Met in February 14.  Completed.  Review reported Dec 2014 – completed.  To be completed in Sept 14. Final Version 12th December 2015 22 | P a g e     Appendix A   Family and Significant others   Sibling 5, F Deceased  Sibling 9, M Sibling 4, F  Sibling 11, M Father 42 Sibling 3, F Child S Mother  34 Final Version 12th December 2015 23 | P a g e   Appendix B  GREENWICH SAFEGUARDING CHILDREN BOARD   SERIOUS CASE REVIEW Terms of reference CHILD S  Introduction: Background to the review Child S was born on the 01/01/2012 and was reportedly in good health but died unexpectedly on the 05/02/13. On 07/02/13 following an initial post mortem a pathologist reported that there was evidence of fractures and a specialist paediatric post mortem was undertaken which revealed severe multiple fractures which were judged to be strongly indicative of non-accidental injury.   The family composition included parents and four living siblings (one child is reported to have died in Somalia). The family originate from Somalia. The mother moved to the United Kingdom in May 2011 when she made an application for asylum and at that point was in the early stages of pregnancy. It is reported that the family were issued with a ‘reunion’ visa and her husband and children joined her in December 2012. The family were placed in the Royal Borough of Greenwich on the 7th December 2012 by the Royal Borough of Kensington and Chelsea who had accepted the family as homeless. Prior to the move to Greenwich the Mother lived in Kensington and Chelsea, Wandsworth and Hackney some of the time living with extended family members.   The family were in contact with universal health services in each of the London borough’s that they lived in. There was no significant contact with Children’s Social Care services in any of the London boroughs that the family lived in.    Decision to initiate a Serious Case review An extraordinary meeting of the Greenwich Safeguarding Children Board Serious Case Review Work Group was held on the 19/02/13 to share information, consider the circumstances of the death and decide whether to initiate a Serious Case Review.   The outcome was that the Chair of the SCR panel wrote to the Independent Chair of the GSCB on the 22/02/13 recommending that the criteria for a SCR were met. The Independent Chair of the GSCB considered the recommendation and decided on the 6/03/13 that a SCR should be undertaken. Ofsted and the Department of Education were informed of the decision to initiate a SCR.  The GSCB Serious Case review panel met on the 14/03/13 to draft the terms of reference.  Process of the Review The GSCB SCR work group agreed   A SCR Panel would be formed to oversee the SCR process.  The panel would be chaired by John Nawrockyi, Director of Adults and Older Peoples services. The Chair of the panel is independent and has had no involvement in the case.  The SCR panel membership will include representatives from the Greenwich Safeguarding Children Board and those agencies that are contributing IMR’s.   The SCR work group   agreed that the SCR would take account of the systems model in reviewing agency contact with the family.    Final Version 12th December 2015 24 | P a g e   Working Together to Safeguard Children 2013 The statutory guidance requires LSCB’s to undertake an SCR when the criteria is met (regulation 5 of the LSCB guidance 2006). In addition the guidance requires that SCR’s address the following:    provide a sound analysis of what happened in the case, and why, and what needs to happen in order to reduce the risk of recurrence  advising the Greenwich Safeguarding Children Board, relevant local authorities and other agencies on lessons to be learned.  agreeing with GSCB partners and other relevant agencies what action they need to take in light of the SCR findings.  be written in plain English and in a way that can be easily understood by professionals and the public alike; and  be suitable for publication without needing to be amended or redacted.  Key Issues to consider in the SCR There was no previous indication that Child S was at risk of significant harm and the family were never referred to a Children’s Social Care department. Given this the SCR will need to focus on the role of universal services;    did professionals have an understanding of the family history prior to their asylum application?  should any additional needs arising from the family circumstances have been identified by professionals in contact with the family particularly given that the family were recently arrived in the UK and seeking asylum?  were the family offered the opportunity to access relevant advice and support from appropriate agencies (i.e. refugee support organisations)?  are there specific issues around ethnicity, language or religion?  whether and what sort of vulnerability assessment might have been undertaken  consider the impact of the family’s mobility in terms of their homeless application and opportunity to access appropriate support  were there any issues, in communication, information sharing or service delivery particularly in relation to the placing authority (RBK&C) and the host local authorities?  was any consideration given to any needs of the other children and the father at the point of their arrival in December 2012?   were there any organisational difficulties being experienced within or between agencies?  Lead Reviewer Amy Weir has been appointed as the Lead Reviewer for the SCR. She is an experienced social care professional who has also worked in child health services and has had considerable experience of Serious Case Reviews.  Ms Weir is entirely independent of any Greenwich agency.  Time Period to be covered The time period of the review will start in May 2011 when the mother arrived in the UK to the outcome of the post mortem on the 7th February 2013.   Organisations participating in the Review Given that the family have lived in four local authorities across London the following organisations have been identified as ‘participating organisations’   NHS Greenwich Clinical Commissioning Group will submit an overarching Individual Management review based on submitted IMR’s from health services (GP, Health Visitor and Midwifery) in Greenwich, Wandsworth, Hackney and Kensington and Chelsea.   NHS Clinical Commissioning Groups Collaborative (Central/West London/ Hammersmith/ Hounslow CCGs  NHS City and Hackney Clinical Commissioning Group  NHS Kingston Clinical Commissioning Group Final Version 12th December 2015 25 | P a g e    NHS Wandsworth Clinical Commissioning Group  Royal Borough of Kensington and Chelsea (Housing Services)  Metropolitan Police Service  Greenwich Children’s Services  Each participating organisation will submit a chronology, in a consistent format, of their involvement with Child S. A chronology template will be provided to each organisation that is undertaking an Individual Management Review.  In addition and given the issues of mobility the following organisations will be formally approached by the Independent Chair of the GSCB requesting any relevant background information that might inform the SCR.   United Kingdom Border Agency   Children’s Services in Wandsworth  Children’s Services in Hackney  Children’s Services in Kensington and Chelsea  London Probation Service  The Greenwich Somalian family network  Involvement of family members Child S’s parents are subjects of a criminal investigation and any approach to the family will only occur in liaison with the Metropolitan Police and Crown Prosecution Service. The SCR panel agreed in principle that at an agreed point in the process the parents could be invited to meet with the Overview Report writer and a SCR panel member to give them the opportunity to contribute to the SCR.   Parallel Investigations The case is the subject of a criminal investigation which is being led by the Metropolitan Police and the Coroner is also involved as there is likely to be an Inquest into the death of Child S but this will not occur until the outcome of the judicial process. The Chair of the Child Death Overview Panel is aware of the decision to initiate the SCR and the case will not be reviewed until all the relevant processes have been completed. Continuing liaison with the Police and Coroner will be necessary and will be co-ordinated by the SCR Panel. The timing of the full publication of the SCR will be determined by the criminal justice process.   Interest from the Family, Public, Media The SCR Panel will manage contact with family, the public or media interest establishing a subgroup to progress the work if required. If the criminal investigation results in a trial a joint inter-agency media strategy will be agreed by the SCR panel.   Independent Legal Advice There is no indication that this is required but this will be kept under review by the SCR Panel.  Other Considerations In what way could the ‘systems methodology’ assist the dissemination of the learning from this Serious Case Review across the agencies in the London boroughs? These terms of reference will be reviewed by the SCR panel as the SCR is progressed.  John Nawrockyi Director of Adults and Older People’s Services Chair of the SCR panel for Child S.  Final Version 12th December 2015 26 | P a g e   Appendix C. Membership of the London Borough of Greenwich Safeguarding Children Board  Serious Case Review Panel   Independent Panel Chair - John Nawrockyi Lead Reviewer (in attendance) – Amy Weir Police CAIT  Greenwich CCG Kingston Clinical Commissioning Group Designated Nurse   Wandsworth Clinical Commissioning Group/ Designated Nurse  ‘Tri Borough’ LSCB Manager(Westminster, Kensington & Chelsea & Hammersmith & Fulham) Senior Quality & Reviewing Officer, Greenwich Children’s Services Housing Needs Manager - Royal Borough of Kensington & Chelsea                      Final Version 12th December 2015 27 | P a g e   Appendix D - List of References   Brandon M, Pippa Belderson, Catherine Warren, David Howe, Ruth Gardner, Jane Dodsworth and Jane Black - Analysing child deaths and serious injury through abuse and neglect: what can we learn? A biennial analysis of serious case reviews 2003-2005  Brandon M, Sue Bailey and Pippa Belderson - Building on the learning from serious case reviews: A two-year analysis of child protection database notifications 2007-2009; DFE 2010  Marian Brandon, Peter Sidebotham, Sue Bailey, Pippa Belderson, Carol Hawley, Catherine Ellis & Matthew Megson - University of East Anglia & University of Warwick – July 12 New learning from serious case reviews: a two year report for 2009-2011   Department for Education – Working Together to Safeguard Children: A guide to inter-agency working to safeguard and promote the welfare of children - 2013  Lambeth Safeguarding Children Board Serious Case Review - Child H (2014)  London Child Protection Procedures 2012  DH 2011 Health Visitor Implementation Plan: A Call to Action  DH Healthy Child Programme 2009  London Councils – Information about operation and purpose of Notify - http://www.notifylondon.gov.uk/Final Version 12th December 2015 28 | P a g e   Appendix E  Pen description of SCR Panel Independent Chair  John Nawrockyi  has been the Director of Adult Social Services, and before that the Director of Social Services, adults and children, for Greenwich Council since 2004. Prior to that, he was the Director of Housing and Social Services for Southend Council. John's career in social care started in the voluntary sector, but he has worked in local government since 1974, covering all aspects of children's, adults' and older people's social services, both as front line worker and senior manager. He also had a one-year secondment into the NHS in 1999 to assist in the application for a local Primary Care Trust to be established.   John is quite active for the Association of Directors of Adult Social Services. He is currently the co-Chair of the Disabilities Network and Secretary of the Workforce Network, and until the programme finished in 2009, was the ADASS Lead for Supporting People.    Pen description of SCR Lead Reviewer  For more than 30 years, Amy Weir has delivered, managed, inspected and advised organisations delivering children services - working for both local and central government.   Since 2006, Amy has worked as an independent children’s services consultant. She has been employed by Ofsted as an inspector; she has been the independent chair of three Safeguarding Boards and chaired SCR panels and written overview reports. She has no connection with services for children in Greenwich or this case.   GREENWICH SAFEGUARDING CHILDREN BOARD Child S SERIOUS CASE REVIEW  SUMMARY FROM ACTION PLAN TO MEET RECOMMENDATIONS  1. The SCR identified that the most significant issue in this case was the family’s mobility. All of the recommendations for individual agencies related in some way to this issue.  2. The only action for the Greenwich Safeguarding Children Board was to work with the London LSCB, NHS England and the individual agencies to raise of awareness of the issues and to track and monitor the completion of the agreed actions. 3. Health:  There were specific but similar actions identified across a number of different NHS Trusts, Community Health Services and Care Commissioning Groups  These actions addressed the need to ensure that there is a robust and effective system in place between GP practices and Health Visiting services, pan London, so that all new registrations of families with children under 5 are notified to those services.  Individual agencies have implemented local changes where needed which are now embedded in practice.  The GSCB has been in contact with NHS England who has discussed this at a London wide level to ensure that learning has been disseminated across London and also nationally.  4. Housing:  There was a review by a housing department of the Notify system. This is an on-line notification system intended to simplify information relating to families placed in other authorities by a housing department.  Information from this review has informed a review led by London Councils of the Notify system and there is currently a draft pan London proposal that is being consulted on. 5. Learning   Learning from this SCR has already been disseminated through the GSCB and other agencies directly involved with the SCR  Following publication learning will be made more widely available across the multi-agency network 6. Conclusions:  The action plan for individual agencies has been robustly monitored and reviewed by the GSCB  All involved agencies have implemented the actions identified, embedded them in to practice and continue to monitor them  Where actions related to London-wide or national bodies these have also been progressed.   