Serious non-accidental injuries to an 8-weeks-old infant boy in February 2017. Learning is included in recommendations. Recommendations include: have appropriate training to ensure marks to a non-mobile baby are referred to the Non-Mobile Baby Pathway with due regard to safeguarding, and consider using photographs when identifying any marks or bruises in non-mobile babies; discharge babies in line with the infant feeding protocol, including close liaison between midwifery and the health visitor; review the midwifery visiting regime to ensure that it addresses the needs of babies and families; transfer significant history about the health needs assessment, antenatal and postnatal information to the child's records so that this information is available to health visitors; consider the effectiveness of handheld records and provide guidance about when direct communication and information sharing between professionals is needed; there is a need to provide professional continuity; GPs should record who was present during consultations about a child and whether this involvement was in person or by telephone; make GPs aware of their safeguarding responsibilities and ensure the Bruising in non-mobile children policy is embedded within their practices.
      
 Title:  Serious case review overview report: Ethan. LSCB: Durham Local Safeguarding Children Board Author: Amy Weir Date of publication: 2020  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.                               SERIOUS CASE REVIEW OVERVIEW REPORT  Ethan Endorsed 20.05.2019                             Amy Weir MA MBA CQSW INDEPENDENT REVIEWER   2 | P a g e   Contents  Introduction ............................................................................................................................... 3  Background ................................................................................................................................ 3 Parallel Proceedings………………………………………………………………………………………………………………..4 The SCR: Process and Methodology ........................................................................................... 4 Independence ............................................................................................................................ 7 Serious Case Review Panel ......................................................................................................... 8 Confidentiality ............................................................................................................................ 9 Family involvement .................................................................................................................... 9 Staff involvement ....................................................................................................................... 9 Race, Religion, Language and Culture ........................................................................................ 9 Summary of Family history ....................................................................................................... 10 Overview of events and agency involvement: 2006 to 2017 .................................................... 12 The SCR Key Lines of Enquiry: Analysis ..................................................................................... 12 Lessons Learned ....................................................................................................................... 20 Summary analysis ..................................................................................................................... 21 Multi Agency Recommendations ............................................................................................. 24 Actions for Single Agencies....................................................................................................... 25 References ................................................................................................................................ 28   3 | P a g e    Introduction  1. The Durham Safeguarding Children Board (LSCB) agreed in November 2017 to commission a Serious Case Review (SCR) into the serious non-accidental injuries sustained by Ethan when he was aged 8 weeks. 2. Regulation 5 of the Local Safeguarding Children Board Regulations 2006 sets out the requirement for Local Safeguarding Children Boards to undertake reviews of serious cases where: I. Abuse or neglect of a child is known or suspected; and  II. Either — (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.  “Seriously harmed” includes, but is not limited to, cases where the child has sustained, as a result of abuse or neglect, any or all of the following: •  a potentially life-threatening injury; •  serious and/or likely long-term impairment of physical or mental health or physical, intellectual, emotional, social or behavioural development. Background  3. Ethan is the third and youngest child of his parents.  4. In February 2017, when Ethan was 10 weeks old, his parents called an ambulance after Ethan had become unresponsive. Ethan had bruising to his face and chest which mother said had been caused by Ethan flinging himself against his father’s face and bruising to Ethan’s chest from being winded. Ethan, aged 10 weeks, suffered multiple injuries including swelling and bleeding to the brain and numerous fractures to the ribs and limbs. 5. There had been limited multi- agency involvement with the family prior to these non- 4 | P a g e   accidental injuries to Ethan.  Parallel Proceedings 6. There has been a criminal investigation by Durham Police and following a criminal trial in 2019, both parents were found guilty of two counts of causing or allowing serious physical harm to a child.   The SCR: Process and Methodology  7. The Local Safeguarding Children’s Board (LSCB) agreed in November 2017 to commission an SCR. The scope of this SCR was to cover the period from May 2016 to February 2017 in the review. 8. The SCR Sub-Committee recommended that the LSCB should conduct a proportionate, appropriate and participative SCR with the emphasis upon professional involvement  to address how agencies had worked together in this case  to identify any learning and aggregate lessons from individual organisations and  to  ensure that an improvement action plan was put in place. 9. Working Together to Safeguard Children (2015) provides guidance for undertaking a Serious Case Review and sets out the purpose and requirements : To 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;  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. 10. The methodology adopted for this review was the Child Practice Review process (Protecting Children in Wales, Guidance for Arrangements for Multi-Agency Child Practice Reviews, Welsh Government, 2012). 11. This process facilitates the involvement of practitioners in the review so that they can reflect  5 | P a g e   together on the case and the learning from it in an informed and supportive way.  12. A Serious Case Review Panel was convened of senior representatives from local agencies involved with the family. This  group provided oversight of the review. None of the panel members had any direct professional involvement with the family. The panel supported the Lead Reviewer in considering the evidence and developing the recommendations. 13. There was limited agency involvement with the family and no specific safeguarding concerns raised prior to the non-accidental injury of Ethan. The following agencies were asked to provide a chronology or brief summary of involvement and these were integrated into a combined chronology.  Durham Constabulary   Primary Care   County Durham & Darlington NHS Foundation Trust   Harrogate & District NHS Foundation Trust   North East Ambulance Service NHS Foundation Trust   Durham Children & Young People’s Services   14. The Lead Reviewer was provided with the combined chronology and agency summaries of involvement so that she could consider in detail the sequence of events and identify any key practice episodes relating to those events. 15. The LSCB SCR Panel agreed the terms of reference for the SCR in addition to the terms of reference set out in national guidance. 16. The SCR panel also commented on the key lines of enquiry included in the terms of reference. The key lines of enquiry were: i. The pattern and frequency of visiting by the community midwives including postnatal review.   6 | P a g e   ii. Mother and Ethan’s discharge from the midwifery service including the robustness of the assessment prior to discharge. iii. The robustness of the handover between the Midwifery Service and Health Visiting Service. iv. The reason for the number of changes of key professionals during the scoping period and whether this had an impact on the quality of practice.  v. The response and actions following Ethan’s attendance at the GP Practice with a history of marks, specifically:   whether the appropriate policies and procedures were followed;   the liaison and information sharing with other key professionals;  whether the attendances were seen in isolation;  whether previous information pertaining to the family were taken into consideration.  vi. How effective and timely was the communication and information sharing between key professionals? vii. How Health professionals utilise the handheld baby record when reviewing Ethan’s health and development. viii. The response by professionals to mother’s reported low mood and whether they considered the impact on the children.  ix. There was a lack of information in respect of Ethan’s father.   17. The SCR has been carried out following a ‘whole system’ approach involving key front line practitioners who worked with the family in a Learning Event held in November 2018. Throughout the review process Ethan and his experience was the central focus of the review process and particularly in relation to the Learning Event.  Independence of The Review  18. The Lead Reviewer, Amy Weir, is an experienced independent safeguarding expert. She has completed more than 20 serious case reviews nationally over the past few years. Amy Weir wrote this report with the support of the LSCB Serious Case Review Panel.  7 | P a g e   Serious Case Review Panel  19. The SCR Panel met on a number of occasions between January and December 2018. The overview report was ratified at the Executive Group in May 2019. 20. The SCR Panel members were:  Title Organisation Independent Safeguarding Expert Chair & Reviewer Business Manager Durham LSCB Admin Co-ordinator Durham LSCB Detective Superintendent –  Force Lead for Safeguarding Durham Constabulary  Named Nurse Safeguarding Children & LAC North Durham, DDES CCGs Named Nurse Safeguarding Children County Durham & Darlington NHS Foundation Trust Named Nurse Safeguarding Children Harrogate & District NHS Foundation Trust Named Lead Professional for Safeguarding North East Ambulance Service NHS Trust Strategic Manager – One Point and Think Family Services  Children & Young People’s Services – Durham County Council Health & Wellbeing Operational Lead Education Durham  – Durham County Council   Confidentiality  21. Working Together to Safeguard Children 2015 sets out a requirement for the publication in full of the overview report from SCRs: “All reviews of cases meeting the SCR criteria should result in a report which is published and readily accessible on the LSCB’s website for a minimum of 12 months. Thereafter the report should be made available on request.” 22. When the report is published it will be fully anonymised to protect the identity of the family and the children.      8 | P a g e   Family involvement  23. The parents were made aware that a Serious Case Review was being undertaken and were invited to contribute. They had a meeting with the LSCB Business Manager in January 2018, and a note of the meeting was provided to the Lead Reviewer. 24. Given that there are other parallel proceedings in place – possible criminal proceedings and recent care proceedings - the Lead Reviewer has not been able to seek the views of parents regarding the services they received.  Staff involvement  25. The staff who were involved with Ethan and his family participated in a Practitioner Event in November 2018. The Learning Event was attended by twenty professionals in addition to the Lead Reviewer, who facilitated the event, and the LSCB Business Manager and the LSCB Admin Co-ordinator. The Learning Event was organised in line with Welsh Government guidance (Child Practice Reviews: Organising and Facilitating Learning Events, December 2012). Notes of the event were taken. 26. The discussion at the Learning Event and the points identified for further action were  collated and these were used to inform the Lead Reviewer’s analysis for the overview report.   Summary of Family history  27. The timescale for this review is limited to the period during the pregnancy with Ethan in May 2016 to February 2017 when it was identified that Ethan had incurred multiple fractures.  28. Within the review there was limited information ascertained about the wider family history. What has been gleaned from collating the information available is integrated within the body of this report.    9 | P a g e   SCR Key Lines of Enquiry: Analysis  29. This section sets out an analysis of key findings and associated recommendations that are designed to offer challenge and reflection for the LSCB and partners. 30. The key lines of enquiry for the SCR were explored through the process of the Learning Event and considered together with the details submitted in individual agency chronologies and brief summaries of involvement. 31. The analysis also draws upon relevant research and upon findings from other serious case reviews. 32. The Midwifery response to meeting Ethan and his mother’s needs. i. The pattern and frequency of visiting by the community midwives was explored to determine whether it was sufficient and in accordance with good practice given Ethan’s low birth weight.  The decision to discharge Ethan from hospital following his birth was based on him being fit for discharge which was discussed at Multi-Disciplinary meeting in the hospital. A meeting was held, and it was acknowledged that Ethan was small, however, it was agreed that he could be discharged.  This was communicated to the Community Midwife on the day of Ethan’s discharge and she arranged a home visit the following day.  On reflection at the Learning Event, it was agreed that the telephone notification to the Community Midwife was not appropriate in this case and there should have been a verbal handover given Ethan’s vulnerabilities; his birth weight was very low, and he was his mother’s third child in three and a half years. It is apparent from the midwifery records that there was a limited pattern of visiting Ethan by the midwives and one consultation took place by telephone. The Health Visiting and Midwifery Partnership – pregnancy and early weeks guidance for birth visit to 10-14 days – sets out the required activity for a midwife with the number of visits to be made linked to the specific circumstances.  In terms of learning there is a need for a greater emphasis on and clarity about how long Community  10 | P a g e   Midwifery provide care in the community during the postnatal period, particularly those with vulnerabilities. In this case there were particular vulnerabilities - Ethan was born at 37 weeks and was small and thin for his gestational dates and it is well-evidenced that caring for such babies can be very difficult for parents to cope with especially with other very young children in the household. ii. It appears that the midwifery service discharged mother and Ethan by telephone on Day 18 without challenging why mother had not attended the 13-day and 16-day postnatal review and without any verbal handover to the health visitor. It appears that mother had self-reported that she and Ethan were doing well, but there is no evidence that this was verified prior to discharge by the midwifery service. This was a delimited response which did not evidence any professional curiosity about why mother had not attended. The fact that no follow-up visit was completed meant that an opportunity to check on Ethan and his progress was missed. This led to the parents being the main source of information about Ethan’s weight, how he was feeding and what problems they were raising. Given Ethan’s small size and low weight, this lack of direct confirmation is of concern.  iii. There was a gap in Ethan being seen from Day 5 following birth to the home visit undertaken by the Midwife. Ethan was seen by the midwife at home on the third day and the fifth day after birth but not thereafter. There was no professional visit for this vulnerable baby for nine days. This seems a very limited response and not within guidelines. It is of note that father contacted 111 on two occasions in December which suggest that the parents were struggling more than they admitted when seen. iv. There was no record of a handover between the Midwife and Health Visitor.  There is no evidence that there was a discussion with the health visitor; this would have enabled consideration between them of Ethan’s small size and low birth weight, lack of engagement by mother and the parents’ caring responsibilities of two other young children at home.   Previous Serious Case Reviews in Durham have highlighted that some information including the  11 | P a g e   antenatal and postnatal risk assessment is not transferred to the child’s records when born and this information stays on the mother’s records which are only with the midwife and so not available for the health visitor to access directly. The postnatal handover report was not readily accessible to the Health Visitor and was only found during information gathering for this Serious Case Review. National guidance  recommends that by day 14 post birth, all women, particularly those with identified vulnerability or need, have received a joint handover/contact visit with their midwife and health visitor; it is recommended that this be a home visit. At discharge of vulnerable women and women who require midwifery input after day 14, the midwife and health visitor to have completed and recorded a verbal handover in addition to a written handover (NICE 37). Ethan was very low in weight and we know that mother and father were seeking advice about his feeding and oral thrush.  33. There are some questions to consider in relation to the Health Visiting Service. v. Would home visits have been more appropriate than clinic visits given Ethan’s low birth weight and Intrauterine Growth Retardation (IUGR)?  Suggesting to mother that she took Ethan to the clinic depended on her taking him. Prior to Ethan’s birth mother had attended all the required appointments but after his birth she missed several specific appointments, but this was not followed up thoroughly. Therefore, relying on clinic appointments for Ethan was risky and did not allow for more observation of the care Ethan was receiving. However, there were only two clinic appointments.  vi. There were several changes of key professionals during the scoping period and there is a need to consider the reasons for the changes of professionals and whether this had an impact on practice.  There were three different health visitors involved. It was apparent from the contributions made by practitioners attending the Learning Event that this happened for a variety of different reasons. Cover over the Christmas period did not seem to be an issue. One health  12 | P a g e   visitor change was requested by mother and this was accepted and a new health visitor was allocated. 34. GPs’ contact with Ethan. vii. There is a need to consider the history of marks on Ethan and the GP’s response to these.  Three different GPs saw Ethan during the review period. From information gathered at the Learning Event, the parents called the GP between Christmas and New Year December to ask for advice about a purple mark on Ethan and they were advised to bring him to see the GP. It appears that the GP who saw Ethan the day after the telephone call, noted a small red mark on the right side of his forehead which was 4mm and thought to be a spider-nevus and not a bruise.  There was also a small spider-nevus noted on his left shoulder.  As there was no apparent history of trauma, arrangements were made for this to be followed up four weeks’ later.  As the marks were not regarded as suspicious the Bruising to Non-Mobile Babies pathway was not followed. There is no indication that safeguarding was considered which, given Ethan’s young age and immobility, it should have been.   viii. Why was the marks seen on Ethan’s face not included within the letter to the Paediatrician for a review of Ethan’s growth following his 6 weeks’ check?  Ethan and both parents attended for the 6-8 week check and there were no concerns regarding the interaction between Ethan and both parents.  A mark on Ethan’s right check was noted as well as the previous attendance in December.  As the main issue was the drop in weight, Ethan was referred to Paediatrics for an urgent growth pattern.  On reflection, those at the Practitioner Event felt that the Bruising to Non-Mobile Babies pathway should have been initiated and the body map utilised. Mother reported to the Health Visitors on two occasions that Ethan appeared to mark easily, and these marks would come and go.  Mother told the Health Visitors that she had seen the GP about this.  The Health Visitors confirmed that they did not observe any marks during her contacts with Ethan.  The Health Visitor reviewed the GP records and noted that Ethan had already been seen and assessed and this was positive practice on checking events.  The GP referral letter to Paediatrics probably should have included reference to the marks presented to  13 | P a g e   the GP and discussed by mother with the Health visitors. Non-accidental injury in a non-mobile baby needs to be considered and not ruled out. None of these professionals involved with Ethan compared notes and spoke directly about what they were seeing and hearing and as a result the possibility of a focus on non-accidental injury was missed.   35. There are issues to consider about the quality and frequency of communication between the health professionals involved and Ethan and his family. ix. How effective was the communication between the Health Visitor, the GP and the Practice Nurse in sharing information about this bruising, Ethan’s weight and other contact with the practice about Ethan’s health? What is the protocol for this and what are the expectations? What, if any, contact did take place in relation to the bruising and Ethan’s weight? Overall, there was little evidence in the records of direct communication between these professionals. As far as the marks on Ethan’s body are concerned, this was perhaps an opportunity when information about this should have been shared.  According to the GP records, the Health Visitor completed a body map in mid- on 19th December which showed no mark on Ethan’s body. It was discussed at the Practice Learning Event that there is no consistent template for Health Visitors and GPs to use for body map recording and that this is an area of learning to ensure consistency.  It was shared at the Learning Event that families that are vulnerable or where there are safeguarding concerns are discussed at the GP Practice Safeguarding meetings which are attended by GPs, Health Visitors and Midwives.  In this case the family was not identified as vulnerable or having safeguarding concerns, therefore, they were not discussed at this meeting. This was a missed opportunity when in fact there were several vulnerabilities particularly Ethan’s low weight. Monitoring Ethan’s weight was not given sufficient focus through the use of shared centile charts to plot progress. The Paediatric discharge letter sent to the GP stated erroneously that Ethan had large birth weight when in fact it was low at 1910g – below the 0.4th centile.     14 | P a g e   x. Was communication between them through SystmOne effective and timely? The attendance and presentation for oral thrush needed to be explored. About which there was no communication between the GP Practice and Health Visitor when Ethan was prescribed medication for this. The lack of sharing of information and practice is concerning. Professionals were not directly sharing information with each other either. Whilst the health visitor and, prior to that the midwife, were in touch with family separately so too was the GP practice, three GPs and three Practice Nurses.  As far as electronic recording and sharing is concerned, the midwives do not use SystmOne postnatally and they document information in the child’s handheld record. GPs have two electronic systems – SystmOne and EMIS and only Community Health staff have access to SystmOne which causes problems in terms of information sharing. There was little evidence of professional curiosity around the oral thrush and its unusually persistent nature and little evidence of liaison between the Health Visitor, Midwife and GP about this issue and further advice on this issue needs to be considered. It is usual practice for Health Visitors to flag significant events as an electronic task to the GPs in order to maintain an audit trail of communication.  Regarding the issues regarding Ethan’s weight, on reflection the Health Visitor should have followed up the task to the GP by telephone to ensure that Ethan was seen in a timelier manner. The Practice Nurse identified oral thrush and worked with mother regarding this issue but there appears to be no contact with the Health Visitor about this. xi. Was the handheld baby record utilised during Health professionals’ contact with Ethan in monitoring Ethan’s weight given his low birth weight. It is the role of the community midwife to explain to parents the way the handheld baby records are to be used but there is no recorded evidence that this occurred. Dependence on these handheld records means that professionals have to rely on the parent to bring and share those records when the child is seen. It is not clear that this happened in Ethan’s case and in the absence of direct communication between professionals this was a further missed opportunity to share information between them. There  15 | P a g e   was no evidence that Health professionals were aware that mother had lost Ethan’s handheld baby records. On reflection, the Health Visitor felt that she should have observed Ethan taking a full feed and should not have taken mother’s information that he was feeding at face value. It is not required that feeding is observed but should this be reconsidered for babies of such low birth weight especially when he seemed to be making such limited progress. xii. The response by professionals to mother’s reported low mood and whether they considered the impact of the children  Mother reported feeling low in mood during several contacts but in the records, there is a lack of evidence that anyone, except the health visitor, had asked mother how she was coping with Ethan and the other two children and suggested action to support her.  The Health Visitor sent a task to the GP. The issues regarding mother’s low mood was discussed at the Learning Event and it was reported that this had been identified just prior to the identification of non-accidental injury to Ethan.   On reflection, it was agreed that the Health Visitor should have followed up the task to the GP by telephone, however, in this case it would not have made a difference to the outcome.  HV1 used the Edinburgh Postnatal depression scale with mother and she offered her listening visits.  Also at the Learning Event it was reflected that consideration should have been given to providing intervention in terms of mother’s low mood.   In terms of early help, universal services provided support to the family in terms of housing and Early Years provision. On reflection, it was felt that a more holistic approach was needed in this case. Issues such as the vulnerability of Ethan, the fact that parents had three children under the age of 5 years, and the number of house moves should have been considered. There is comparatively little mention of father in the records. However, he was present for almost all of the contacts between practitioners and mother. It was father who initiated two calls to 111. There is no description in the records of him and the focus is solely on mother and this is a significant gap in practice for understanding all those involved in Ethan’s life. On one occasion mother told the Health Visitor that she found it difficult to talk in front of father and the children about her own feelings and needs. There is no evidence that this cue was followed up.     16 | P a g e   Lessons Learned – Positives and gaps in practice  36. From the accounts of the professionals who attended the learning event that there were many positives in the practice with this family identified. i. At booking a vulnerability assessment was completed which was a tool used to identify vulnerabilities.  In this case it was felt that there were no vulnerabilities or additional needs identified. ii. Mother was encouraged by both Midwifery and Obstetrics to engage with Smoking Cessation, however, she still declined this. iii. The Health Visitor had reviewed the family’s previous Health Visitor’s records but on reflection she felt she could have also spoken with them as well. iv. An assessment of mother’s mental health using the Edinburgh tool was completed and mother was offered the Listening Service. Mother’s low mood was explored, and mother felt that as she had young children she found difficult to focus on herself but intended to see the GP about this.    v. The Practice Nurse identified oral thrush and worked with mother regarding this issue. vi. The Health Visitor and the GP identified Ethan’s continuing weight gain issues. The Health Visitor prompted the GP about this. The GP made an urgent routine referral to Paediatrics. vii. After the 999 call was made, there was an immediate safeguarding referral submitted and notification to the Police by the Ambulance Service. viii. The work of Emergency Department’s staff to address Ethan’s critical medical needs was prompt when he presented at hospital in February 2017.     17 | P a g e   Summary Analysis  37. The ante-natal booking process was thorough, but the midwife was not aware that mother had sought an early termination of this pregnancy. This was a system issue and a missed opportunity to explore this further, particularly the reason why she changed her mind. 38.  A multi-disciplinary discharge planning meeting should have been convened to consider all the factors, Ethan’s low birth weight and phototherapy and a plan put in place regarding visiting patterns.  Ethan would not have been discharged if he was not medically fit for discharge. 39. The level of postnatal visiting by the midwifery service to the home was lower than might have been expected given the child’s circumstances of low birth weight.  The postnatal contact should have taken place in the form of a home visit as opposed to a telephone call. 40. There was a lack of thorough and verbal communication between health professionals in terms of Ethan’s discharge from hospital and then from midwifery care to the health visitor. 41. This resulted in a single professional’s approach without appropriate sharing and checking out of information they each had. For example, Ethan’s weight could have been more effectively monitored through shared use of a centile chart so that every time he was seen the situation could be reviewed and updated. 42. The GPs approach to the contact with Ethan was from a medical and clinical point of view as opposed to a holistic assessment and each contact was seen in isolation.  43. There were many positive indicators that the parents were coping and managing Ethan’s care appropriately.  i. Ethan’s parents were already parents and there had been only one previous minor concern about the care of one of the other children. ii. The parents were in a long term relationship and father was the biological father of all three children. iii. Father’s interaction with Ethan was observed to be positive and there was no evidence of  18 | P a g e   maternal ambivalence between Ethan and his mother. iv. The parents engaged with agencies including Midwifery, Health Visiting and the GPs. v. There were no significant events identified during the Primary health visitor visit. Parents were present during Health Visiting visits and engaged well with the Health Visitor and a positive interaction was noted between Ethan and his parents. vi. Parents sought advice from services such as 111, GP, Practice Nurses and Health Visitor. vii. There were no issues regarding the presentation of the other children. viii. The family had local extended family support. 44. There were also some significant vulnerabilities for Ethan and the family and areas not fully explored with appropriate professional curiosity. Some of these were identified but others were not fully discussed or shared. i. All three children of the family were all born close together. ii. Mother had sought an early termination of this pregnancy iii. Ethan’s low birth weight. iv. Smoking in the household by both parents and by mothers during pregnancy increases the risk of respiratory illness in children under one years of age. v. Smoking during the pregnancy.  Mother was offered Smoking Cessation at various points during pregnancy and she declined this.   vi. Information about how Ethan was feeding, and his progress relied to a conservable degree on self-reporting by mother.   vii. Father was always present at home visits which resulted in little opportunity to explore with mother on her own if there were any issues she needed to discuss including any possible domestic abuse.  Mother stated that she felt inhibited to speak when the children’s father was present. viii. Generally, there was  a lack of consideration of father as all the focus was on mother.  19 | P a g e   45. Improvements have already been made to service delivery since Ethan was injured. i. The booking process was already improved at the point that Ethan was conceived due to learning from previous Serious Case Reviews. ii. Improvements have been made to the antenatal risk assessment in that relevant history is obtained in respect of both parents.  The risk assessment is more in depth in terms of the questioning to facilitate professional curiosity.  The risk assessment has also been revised to include the Home Environment Assessment Tool.  The antenatal risk assessment is scanned and shared with the Health Visiting Service. iii.Mother had sought an early termination of pregnancy and this was a systems issue and a missed opportunity to explore this further, particularly the reason why she changed her mind.  This is now part of the Health Needs Assessment in terms of whether the pregnancy was planned and the views of both mother and father regarding the pregnancy.  This is also now part of the antenatal risk assessment and this line of questioning takes place at booking. iv. CO monitoring is now offered to monitor the CO levels of both mother and father.  There are now interventions visually in terms of the effects of smoking during pregnancy on the placenta which was found to be extremely impactful. v. There is now a greater emphasis on perinatal mental health which is discussed as part of the postnatal risk assessment and this is an area of improved practice. vi. The Health Visiting Service now has a Vulnerable Parent Pathway. However, in this case the family would not have met the criteria as it only considers current and not historical vulnerabilities. vii. The Family Health Assessment Tool is now more in depth and includes the role of the father. viii. The template for the 8-week baby check has been revised and now includes more information around safeguarding and body maps.  20 | P a g e   ix. The Faltering Weight Policy was reviewed and revised by Harrogate & District NHS FT in light of the learning identified from this case. Multi Agency Recommendations for the DSCP  46. DSCP to seek assurance that the relaunch of the Bruising to Non-Mobile Babies Protocol has had an impact and that there is appropriate training in place to ensure that any marks to a non-mobile baby is referred to the Non-Mobile Baby Pathway with due regard to safeguarding, and the use of photographs should be considered when identifying any marks or bruises in non-mobile babies. 47. In terms of Early Help, the support they received focused on Housing issues and Early Years provision rather than support to mother’s and father’s parenting and well-being. A more holistic approach is needed. Advice to be provided to ensure that holistic needs and not just practical needs.  Actions for Single Agencies  48. The agencies involved in the review have each developed an individual agency action plan to deliver improvements identified. The delivery of the improvement plans will be monitored through the Serious Case Review Thematic Tool maintained by the LSCB Business Unit. Midwifery 49. The discharge of Ethan was not in line with the Infant Feeding Protocol and there should have been closer liaison with the Health Visitor, so these processes need to be reviewed and updated to ensure that they are effective. 50. The midwifery visiting regime needs to be audited and reviewed to ensure that it is addressing the needs of babies and families. 51. The quality and requirements of postnatal care should be reviewed, and staff reminded of these requirements. 52. The handover process between Midwifery Service and Health Visiting Service needs to be  21 | P a g e   reviewed and updated, if necessary, to ensure that it complies with national and local guidance. 53. Significant history, the Health Needs Assessment, antenatal and postnatal information in the mother’s midwifery notes should be transferred to the child’s records so that this information is readily accessible to health visitors. 54. The effectiveness of the use of handheld records needs to be considered and guidance provided about when direct communication and information sharing between professionals is required. 55. Much of this activity was during a holiday period with many different professionals being involved and there is a need provide guidance about the need to seek to provide professional continuity – GP, Health Visitor, Midwifery. 56. The Trust to consider adopting Harrogate & District NHS FT’s Faltering Weight Policy. Primary Care - Health Visiting and GPs 57. Communication and information sharing needs to be improved in terms of liaison around the care of young infants particularly between the GP and Health Visitor but also considering the contact with Practice Nurses.   58. The effectiveness of the use of handheld records needs to be considered and guidance provided about when direct communication and information sharing between professionals is required. 59. Standardisation of documentation and the use of templates such as body maps should be considered to ensure consistency between Health professionals, e.g. GP and Health Visitor. The shared use of centile charts by Health Visitors and GPs should be considered in case of low birth weight babies.   60. GPs need to document who was present or spoken to in consultation with clarity about when  22 | P a g e   these were by telephone and when in person with the child being seen. 61. GPs should be made aware of their safeguarding responsibilities and ensure the Bruising in non-mobile children policy is embedded within their practices     23 | P a g e    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  Brandon M, 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 – 2015  Department of Health – Public Health England – Health Visiting Programme: Pathway to support professional practice and deliver new service offer: Health visiting and midwifery partnership – pregnancy and early weeks.  Durham LSCB – Bruising in Children Pathway - adapted with permission from Hampshire LSCB Updated 25/10/13 Final version     24 | P a g e   NICE Postnatal care up to 8 weeks after birth: Clinical guideline [CG37] Published date: July 2006   NSPCC 2011 - All Babies Count  NSPCC Learning from SCRs 2018  NSPCC Learning from case review briefings - Summary of risk factors and learning for improved  practice around working with children aged two and under - November 2017  Welsh Government – Protecting Children in Wales – Guidance for Arrangements for Multi-Agency Child Practice Reviews (2012)   