Death of a young boy as a result of injuries sustained as a consequence of his mother's actions. Mother arrested and charged with Child K's murder; she pleaded guilty to manslaughter on the grounds of diminished responsibility. Psychiatrists concluded that she was suffering from an acute mental disorder at the time of the incident. Father was a registered sex offender following conviction at age 16 and was subject to an indefinite Sexual Offences Prevention Order. Child K was subject to a Child Protection Plan when a few months old and his sister from birth due to risk of sexual abuse and neglect. Ethnicity or nationality of Child K is not stated. Learning: a more thorough assessment of mother's background would have identified high risk factors including a family history of mental illness and childhood abuse; no-one knew the mother used illegal drugs and parents were not challenged regarding their lack of engagement with the drug project; the risk the father posed to his child was not assessed by the time Child K was born; concerns about the family were not discussed at the multi-disciplinary team meetings held at the GP practice; parents were often not present for planned visits. Recommendations: practitioners must be provided with appropriate knowledge and skills to identify those at risk of developing mental health problems; relevant learning is disseminated to organisations, such as faith establishments, that are likely to encounter people at times of crisis; provide information to be used by GPs when referring women for terminations.
      
    Serious Case Review No: 2019/C7893   Published by the NSPCC On behalf of an unnamed local safeguarding children board      This report was written by an independent author and is owned by the commissioning LSCB.  This report is published by the NSPCC with the agreement of the National Panel of Independent Experts.  Publication of this report by the NSPCC does not constitute endorsement of the contents. Copyright of this report remains with the commissioning LSCB.     Unnamed Safeguarding Children Board  Serious Case Review concerning Child K  Overview Report   January 2019  Serious Case Review concerning Child K; Overview Report     Page 1 of 38  Table of Contents    Page 1. The child and the circumstances leading to decision to carry out a Serious Case Review  2 2. The Review Process  2 3. The Facts - Summary of Agency Involvement  4 4. Analysis  12 5. Previous Serious Case Reviews    27 6. Learning from the Review 27  7.  Action Taken by Agencies Since the Events Considered in this Serious Case Review  30 8. Recommendations  31     Appendices Appendix 1 – Key Lines of Enquiry Appendix 2 – Recommendations from Agency Reports   Serious Case Review concerning Child K; Overview Report     Page 2 of 38  1.  The child and the circumstances leading to the decision to carry out a Serious Case Review  1.1 Child K died as a result of the injuries sustained as a consequence of his mother’s actions.  His mother was arrested and charged with Child K’s murder.  She subsequently pleaded guilty to manslaughter on the grounds of diminished responsibility.  Psychiatrists concluded that she was likely to have been suffering from an acute mental disorder at the time of the incident and she was given an indefinite hospital order by the Court.   1.2 Child K was the first child of his parents and spent the whole of his short life living with them both.  His mother was 21 years of age at the time of Child K’s birth and his father was 19.  Child K had a younger  sister . Prior to Child K’s birth, the family was referred to Children’s Social Care due to concerns relating to his father’s history.  Child K was made subject to a Child Protection Plan when he was a number of months old and his sister was made subject to one at birth.  Both children remained subject to these plans at the time of Child K’s death. 2. The Review Process  2.1 Chapter 4 of Working Together to Safeguard Children 2015, states that Serious Case Reviews and other case reviews should be conducted in a way which: ➢ Recognises the complex circumstances in which professionals work together to safeguard children.   ➢ Seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did.  ➢ Seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight.  ➢ Is transparent about the way data is collected and analysed.  ➢ Makes use of relevant research and case evidence to inform the findings.  2.2 In order to meet these requirements this Serious Case Review has been undertaken using a ‘systems approach’1, as recommended by Munro (2011) and authorised within Chapter 4 of Working Together to Safeguard Children 2015.  2.3 A Serious Case Review Panel with the following membership was established to oversee the review: • Independent Lead Reviewer & Overview Report Author • Director of Improvement – Action For Children • Head of Safeguarding - District Care Foundation Trust • Named Nurse –Teaching Hospitals Foundation Trust • Early Years Manager - Children’s Services, Local Council                                             1 The systems approach “focuses on a deeper understanding of why professionals have acted in the way they have, so that any resulting changes are grounded in practice realities” (Munro, 2011).  It “looks for causal explanations of error in all parts of the system not just within individuals” (Munro, 2005). Serious Case Review concerning Child K; Overview Report     Page 3 of 38  • Head of Service, Social Work – Children’s Services, Local Council • Designated Doctor – Clinical Commissioning Group • Deputy Designated Nurse - Clinical Commissioning Group • Neighbourhood Director – Local Housing Provider • Deputy Team Leader Social Care - Legal Services, Local Council • Head of NIPS – National Probation Service • DCI Safeguarding –Police • Board Manager Safeguarding Children’s Board • Named Professional for Safeguarding Adults,   • Local Ambulance Service NHS Trust  2.4 The Review Panel decided that the review should consider a period from when the mother first attended an antenatal appointment to the day when Child K died.  Agencies which had been involved with the family between these dates were asked to provide chronologies and brief reports of their involvement including relevant background information which pre-dated this time period.  In analysing their involvement the agencies were asked to consider 16 key lines of enquiry agreed by the Lead Reviewer and Serious Case Review Panel (appendix 1).  The key learning from these reports has been used to inform this Overview Report.  2.5 Reports were provided by the following agencies: • Action For Children • District Care NHS Foundation Trust  • Teaching Hospitals NHS Foundation Trust • Children’s Social Care, Local Council • Children’s Social Care, Local Council – Independent Review Team  • General Practice • Local Housing Provider • Legal Services, Local Council • Police • Ambulance Service NHS Trust   2.6 Chapter 4, paragraph 10 of Working Together to Safeguard Children 2015 lists seven “principles for learning and improvement” that should be applied to all reviews.  One of these is that “professionals must be involved fully in reviews and invited to contribute their perspectives without fear of being blamed for actions they took in good faith”.  In carrying out this review the Lead Reviewer held a ‘Learning Event’ to which front staff and their managers were invited.  This helped the Lead Reviewer to gain a greater understanding of the context in which practitioners worked with the family and the reasons for the decisions they made and the actions they took.  This in turn has assisted with drawing out relevant learning and recommendations for action and as such has been an important part of the systems approach that has been used.   Serious Case Review concerning Child K; Overview Report     Page 4 of 38  2.7 Another principle is that “families, including surviving children, should be invited to contribute to reviews. They should understand how they are going to be involved and their expectations should be managed appropriately and sensitively”.   The Safeguarding Children Board Manager met with the father to make him aware of the Serious Case Review and to invite him to meet with the Lead Reviewer so that he could contribute to the review.  However, the father decided that he did not want to contribute in any way.  The Designated Doctor for the CCG, who is also the Chair of the Serious Case Review Sub-Group spoke to the Consultant Forensic Psychiatrist in the secure hospital with a view to discussing how the mother could contribute to the review.  However, it was the view of the psychiatrist that the mother’s mental health was not strong enough for her to contribute.  The Lead Reviewer and Safeguarding Children Board Manager did meet with the maternal grandmother, who had been present in the property when Child K had died.  2.8 Police provided the Lead Reviewer with the Serious Case Review with information gathered during the criminal investigation about contact the family had with a local church in the weeks prior to Child K’s death.  As part of this Serious Case Review, the Lead Reviewer met with two the Interim Safeguarding Lead/0-30 Pastor and the Community Outreach Pastor from the church to discuss this further.  Relevant learning is included within this report.    2.9 The Lead Reviewer has also been given access to a final psychiatric report and two addendum reports written following an assessment undertaken by a consultant forensic psychiatrist on the instructions of relevant police force.  Relevant findings from this assessment are included within this Overview Report.   3. The Facts - Summary of Agency Involvement   3.1 This section of the report provides a factual summary of key areas of agency involvement with the family.  It is not a comprehensive record of all contacts with the family but focuses on those episodes that are considered to be significant to the way the case developed.    3.2 Key Practice Issue 1 - Supervision of Sexual Offences Prevention Order  3.2.1 Three years prior to the death of Child K, the father was convicted  of a sexual offence against a twelve year old girl committed the previous year when the father was 16 years of age.  He was sentenced to a Youth Rehabilitation Order with a supervision requirement.  He was also made subject of an indefinite Sexual Offences Prevention Order (SOPO) and as such has been required to comply with the provisions of the sex offender register since that date. This has entailed unannounced visits from police public protection officers (PPO) and regular Sex Offender Register Reviews. During the period covered by this Serious Case Review, these reviews were undertaken in February, July, August and November xxxx and March, June and September xxxx.  Two PPOs were involved in undertaking these visits and reviews. Serious Case Review concerning Child K; Overview Report     Page 5 of 38   3.2.2 The father’s PPO first became aware of his relationship with the mother when carrying out a Sex Offender Register Review.  The mother was present during the visit and the PPO made her aware that the father was subject to a SOPO.  3.3 Key Practice Issue 2 - Antenatal and postnatal health care in relation to Child K  3.3.1 Child K’s mother accompanied her sister to an ante-natal appointment with a specialist midwife.  During this appointment Child K’s mother informed the midwife that she herself was pregnant.  Later that month, she attended a booking appointment with a midwife and was found to be approximately 19 weeks pregnant.  She named the father but he was not present at the appointment.  The midwife was not aware that the father was subject to a Sexual Offences Prevention Order and could only have been aware of this, at that time, if the mother had shared the information.  3.3.2 The mother attended for a scan the following month but did not then engage with Maternity Services for three months when she attended an antenatal appointment.  During the three month period between the scan and the antenatal appointment she was sent a midwifery appointment three times but did not attend and was not present on four occasions when the midwife tried to undertake a home visit.  Three more antenatal appointments were arranged by the midwife and the mother did not attend any of these, although on the second date the midwife managed to contact her and she attended later that day.  On the final occasion, the father attended and said that the mother had not done so because she was having pain. This was four days before Child K was born.  No particular health concerns arose during the pregnancy    3.3.3 During the same period health visitors tried three times to undertake an antenatal core appointment.  They was unable to gain access on the first two occasions but managed to do so on the third.  3.3.4 Child K was born in hospital and discharged home the following day.  Community midwives carried out four postnatal home visits to Child K and his mother and he was taken to two clinic appointments.  3.3.5 Child K was taken on schedule for his 8 week baby check and for his first and second set of primary immunisations. He was never taken for a third set of primary immunisations because by that time his mother refused them for fear of them causing harm.  3.3.6 The health visitor completed a birth visit at which both parents were present.  She made two unsuccessful attempts to undertake a follow up visit and on the second occasion saw the father who she found to be confrontational.  The health visitor carried out a joint visit with the community resource worker  in May and further visits in July and August.  From late September to early November the health visitor made Serious Case Review concerning Child K; Overview Report     Page 6 of 38  three unsuccessful attempts to visit the family and two attempts to contact them by phone.    3.3.7 In November the health visitor visited and assessed the mother’s maternal mood which showed high anxiety. At this point the mother disclosed a history of anxiety from a young age and that she had been prescribed antidepressants by the GP but had run out of medication. The father did not engage much with the visit until the health visitor discussed Child K’s nutrition, when he interrupted her and asked what was wrong with his current diet.   3.3.8 Early the following year the health visitor undertook a developmental assessment for Child K and at this visit Mum stated she was pregnant, but did not know how many weeks.    3.4 Key Practice Issue 3 - Antenatal and postnatal health care in relation to Child K’s Sister  3.4.1 The mother saw a GP with a late period and symptoms of pregnancy, the GP asked her to undertake a home pregnancy test and return if positive.  The mother did not return but six weeks later, the mother told the health visitor she was pregnant.  The following day the health visitor asked the GP to do a pregnancy test; this was positive and an examination suggested that the mother was approximately 20 weeks pregnant.  Over a month later, the mother attended a midwifery booking appointment having failed to attend twice.  Five days later she had a scan and was found to be 37 weeks pregnant.  A female child was born at full term and discharged home with her mother two days later.  They were discharged from midwifery care when the baby was two weeks old.  3.4.2 The baby did not have an 8 week baby check and her only contact with a GP during Child K’s lifetime was when she was four months old.  She was not taken to three booked GP appointments prior to this and missed an appointment with a Nurse Practitioner the week before Child K’s death. By the time of Child K’s death had not yet received any childhood immunisations.  3.4.3 Following the birth of Child K’s sister the health visitor visited approximately monthly although on occasion there was no reply when she visited the home and she had to rearrange the visit.  The health visitor also undertook assessments of the mother’s maternal mood and postnatal attachment.   3.5 Key Practice Issue 4 - Family Support and Child Protection   3.5.1 Within two weeks of the mother attending the maternity booking appointment for her pregnancy with Child K, Children’s Social Care, the Police and the midwife were all aware that she was pregnant and that the father was a registered sex offender.  As a Serious Case Review concerning Child K; Overview Report     Page 7 of 38  result of becoming aware of this information, Children’s Social Care referred to Legal Services for a Legal Gateway Meeting at which it was agreed that the threshold for Public Law Outline (PLO) was met and that a pre-birth assessment should be undertaken.  The Social Work Team referred the family to a Family Centre for pre-birth work to form part of the assessment.  A community resource worker was allocated to undertake this work and carried out the first visit nearly three months later.  3.5.2 The PLO meeting was held following the Legal Gateway Meeting and a review meeting was arranged for three months later with the intention that the pre-birth assessment would be completed by that date, In the event, the PLO review did not take place and the pre-birth assessment was not completed until three days after Child K was born.    3.5.3 One month after the cancelled PLO review meeting and just two days before Child K was born, a strategy meeting was held at the Multi-agency Safeguarding Hub (MASH).  A decision was taken to progress to an Initial Child Protection Conference but this did not take place.    3.5.4 Maternity staff at the hospital informed Children’s Social Care of Child K’s birth and were told that he could be discharged with his mother as she would be supervising his contact with his father.  Two days later a telephone discussion took place between Police and Children’s Social Care regarding whether the father could continue to live in the family home.  Following a home visit Children’s Social Care decided that the father could remain there but could not have unsupervised contact with Child K.  The parents agreed that the mother would supervise all contact.  3.5.5 Three months later another strategy meeting was held and a decision reached again that the case would be taken to Initial Child Protection Conference.  The subsequent Conference was held the following month and it was agreed that Child K would be subject to a Child Protection Plan due to the risk of sexual abuse but with neglect also highlighted.  A risk assessment relating to the father was finalised when Child K was 7 months old and determined that he should not have unsupervised contact with Child K.  A contract of expectations remained in place which required the mother to supervise all contact between Child K and his father.    3.5.6 Prior to the birth of Child K’s sister, an Initial Child Protection Conference was held in respect of the unborn baby and a Review Child Protection Conference in respect of Child K.  It was agreed that both children would be subject to Child Protection Plans due to being at risk of sexual abuse with neglect also a concern.  10 days later Child K’s sister was born and the following day the social worker advised Midwifery staff that when the baby was ready to be discharged she could go to the family home with her mother.  Following the Child Protection Conference, the social worker referred the family to the local children’s centre which was managed and run by Action for Children.  The family was invited to attend groups at the children’s centre and a family support worker was allocated to work with them. Serious Case Review concerning Child K; Overview Report     Page 8 of 38   3.5.7 Two months later, the social worker commenced another risk assessment of the father.  The father missed two assessment sessions but attended rearranged sessions and a number of months later it was agreed that he could have unsupervised contact with the children.  3.5.8 Both children remained subject to Child Protection Plans at the time of Child K’s death although the social worker had told the mother just four days previously that they were considering recommending that the case be stepped down to Child in Need.  3.6 Key Practice Issue 5 - Anxiety and depression reported by the mother  3.6.1 A year before the death of Child K, the mother presented at the GP practice with low mood and disclosed physical abuse as a child.  She denied thoughts of deliberate self harm or suicide and said that she did not want to undergo counselling.   GP5 prescribed 21 days of antidepressant and asked the mother to come back for review in three weeks.    3.6.2 In total the mother received three prescriptions for the antidepressant, totalling 81 days’ supply.  The GP tried to arrange an appointment to review the medication after the second prescription was issued but the mother did not respond to these attempts.  The third prescription was issued when the mother requested this when attending an appointment with Child K.  She told GP5 that she had found the medication to be helpful and that she was not crying or feeling as low as she had been.  3.6.3 In between the second and third prescriptions, the mother’s mental health was discussed at a Review Child Protection Conference and one action from the Conference was for health visitor 2 to assess the mother’s maternal mood on the next visit to identify any low mood.  Health visitor 2 did this using GAD-72 and PHQ-93 screening tools and the scores were indicative of high anxiety.  The mother disclosed history of anxiety from a young age and said that she had been prescribed anti-depressants by the GP but had run out of medication.  Health visitor 2 discussed a referral to Improving Access to Psychological Therapies (IAPT) but the mother                                             2 GAD-7 is a screening tool and severity measure for General Anxiety Disorder.  It involves the patient answering seven questions relating to anxiety over the previous two weeks with each having the answers ‘not at all’, ‘several days’, ‘more than half the days’ and ‘nearly every day’.  These answers elicit scores of 0, 1, 2 and 3 respectively and the scores are aggregated to give an overall score.  Scores of 5, 10 and 15 are taken as the start points for mild, moderate and severe anxiety. Source: https://patient.info/doctor/generalised-anxiety-disorder-assessment-gad-7 accessed 24 August 2018.  3 PHQ-9 is a Patient Health Questionnaire used to monitor the severity of depression and response to treatment.  It involves the patient answering nine questions with each having the answers ‘not at all’, ‘several days’, ‘more than half the days’ and ‘nearly every day’.  These answers elicit scores of 0, 1, 2 and 3 respectively and the scores are aggregated to give an overall score.  Scores of 5, 10, 15 and 20 are taken as the start points for mild, moderate, moderately severe and severe depression.  Source: https://patient.info/doctor/patient-health-questionnaire-phq-9 accessed 24 August 2018.  Serious Case Review concerning Child K; Overview Report     Page 9 of 38  declined saying that she did not like to talk about her feelings but was happy to continue to talk to health visitor 2.  3.6.4 The next reference to the mother’s mental health was during a Midwifery booking appointment 4½ months later.  During the appointment the mother said she had been involved with mental health services and had been taking Fluoxetine for five months but had stopped taking it two to three months previously.  The midwife asked the questions within the NICE guidance on mental health in pregnancy and the mother answered no to all of these and said that she did not want any support.    3.6.5 When Child K’s sister was nearly five weeks old, health visitor 3 carried out a home visit when the whole family and the maternal grandmother were present.  The maternal grandmother reported that the mother had been feeling low and encouraged her to tell the health visitor about this.  The mother said that she sometimes woke up feeling low and seemed to think her feelings were related to the housing situation and not being able to let the children out or look out of the window.  Health visitor 3 encouraged her to apply for a house with a garden, and the maternal grandmother agreed and suggested that the family would be better living nearer her as they would have more support.    3.6.6 A Core Group meeting took place when Child K’s sister was 6 weeks old where reference was made to the mother feeling low and an agreement that professionals and the father would monitor this.  Two weeks later health visitor 3 carried out a further home visit and assessed the mother’s mental health using GAD-7 and PHQ-9 screening tools gaining scores of 1 and 4 respectively.  These scores are within the normal range and the mother described herself as okay.    3.6.7 Over a month later, the mother again told health visitor 3 that she felt low when she woke up but she attributed this to her housing situation and said that she felt better when she got up.  The health visitor completed the maternal post natal attachment scale which did not highlight any concerns.  The next visit by health visitor 3 was the following month and the record does not include any reference to the mother’s mental health.  The record does show that the mother was still unhappy with her housing situation and wanted to move.  3.7 Key Practice Issue 6 - Termination of pregnancy   3.7.1 The mother underwent a termination of pregnancy the month before Child K died.  She had previously failed to attend two appointments at the clinic having been referred by her GP.  None of the other practitioners working with the family knew about this pregnancy or the termination until after Child K had been killed.  3.8 Key Practice Issue 7 - The mother’s mental health during the last five weeks of Child K’s life.  Serious Case Review concerning Child K; Overview Report     Page 10 of 38  3.8.1 Week One: mother phoned a church and spoke to a member of staff for between 30 and 40 minutes.  During the homicide investigation the staff member provided an account of this contact to the police.    3.8.2 At the beginning of the phone conversation the staff member considered the mother to be very distressed, confused and struggling to get her words out.  As the conversation progressed the mother calmed down a little and started to discuss her brother.  She said that he had been ill for a long time with what the doctors had said was a mental health issue but she thought he had been possessed by a demon.  The mother said that her family and partner thought she was crazy but she knew something bad was happening and she needed to stop it but did not know what to do.  The staff member asked a number of questions such as whether the mother had a social worker or if she had been diagnosed with any physical or mental health conditions.  The staff member did not know whether the mother had any children and no mention was made of this during the telephone call.  The staff member and mother arranged to meet the following Sunday at the church.  3.8.3 Five minutes after the call was ended, the father phoned the staff member and said that he did not understand and did not know what was happening.  An hour or so later the father came into the church and asked to speak with a pastor.  He was told that this was not possible, that Sunday had been arranged and that was all that they could do.  He said this was fine and left.     3.8.4 The staff member was unwell on the following Sunday and unable to keep the appointment.  The staff member sent a text message to the mother and offered to meet during the week instead.  No response was received to the text message and no further contact was received from either parent.    3.8.5 The day after the mother had phoned the church social worker 5 carried out a home visit and saw all the family members.  The record makes reference to the property not being as tidy as it had been recently with clutter around the living room but good conditions in the rest of the property.  The parents said that Child K had just made the mess.  The record gives no indication that there was any concern regarding the mother’s mental health and there is no reference to her having contacted the church the previous day.  3.8.6 Week Two: the health visitor visited the home and the mother spoke about finding comfort in reading the Bible and that her faith in God had been renewed. She referred to being hurt by her sister’s boyfriend when she was 2-3 years old and described physical symptoms of dizziness, chest pains and difficulty catching her breath.  The health visitor did not have any particular concerns about the mother’s mental health during this visit but advised her to see the GP regarding her physical health symptoms.  Serious Case Review concerning Child K; Overview Report     Page 11 of 38  3.8.7 The following day, a Core Group meeting was held which was attended by the social worker, health visitor and the father.  There is no indication in the record as to why the mother did not attend and no reference to any concern about her mental health or behaviour.    3.8.8 Week Five, the social worker undertook a home visit and saw the whole family.  The parents told the social worker that they were planning to marry. This was considered by the social worker to be a generally positive meeting.  The social worker said that if progress against the child protection plan continued they would recommend that the case stepped down from Child Protection to Child In Need.  The social worker recorded that the home conditions appeared good and the children well cared for.     3.8.9 Two days before Child K’s death, the family visited a different church to the one the mother had phoned the previous month.  The parents told someone who was working at the church that they wanted the children to be baptised.  They were spoken to in an office and their details were taken.  They were told that the relevant person from the church would be in touch.  The parents were observed to be calm, smiling, happy and grateful and the children to be happy, smiling and well behaved.  3.8.10 During the homicide investigation the father, maternal grandmother and maternal aunt provided information about the mother’s behaviour changing in the four weeks or so leading up to Child K’s death.  This included her talking about God and the Devil and stating that the Devil was inside her brother, who had long standing mental ill health and had recently been detained in a mental health setting.  The brother had spoken with the mother about religion and God in what was described as an obsessional and irrational way and had provided her with religious literature.  None of this information was shared with any of the agencies working with the family prior Child K’s death and professionals who met with the mother during the last few weeks of Child K’s life did not identify any changes in her behaviour.  The maternal grandmother was present in the property when Child K was killed.  She subsequently told the Lead Reviewer that she had not seen the mother much for a few weeks prior to this day but on arriving at the property she noted that conditions had deteriorated in respect of cleanliness and tidiness.  She also noted that the mother was not properly dressed and was behaving strangely, running around the property and talking about the wind.  3.8.11 The maternal grandmother also told the Lead Reviewer that, after Child K died, the father told her that the mother had been behaving strangely for a period of time.  He cited her standing outside at 3:00 a.m. staring at the sky and an occasion when she had attempted to walk in front of a car with a pram.  The maternal grandmother told the Police that the father had made her aware of concerns about the mother’s behaviour approximately three weeks before Child K’s death, and the maternal aunt had done so the following week.  4. Analysis   Serious Case Review concerning Child K; Overview Report     Page 12 of 38  This section contains an analysis of aspects of this case by considering the key themes to emerge.    Theme 1 – Mother’s Mental Health: what was known, how it was assessed and the action taken as a result.  4.1.1 Psychiatrists have concluded that Child K’s mother was suffering from an acute mental disorder when she killed her son.  From the information provided to this review and to the criminal investigation by a church and family members, it appears that during the last few weeks of Child K’s life there were occasions when his mother was distressed and/or exhibited unusual behaviour.  This information was not shared with any of the professionals working with the family and none of the professionals who visited the family home ever had any concern, from their own observations, that the mother was experiencing significant mental health problems or that she might represent a risk to her children.  She was seen by a social worker one day after she had spoken to the church worker and again four days before she killed Child K.  She was also seen by a health visitor nine days after she had spoken to the church worker.  Both the health visitor and the social worker had met with the mother on a number of occasions prior to these visits so they were familiar with how she usually presented.  Neither had any concerns about her mental health during these visits; indeed they found both parents to be in a good frame of mind, talking positively about the future.  It is evident from how the mother presented during these visits, and the observations in the second church, two days before Child K was killed, that the mother was not in a state of constant mental distress during the final weeks of Child K’s life.  Equally it seems highly likely that she suffered mental distress on more than one occasion during this period.  4.1.2 The GP appointment referenced in 3.6 was the first time within the period covered by this review, that the mother had disclosed anxiety and depression to anyone from any of the agencies involved.  Anxiety and depression screening carried out by both Maternity and Health Visiting Services during her pregnancy with Child K and following his birth had not indicated any concern.      4.1.3 There were a number of missed opportunities during the GP consultation in referenced in 3.6.   It is reasonable to expect a GP, when assessing and treating depression in an adult, to establish whether they have parenting responsibilities and how their depression impacts on their ability to discharge those responsibilities.  However, there is no documentation regarding the impact of the mother’s depression on her ability to parent which suggests that this was not assessed.    4.1.4 Furthermore, at the time of the appointment the notes suggest that the GP did not recognise the mother’s presentation as being postnatal depression. The risk factors for antenatal depression are broadly social vulnerability, childhood abuse, domestic abuse and a previous history of depression.  Risk factors for postnatal depression are antenatal depression or previous depression.  Bereavement by miscarriage, stillbirth or neonatal death is also more likely to lead to mental health problems in both parents.   Serious Case Review concerning Child K; Overview Report     Page 13 of 38  NICE guideline CG192, published December 2014 states that for suspected mental health problems in pregnancy or the postnatal period, women should have a comprehensive mental health assessment to support accurate diagnosis and ensure early appropriate treatment. In this case, the GP enquired about suicidal thoughts but overall there was not a comprehensive assessment of risk.    4.1.5 The likely impact of what was believed to be depression, on the mother’s family was not assessed and it appears that the GP did not have an understanding of her home situation.  Had this been explored it would have become apparent that she had a young child to care for. There were at this point multiple entries in the child safeguarding node in the mother’s record which should have been visible to the GP unless they had not been granted access rights to view the template. This is a risk for locum GPs, as each Practice they work in must separately grant them the rights to view safeguarding information.  With the exception of one part time salaried GP, all of the GPs in the Practice with which the family was registered are locums.  It is not known whether the locum GP was able to view the relevant safeguarding records during this consultation.   4.1.6 Routine enquiry about drug and alcohol use should take place at every consultation with a mental health focus.  However, there is no documentation regarding the mother’s drug or alcohol use.  4.1.7 Child K’s mother’s attendance was not communicated from the GP to health visitors or Children’s Social Care. No measures were put in place to keep her and her family safe with regards to her mental illness.  Better communication between agencies at this stage could have raised awareness of the mother’s vulnerability and enabled a plan of support to be agreed.  4.1.8 Notwithstanding the absence of communication from the GP concerning the mother’s presentation, agencies became aware of it when the mother told the community resource worker that she had run out of her anti-depressant tablets.  This resulted in the health visitor undertaking an assessment eight weeks after the mother had seen the GP.   If the health visitor had been told by the GP about the mother’s presentation the health visitor may have undertaken the home visit sooner.  Although the mother did not want to be referred to Improving Access to Psychological Therapies she did talk about her feelings and the health visitor’s view was that they had a positive discussion and the mother had engaged with this.    4.1.9 Once agencies were aware of the mother’s attendance at the GP her maternal mood was assessed periodically by the health visitor.  These assessments indicated varying levels of anxiety and depression but did not raise significant concerns.  The mother did not receive any medication after November xxxx and refused all offers of talking therapies.  The mother herself identified her property housing situation as being a significant factor affecting her mood although she also told the GP and midwife about abuse she had suffered as a young child. Serious Case Review concerning Child K; Overview Report     Page 14 of 38   4.1.10 Although the mother’s apparent anxiety and depression was discussed at Core Group meetings it did not feature in social work assessments.  Therefore it appears that the possible impact on the care of the children was not appropriately assessed.  This is a significant omission and is of particular significance in this case where the mother was expected to supervise all of the father’s contacts with his children.   4.1.11 The mother was already pregnant with Child K’s sister by the time of the GP appointment in referenced in 3.6.  However, the GP did not know about the pregnancy and therefore could not factor it into any assessment of the situation.  It is not known whether the mother suspected she was pregnant at that time.  When she presented to GP12, referenced in 3.4.1 with a history suggestive of being several months pregnant, GP12 did not demonstrate awareness that the mother already had a young child on a Child Protection Plan and had recently been taking an antidepressant.  This suggests a lack of professional curiosity in not establishing the psychosocial situation.  The situation warranted a degree of urgency in confirming the pregnancy, as this would require urgent referral for antenatal care as well as a referral to children’s social care for a pre-birth assessment.  Mother’s last prescription for a 28 day supply of antidepressant had been issued 10 weeks previously.  There is no evidence that the risk of psychological deterioration from an abrupt discontinuation of an antidepressant in pregnancy was considered by the GP.  4.1.12 The maternity booking appointment took place when the mother was over 36 weeks pregnant.  At this appointment the mother herself told the midwife that she had been involved with mental health services but had stopped taking anti-depressants two to three months previously.  Screening questions indicated that she was not depressed at that time and the mother said she did not want support with her mental health.  4.1.13 Although professionals believed that the mother was experiencing anxiety and depression it appears that no-one considered whether she might go on to develop an acute mental health disorder.  This review has identified historical issues that suggest the mother was at risk of mental ill health.  Firstly, there is a history of mental health problems in the mother’s family which suggests there might be a genetic predisposition to mental ill health.  Secondly, historical Children’s Social Care files show that both parents had experienced parental conflict, domestic violence and neglect in their childhoods.  The mother was subject to a child protection plan under the category of emotional abuse when she was five years old and there were concerns when she was around 15 years old about her becoming involved with child sexual exploitation.    4.1.14 The psychiatrist who assessed the mother on the instructions of the Police believed that the symptoms she exhibited were consistent with paranoid schizophrenia.  The psychiatrist further believed that when the mother presented at the GP some months Serious Case Review concerning Child K; Overview Report     Page 15 of 38  after Child K’s birth, the symptoms she described were most likely due to a prodromal4 phase of schizophrenia rather than anxiety and depression.  The mother described to the psychiatrist considerable drug use from 17 years of age, including cocaine, cannabis and amphetamines.  She also told the psychiatrist that she continued with frequent use of cannabis and occasional use of amphetamines throughout both pregnancies and that she had used amphetamines on the day she killed Child K.  The psychiatrist believed it likely that the paranoid schizophrenia was exacerbated by drug use.  Toxicology tests were not undertaken when the mother was arrested but she did test positive for cannabis and amphetamine after she was charged.  Agencies’ knowledge of and response to parental drug use is considered in Section 4.2 of this report.  4.1.15 The psychiatrist also believed that the termination of pregnancy was a significant stressor for her and a significant factor in exacerbating her underlying condition.  After Child K’s death, the maternal grandmother told the PPO that the mother felt bad about having a termination, described ‘killing the child’ and expressed concern that the maternal grandmother would be angry with her for what she had done.  The maternal grandmother told the Lead Reviewer that the mother had the termination because she felt unable to manage a third child at that stage and could not afford to do so.  The maternal grandmother added that the termination had a big impact on the mother and she was upset and distressed afterwards with a feeling of guilt.  Because none of the agencies who were working with the family, other than the GP, knew about the termination they were not able to factor this into any assessment or consider whether to provide additional support.  4.1.16 The referral from the GP in respect of the termination was made by letter, which is the usual practice for such referrals.  The referral did not contain any information about the mother’s existing children, including that they were subject to Child Protection Plans.  It is not routine for such information to be included.  Adult nurses, such as those at the clinic do not have any access to SystmOne, the information system used by GPs and health visitors, and therefore they would not have been able to use this to find out about the Child Protection Plan.  Safeguarding children is everybody’s business and it is the view of the Review Panel that it would be appropriate for the clinic to be informed when a woman whose children are subject to Child Protection Plans is referred for a termination.  This would enable the staff at the clinic to make further enquiries if they have concerns.    4.1.17 The referral from the GP did share some historical concerns, identifying abuse the mother had suffered during her childhood.  It also made reference to PHQ-9 and GAD–7 scores but did not include any explanation of what the scores would indicate for someone not familiar with using these tools or assessing mental health.  It did not make reference to the medication that the mother had been prescribed the previous year.  Nine months had passed since the GP had issued a prescription for                                             4 A phase that refers to the early symptoms and signs of an illness that precede the characteristic manifestation of the acute fully developed illness. Serious Case Review concerning Child K; Overview Report     Page 16 of 38  antidepressants and the mother had not consulted the GP about her mental health throughout that time.  Nevertheless, if the family had been discussed at the GP practice’s multi-disciplinary team meetings, as would have been appropriate given the family circumstances, the GP may have been aware of the mother’s on-going reports of anxiety and depression.  This is information that it would have been appropriate to share with the clinic.  Prior to undergoing the termination, the mother will have attended a pre-assessment clinic where she should have been asked about any factors that might pre-dispose her to mental health problems.  This Serious Case Review has not had access to the mother’s psychiatric records as it was deemed that she was not well enough to give consent.  Therefore the Lead Reviewer does not know what information was gleaned about the mother’s pre-disposition to mental health problems.  It has, however, been reported that the mother declined any follow up from the clinic after her termination.         4.1.18 The mother did not inform any of the professionals working with her that she was pregnant and planning to have a termination.  Similarly she made no mention of this afterwards.  Clearly, a woman’s decision to terminate a pregnancy is a sensitive and highly confidential issue that should not be shared unnecessarily.  This review does not suggest that GPs should routinely share information about terminations with other health professionals or with Children’s Social Care even when other children in the family are subject to Child Protection Plans.  However, GPs should always consider whether information should be shared in individual cases in order to protect children.      4.1.19 It is unfortunate that no-one who had concerns about the mother’s mental health in the last few months of Child K’s life shared their concerns with any of the services involved.  Throughout the period covered by this review, the parents displayed limited engagement with agencies and were selective in what information they shared.  For most of the period covered by this review, the father was not allowed to have unsupervised contact with his children.  It is therefore reasonable to surmise that he would have been reluctant to share any information that might cast doubt on the mother’s fitness to provide the necessary care as he would be concerned that this might result in the children being removed.  4.1.20 The church worker who spoke to the mother had concerns about her mental health but did not ask the mother whether she had any childcare responsibilities and appears not to have considered whether the mother’s mental health might constitute a risk to any children.  Although the acting safeguarding lead at the church has told the Lead Reviewer that staff receive annual training in safeguarding children it is not expected that staff will proactively ask people about their childcare responsibilities even when they have concerns about that person’s wellbeing.  4.1.21 During the period covered by this review there were occasions when the mother acted in ways that could have been judged as not in her children’s best interests.  For example, she was late in disclosing that she was pregnant with both pregnancies but especially the second one, she missed antenatal and postnatal appointments, did not Serious Case Review concerning Child K; Overview Report     Page 17 of 38  take Child K for his third immunisations and did not take Child K’s sister for her 6-8 week check or for any of her immunisations.  In addition, she did not always take notice of advice given by health professionals, such as safe sleeping advice.  However, there is no indication that any of these acts resulted from a wish to harm either child and the failure to attend for immunisations appears to have been a decision  made by both parents because they were distressed when Child K suffered the usual side effects to the immunisations he had.  Furthermore, several professionals commented positively on both parents’ interactions with the children.    Theme 2 – What was known about parental drug use, were appropriate enquiries made and action taken?  4.2.1 During a review conducted two years prior to the death of Child K, the PPO noted a ‘faint odour of cannabis’ in the parents’ property.  The father admitted using cannabis and was warned about the potential legal consequences of this.  Subsequently the father was always open with the PPO that he used cannabis but he would not talk about his use and became hostile when asked about it.  4.2.2 The initial social work assessment found no evidence of the mother currently misusing drugs, but identified she had used cannabis in the past.  It was identified in the same assessment that the father used both illegal and legal drugs, such as cannabis, tobacco and alcohol. He self reported having used cocaine in his past and it appeared that his substance misuse was more extensive than the mother’s.  Both parents were referred to a drugs and alcohol project for an assessment and support, but they both failed to attend.  However, despite this action being included in the multi agency child protection plan, neither parent was challenged about their non-engagement with the project and no further action was taken about possible drug use.     4.2.3 A referral was also made to the local authority drug and alcohol team to assist in contributing to the parenting assessment.  It is not clear what happened to this referral as they did not undertake an assessment, nor is there any evidence that they contributed, or were consulted, in respect of future assessments.  4.2.4 Past and current drug use, of either parent, did not form part of the social work assessment or safety plan.  There was no cross referencing to the impact that cannabis can have on brain development and the risk to increase mental health issues, especially in young people.  These issues would have been considered as part of a drug use and parenting assessment that was requested prior to Child K’s birth, had it taken place.    4.2.5 Information was shared about the father’s cannabis use at the initial child protection case conference referred to in 3.5.5 .  Health visitor 2 asked him about this at a subsequent visit and he reported that he had stopped smoking cannabis prior to Child K’s birth.    Serious Case Review concerning Child K; Overview Report     Page 18 of 38  4.2.6 No agencies ever had concern that the mother was misusing drugs or alcohol and during visits to the property, including unannounced visits by the PPOs, practitioners did not notice the smell of cannabis or see any drugs paraphernalia.  Furthermore, no-one observed either parent to be under the influence of alcohol or drugs at any time.  4.2.7 The mother’s GP had no knowledge of the mother misusing substances and, as identified in section 4.1 of this report, routine enquiry about drug and alcohol use did not take place as it should have done at consultations with a mental health focus.    Theme 3 – The Response to the Initial Referral to Children’s Social Care and Subsequent Child Protection Processes  4.3.1 The reason the family was referred to Children’s Social Care when the mother was pregnant with Child K was that the father was subject to a Sexual Offences Prevention Order.  This was an appropriate referral and it was made in a timely fashion.  There was some good information sharing at this time.  However, at the point of the duty social worker review in the MASH, no statutory checks were undertaken other than with the Police in respect of the father.  Checks should have been undertaken with all agencies involved with either parent, or where there might be a presenting issue that could impact on parenting ability.    4.3.2 There was a lack of clarity of the risk posed by the father to the unborn baby and a lack of understanding by the social work staff of what the respective professionals involved and previously involved with the father were saying about his risk level and what that meant. The confusion started in the Assessment team where a student social worker was allocated the case alongside an experienced social worker and although the student social worker liaised with the relevant police personnel and the Youth Offending Team there is no coherent sense of what risk the father might pose to the unborn baby.  At this point an assumption was made that the mother would be parenting the baby on her own.  4.3.3 Following a pre-assessment, Children’s Social Care commenced the PLO process, having sought legal advice to confirm that the threshold was met, and referred for a pre-birth assessment.   The PLO process was premature at this stage.  It would have been more appropriate if Section 47 enquiries had been undertaken to establish risk and gather all relevant information from other agencies.  If necessary, the case could then have progressed to an Initial Child Protection Conference and the completion of a social work assessment, including an assessment of possible risks posed by the father as a result of his previous offence.  When any risks had been established, a decision could have been made, before the baby’s birth, as to whether the father could live in the household or not.  If it was decided that he could not live in the household and the parents were not co-operating, then PLO could have been initiated at that stage.  (For action taken since this time see Section 7).  Serious Case Review concerning Child K; Overview Report     Page 19 of 38  4.3.4 After the PLO meeting the case was transferred to a long-term social work team which was also in line with the procedures in place at that time. After this transfer there was significant delay in starting the pre-birth assessment with no meaningful work being undertaken by the social worker or the community resource worker until more than two months later.  This delay included 18 days between the PLO meeting and case transfer and a further 16 days between transfer to the long-term team and allocation to a social worker. This also included a bank holiday period which inevitably added a further delay.  Subsequently, the social worker had difficulty contacting the parents and a period of sick leave.  In addition there were low numbers of staff available to cover the work and the team manager was inexperienced and fairly new to the Local Authority.   Although social worker 1 had made a referral to the family centre, the community resource worker’s first contact with the family was not until nearly three months later.  After this first contact, the community resource worker had difficulty securing the parents’ engagement and some planned assessment sessions did not take place because the parents were not at home.  Because of the above delays the pre-birth assessment was not completed before the PLO review.  4.3.5 The PLO review meeting was cancelled because the social worker was on sick leave and the team manager was otherwise engaged.  Both the social worker and the team manager subsequently stated that they did not know that the meeting had been scheduled for that date which suggests a communication breakdown when the case was transferred to the team.  If the meeting had taken place it would have highlighted the delay in completing the assessment and provided an opportunity to take stock of the situation.  Children’s Social Care should have set a new date for the review meeting but this was never done.  Therefore the PLO process came to a halt although it was not formally ended.  (For action taken see Section 7)  4.3.6 Children’s Social Care and Midwifery Services have a joint protocol for a pre-birth safeguarding plan to be considered prior to a birth in cases where there are child protection concerns.  The purpose of this plan is to identify what, if any, safety plans are needed in the hospital at the time of the birth to protect the baby and others.  No safeguarding birth plan was completed for Child K even though Children’s Social Care had identified at the point of referral that the father posed a potential risk to his child.    4.3.7 The strategy meeting in referenced in 3.5.3 was held because the social worker’s view, from the assessment, was that an Initial Child Protection Conference should be held due to a lack of engagement from the parents.  The strategy meeting should have involved Children’s Social Care, Police and the Midwifery Service as a minimum.  Given the involvement of the Health Visiting Service during the antenatal period it would have been prudent to have also involved that service.  In practice the meeting only involved the Police and the social worker.  Despite the outcome of the strategy meeting, an Initial Child Protection Conference was not arranged.  Social worker 2 left the job within days of this meeting and it appears that the recommendation to convene an Initial Child Protection Conference was not passed on to the team manager or an agency social worker who took over from social worker 2. Serious Case Review concerning Child K; Overview Report     Page 20 of 38   4.3.8 As explained in paragraph 4.2.2, decisions should have been made before Child K was born as to whether he required a Child Protection Plan and whether his father could live in the same home as him.  However, because of the omissions and delays within the child protection process, and some uncertainty about whether the parents were living together, this had not been done.   This was a far from satisfactory situation and one that should not have arisen.  On the day the mother went into labour, social worker 2 told the team manager that the outcome of her assessment was that the mother could parent the baby as a single parent but that there would need to be an Initial Child Protection Conference.  However, it quickly became evident that the parents intended to live together and it appears that there had been no planning for this scenario.  Children’s Social Care was initially of the view that Child K’s father should not be allowed to remain in the property but the PPO made representations on his behalf that he be allowed to remain there.  Following a visit by the social worker to the parents it was agreed that he could remain there but that he would only have supervised contact with Child K.   The PPO’s view was that the potential escalation of risk that would be caused by the father’s sudden homelessness was greater than any potential risk he posed to his son, which the PPO considered to be very low.    4.3.9 The decision that Child K’s father could remain in the family home was a risky decision for a number of reasons.  Firstly, at the time Child K was born, Children’s Social Care had not undertaken a risk assessment of his father.  Secondly, Child K’s mother had told the health visitor that she did not know why the father was not allowed to be with her and, the community resource worker told their manager that the mother appeared not to understand the risk posed to the child by the father. Therefore the mother’s willingness to adhere to the agreement should have been questioned.  Thirdly, irrespective of the parents’ willingness to adhere to the agreement it was unrealistic to expect them to be able to do so whilst the father was living in the family home.  It could be anticipated that this would put added stress onto the parents and increase the likelihood of them displaying disguised compliance, whereby they tried to demonstrate that they were complying with the contract of expectations whilst not actually doing so.  Children’s Social Care reports that at the time of Child K’s birth it was not uncommon for contracts of expectation to be used in this way.  It is now expected that there will be a full assessment using the Signs of Safety approach.   4.3.10 The decision to hold a second strategy meeting was reportedly made because the agency social worker was concerned that the parents were not engaging well with the health visitor and her, and not accepting advice.  As with the previous strategy meeting, this one only involved the Police and social worker and there was no input from the health visitor, although this would have been appropriate.  The subsequent Initial Child Protection Conference should have been held within 15 working days of the strategy meeting but did not take place for 27 working days.    Serious Case Review concerning Child K; Overview Report     Page 21 of 38  4.3.11 It is thought unlikely that the family would have been referred to Children’s Social Care if the father had not been a registered sex offender.  Therefore, a crucial part of any assessment should have been on whether he would constitute a risk to his child.  However, the risk assessment of the father was not started until after Child K was born and had not been completed at the time of the Initial Child Protection Conference.  At the Conference, the mother still did not accept that the father presented a risk of harm due to his sexual offending and the father was noted as being difficult to work with.  The Conference did not grip the issue of non co-operation or non acceptance of the concerns by the parents and agreed that Child K’s father should continue to live in the family home with all contact between him and the child should be supervised by the mother.  Several recommendations were made at the Conference but they were not sufficiently SMART.  They are specific about the staff concerned in a specific activity but do not have timescales or clear indicators of progress, making them hard to measure.  4.3.12 The agency social worker tried to undertake a risk assessment of Child K’s father but he did not initially co-operate and failed to attend some planned assessment sessions.  The assessment was finally concluded but the risk had not been fully assessed due to the father’s non-cooperation.  Because of this it was concluded that any contact between Child K and his father should continue to be supervised by Child K’s mother.  As a result of this outcome, the father refused to work with the social worker and this led to the next change of social worker.  4.3.13 After a further change of social worker, a second risk assessment of the father was completed.  This assessment was undertaken in liaison with the PPO, it explored the father’s background and experiences and his more recent relationships.  The outcome of this assessment was that the father was to be allowed unsupervised contact with his children.  However, this risk assessment did not consider specific risk, risk of relapse or safety plans if risks developed.  Children’s Social Care did not request a full copy of the Active Risk Management System (ARMS) assessment from Police.  However, the Police provided summaries which indicated that the father’s risk level was reducing because of the positive impact on his motivation of having a child and being in a relationship.   4.3.14 When the Initial Child Protection Conference did take place, some concerns were noted regarding lack of stimulation of Child K, him being weaned prematurely and the father’s cannabis use.  As a result neglect was highlighted as a concern in the Child Protection Plan.  It is also clear that there were many examples of the parents not engaging with services, not taking their children to medical appointments and not accepting advice (see section 4.4).  Nevertheless, it has been suggested by practitioners involved that these concerns alone would not have met the threshold for Child Protection or even Child in Need support and that, if the father had not been a registered sex offender, the family would probably have been supported at the level of Early Help.  This reinforces the view that there was a lack of clarity and focus on the risks and what needed to change.   Serious Case Review concerning Child K; Overview Report     Page 22 of 38   Theme 4 – Communication Gaps  4.4.1 There were several examples of practitioners communicating well, particularly when the mother’s pregnancy with Child K was first known about.  However, this Serious Case Review has identified several occasions when practitioners did not appropriately share significant information about the family.    4.4.2 The mother self-referred to Maternity Services when she was pregnant with Child K.  At the time of this booking there was an expectation that following all self-referrals to the Maternity Service, the maternity administrator should contact the registered GP practice to seek further information, including past medical history and any previous safeguarding concerns.  However, there was no robust system in place for this and it was not routinely done, including in this case.  (For action taken see Section 7)  4.4.3 Maternity Services did refer the mother to the Health Visiting Service but did not include information about the father being a registered sex offender, even though this information was known to the midwife.  The health visitor had made two unsuccessful attempts to visit the family to undertake an antenatal visit before finding out, from a colleague, that the father was a registered sex offender.  At the time the referral was made, the Health Visiting Service was undergoing organisational change.  Health visitors had previously been attached to and based in specific GP practices and it was straightforward for midwives to know which health visitor to contact with information such as this.  It was suggested, at the Learning Event, that the midwife may not have known which health visitor to contact with information about father’s status.  If the health visitor had been made aware of the father’s status and the subsequent safeguarding concerns she would have followed guidance in the Health Visiting Standards and Safeguarding Children’s Policy relating to no access visits where there are safeguarding concerns.  This may have resulted in the antenatal visit being carried out sooner than it was.  4.4.4 The mother moved home and changed GP Practice before health visitor 1 ever managed to meet with her.  This necessitated a change of health visitor.  There was a delay of more than two weeks before health visitor 1 handed over to the new Health Visiting Team and it appears that there was no robust system in place for Health Visiting Teams to be informed when families register with a new GP within the area.  Again the implication of this for the family was a further delay in the antenatal contact being undertaken.  This further contributed to a period of two months between the initial planned antenatal contact and the actual visit.  4.4.5 There is no evidence of communication or handover from the midwife to health visitor 2 after Child K was born.  The Health Visiting Standards (2011) recommends that a communication system is set up with the midwife to enable a safe handover of the care between professionals.   Serious Case Review concerning Child K; Overview Report     Page 23 of 38  4.4.6 The decision as to whether or not the father could live in the family home was not clearly communicated to all relevant agencies.  For example, the Health Visiting records contained conflicting information.  It is not clear whether this was due to poor communication or a lack of clarity over the decision.  4.4.7 Neither child’s GP record contains any evidence of them being discussed at practice safeguarding multi-disciplinary team meetings.   These meetings are reportedly held every two months by the GP practice although no minutes are available for any meetings held during the period covered by this review.  In view of the father’s status as a registered sex offender and subsequently the children being subject to Child Protection Plans such discussion should be expected.  4.4.8 Paragraph 4.1.7 notes that GP did not inform the health visitor of the mother’s disclosure of anxiety and depression in September.  Once the health visitor became aware that the mother had been prescribed antidepressants by the GP it would have been good practice for her to talk to the GP about the mother’s mental health.  The health visitor did not do this and therefore there was a breakdown in communication on both sides.  4.4.9 When the GP referred the mother to Maternity Services in connection with her pregnancy with Child K’s sister, the GP did not make reference to mother’s recent presentation with anxiety and depression or to Child K being subject to a Child Protection Plan.  Fortunately, the midwife noted on the maternity records that there had been safeguarding concerns during the mother’s pregnancy with Child K and investigated this further.  This was good practice.  4.4.10 Paragraphs 4.1.15 to 4.1.17 of this report discuss the information sharing in connection with the termination that the mother had.  This identifies that the GP did not inform the clinic of the mother’s anxiety and depression or that her children were subject to Child Protection Plans.  4.4.11 A number of practitioners commented on having difficulty making contact with Children’s Social Care in connection with this and other cases.  A particular problem was that phone calls and emails would go to an individual practitioner’s voicemail and inbox.  If that practitioner was away from work no-one else picked up the messages.  It was evident from discussions at the Learning Event that there was no consistent method used by practitioners to escalate concerns when they were unable to contact a member of staff in Children’s Social Care.  Records provided to this review detail occasions when the health visitors left message s for social workers and did not receive a response for several days.  (For action taken see Section 7)  4.4.12 There were at least two occasions when communication broke down within Children’s Social Care as a result of changes of social worker.  After the initial PLO meeting the case was transferred to a long-term assessment team.  The date of the PLO Review Meeting was not passed on with the result that it was cancelled.  When SW2 left the Serious Case Review concerning Child K; Overview Report     Page 24 of 38  decision to hold an Initial Child Protection Conference was not passed on and the Conference was not arranged.  Theme 5 - Lack of Engagement by the Parents and the Agency Response to this Lack of Engagement   4.5.1 Throughout the period covered by this review there were times when agencies found it difficult to engage with the parents.  The mother presented late when pregnant with both Child K and his sister and missed the first two appointments for a termination.  Numerous appointments with Maternity and Health Visiting Services were missed and the mother did not attend the GP Practice for a planned review of her antidepressant medication.  4.5.2 The specialist midwife at the One Stop Clinic displayed good proactive practice when the mother attended with her sister and said that she was pregnant.  The specialist midwife knew that the mother’s sister was difficult to engage and thought that the mother may be similar.  Therefore the midwife ensured that the mother knew that she had to attend a booking appointment at the hospital.  4.5.3 Health Visiting and Maternity staff demonstrated perseverance in trying to contact the family. This included repeated visits, attempted phone calls and liaising with other professionals.  However, health visitor 1 did not follow the Health Visiting Standards (2011) that were in place at the time of the pregnancies.  These advise that after two no access visits for the antenatal contact the address should be checked with Child Health and the GP and a letter sent to the family outlining the purpose of the antenatal visit.  The current Health Visiting Standards (2017) recommend that after one no access antenatal visit checks should be made with other agencies involved and a further appointment offered; if there is still no access the non-engagement pathway should be followed.  The protocol in Maternity Services is that if a woman does not engage on three separate occasions, they are referred back to the GP.  In this case, the midwife did not refer back to the GP but went beyond what was expected and continued to try to make contact.  This was due to the midwife’s concern for the unborn baby. Following another unsuccessful attempt to visit the midwife sought supervision from the safeguarding midwife; this was appropriate action to take.    4.5.4 The parents were not always present for planned sessions with the social workers and community resource worker.  This included sessions planned as part of the pre-birth assessment and the risk assessments of the father.  The parents’ non-engagement contributed to the delays in the completion of these assessments.  4.5.5 As explained in Section 4.2, Children’s Social Care referred both parents to the drug project shortly after the PLO meeting.  They did not engage with the project and there is no evidence that they were challenged regarding their lack of engagement.    Serious Case Review concerning Child K; Overview Report     Page 25 of 38  4.5.6 The parents did not consistently engage with the GP Practice when their children had appointments.  When child K was 6 months old, the health visitor noted that Child K had a yellow tinge to his skin and had to persevere before the parents took him for a GP appointment.  There were three consecutive missed GP appointments for Child K’s sister and she was never taken for an eight week check (although it is not clear if this was ever offered) or for immunisations.  Child K was not taken for his third immunisations.  There is no evidence to suggest that the GP Practice had a robust mechanism in place to deal with children not brought to appointments.  Two of the three missed GP appointments were followed up with a single text message but there is no evidence that a clinician reviewed Child K’s sister’s records after her missed appointments or that there was any communication with the health visitor.  There is also no documented acknowledgement from the Practice that the missed appointments posed a potential risk to the health and wellbeing of the sister of Child K or that they constituted potential neglect.   The missed appointments do not appear to have been put into context with the children being subject to Child Protection Plans.  The GP Practice did make several attempts to engage the mother in a review of her antidepressant medication.  4.5.7 The family did not engage well with the female family support worker who was in initially allocated to work with them from Action for Children.  There is evidence that the family support worker was tenacious in her attempts to engage with the family and case file notes indicate a series of texts, telephone calls and attempts to visit the home.  Information was posted to the family after these unsuccessful attempts to undertake a home visit.  Following discussion at a Core Group meeting referred to in 3.6.6, a decision was taken to reallocate the family to a male family support worker.  The rationale for this appears to have been that a priority action was to engage the father and there was a history of non-engagement and a level of hostility from him towards professionals, particularly females.  It appears that this strategy had some success in respect of improving engagement and that the male worker had started to establish a positive relationship with both parents.  However, there does not appear to have been full consideration of how the plan for a male worker would fit into the wider plan of protection for the children, or how it may potentially collude with the father’s perception of females rather than challenging it. Furthermore, the promotion of the father’s role within the family appears to be at odds with the agreement that was in place at that time that he could not have unsupervised contact with the children.  An additional concern with this decision was that there were no male staff within the Family Support Team so a worker from the Action for Children Health Team at the children’s centre was allocated this work.  However, staff within this team do not have monthly structured case supervision in the way that Family Support Team staff do.   4.5.8 It was suggested at the Learning Event that the parents’ level of engagement varied depending on their feelings towards the individual practitioners although this is difficult to evidence.  However, there does appear to have been better engagement, with fewer missed appointments than there had been previously.    Serious Case Review concerning Child K; Overview Report     Page 26 of 38  4.5.9 On some occasions the parents’ non-engagement manifested itself in confrontational behaviour or a refusal to accept advice regarding childcare.  For example, when health visitor 2 shared public health information regarding safe sleeping and immunisations the parents disputed this and the mother said that she listened to the advice given but chose not to act on it.  It is reported that on at least one occasion, as referred to in 3.3.7, this had an impact of the delivery of service, when health visitor 2 had concerns about the home conditions but did not feel she could address these because of the parents’ confrontational approach.    4.5.10 The mother consistently refused offers of support with her anxiety and depression, telling the GP, health visitor and midwife at various times that she did not want support.  She also refused any follow up after the termination.    Theme 6 - Drift & Delay  4.6.1 This report has identified several areas of delay in the work that Children’s Social Care undertook with this family.  These have been considered in the preceding analysis and relate to the PLO process, the pre-birth assessment, risk assessments and Initial Child Protection Conference.  Once it was decided at the Initial Child Protection Conference that a Child Protection Plan was required a Core Group meeting should have been held within 10 days and subsequent Core Group meetings should have been at least once every six weeks. These timescales were not met.  4.6.2 A particular challenge for Children’s Social Care in this case was the frequent changes of social worker. The change from social worker 1 to social worker 2 was due to a planned transfer to the long-term team.  Subsequently the family was allocated to five different social workers between the time period covered in this review.  There is evidence of communication breaking down at times when the social worker changed and this problem will have been exacerbated because there are big gaps in the case recording.  Furthermore, changes of staff are always like to cause a degree of disruption whilst relationships are developed and trust is hopefully built up.  Theme 7 – Did agencies recognise and assess risk in respect of maternal cousin (L) having contact with Child K’s mother?  4.7.1 L is a maternal cousin of Child K and at the time of his death, she was subject to a Care Order and placed at home with her parents.  She was present in the address when Child K died, as she was visiting with the maternal grandmother.    4.7.2 This review has found that the identified risk factors in this case were primarily around the father’s sexual offending history and not around the mother.  Indeed the mother had been assessed as being able to safely supervise contact between the father and their children.  No-one working with the family had concerns that the mother might develop an acute mental health disorder and they did not observe any concerning behaviour from her in the weeks leading up to Child K’s death.  People who did Serious Case Review concerning Child K; Overview Report     Page 27 of 38  observe such behaviour did not share their concerns with agencies.  Consequently, it is the view of this review that no information was available that she should have led professionals to have concern that L, or any other children, might have been at risk having contact with Child K’s mother  5. Previous Serious Case Reviews  5.1 Three years before the death of Child K, another child also died locally in similar circumstances.  The Safeguarding Children Board undertook a Serious Case Review in relation to the death of this child.    5.2 Although the family circumstances for the two cases were quite different, both reviews found that the respective mothers were suffering from an acute mental disorder at the time they killed their children.  Both reviews have also found that none of the practitioners who were working with the mothers were aware that they were suffering from these mental disorders or had noticed any significant changes in their presenting behaviour.  Similarly both reviews have found factors within the mother’s lives and backgrounds that made them high risk of experiencing mental health problems.    5.3 A further finding in both reviews is that there was insufficient communication between the GPs and health visitors.  6. Learning from the Review  6.1 The reason the family was referred to Children’s Social Care when the mother first became pregnant with Child K was that the father was a registered sex offender.   Had it not been for this, it is likely that services would have been provided at the level of Early Help.  However, the tragic event that led to this Serious Case Review being undertaken had no direct connection with the father’s history but was due to Child K’s mother suffering from an acute mental disorder that no-one working with her had anticipated.  6.2 This review has considered the dual aspects of the mother mental health and the child protection process in detail and has identified the main issues that impacted upon these.  The learning points that emerge from the analysis are set out below.  6.3 Mother’s mental health i. Notwithstanding concerns about some aspects of the mother’s care of the children, no agency ever had concerns that she would deliberately harm either child.   ii. Professionals working with the family understood that the mother had suffered with anxiety and depression at times since Child K had been born.  However, the GP did not identify this as postnatal depression which impacted on the response that was provided.  Furthermore, the possible impact on her care of the children was not appropriately assessed. Serious Case Review concerning Child K; Overview Report     Page 28 of 38  iii. The psychiatrist who assessed the mother on the instructions of the Police believes the symptoms she described were most likely due to a prodromal phase of schizophrenia rather than anxiety and depression. iv. Child K was killed whilst his mother was suffering from an acute mental disorder but no-one ever identified the mother as being at high risk of suffering an acute mental disorder.  It is believed likely that this was due to paranoid schizophrenia exacerbated by drug use. v. A more thorough assessment of the mother’s family history, including use of historical information, should have led to identification of high risk factors with regard to her mental health, including a family history of mental illness and childhood abuse. vi. Practitioners were not aware of any recent history of drug use by the mother. vii. The termination of pregnancy is believed to have been a significant stressor for her and a significant factor in exacerbating her underlying condition.  Other than the GP, no-one working with the family knew of this termination. viii. For a period of several weeks immediately before Child K’s death, there were times when the mother displayed disturbed behaviour but this was not seen by any of the practitioners who were working with the family. ix. No-one who witnessed the mother’s disturbed behaviour reported it to any of the agencies involved with the family. x. The long-standing arrangement that the father could not have unsupervised contact with his children is likely to have contributed to the father’s unwillingness to share concerns about the mother’s mental health. xi. The church worker who spoke to the mother whilst she was distressed did not seek to establish whether she had any caring responsibilities.  6.4 Parental drug use i. There was some knowledge that the father used cannabis on a regular basis but no-one knew that the mother used illegal drugs and no signs of drug use were noted in the property or in the parents’ presentation. ii. The parents were not challenged regarding their lack of engagement with the drug project. iii. Past and current drug use, of either parent, did not form part of the social work assessment or safety plan.   iv. It is likely that drugs were a significant contributory factor in the mother’s mental disorder when she killed Child K. v. Drug taking can have a rapid and significant impact on a person’s behaviour and presentation.  Where there are concerns that a service user may be using drugs it is useful to undertake unannounced visits and visits at different times of the day.   6.5 Child Protection Process i. The initial referral to Children’s Social Care was timely and appropriate but the early use of PLO was premature. Serious Case Review concerning Child K; Overview Report     Page 29 of 38  ii. Significant delays arose including delays completing the pre-birth assessment and the risk assessment of the father and in holding an Initial Child Protection Process.  As a result of these delays, suitable plans to keep Child K safe were not in place when he was born.  iii. The initial reason for the family being referred to Children’s Social Care was that the father was a Registered Sex Offender and his partner was pregnant.  However, the risk he may pose to his child had not been assessed by the time the child was born. iv. Even when a risk assessment was undertaken it is not evident that it was appropriately focussed on the father’s sex offending. v. The pre-birth assessment did not consider the parent’s own childhood experiences. vi. It is not clear what decisions or actions resulted from the pre-birth assessment. vii. Recommendations made at the Initial Child Protection Conference, and subsequent Review Conferences were not sufficiently SMART. viii. The expectation that Child K’s mother would be both able and willing to prevent her partner from having any unsupervised contact with Child K and later also with his sister was unrealistic and not based on a robust assessment of risk. ix. Throughout the period that the father was unable to have unsupervised contact with his children he was concerned about the risk of them being removed from him.  This is likely to have impacted on his willingness to share concerns about the mother’s behaviour in September and October xxxx.  x. Health Services were not as involved in the Child Protection Process as would have been appropriate.  In particular, midwives and health visitors were not included in the strategy meetings. xi. Children’s Social Care has now made significant changes to the PLO process and the use of contracts of expectation.  6.6 Interagency Communication i. There were several occasions when information was not shared appropriately between agencies.  This included information about the mother’s mental health and the father’s status as a registered sex offender. ii. Despite the concerns about the family, they were not discussed at the safeguarding multi-disciplinary team meetings held at the GP Practice. iii. Agencies sometimes had difficulty contacting the social workers. iv. There were breakdowns in communication within Children’s Social Care when changes of social worker took place.  6.7 Lack of engagement by the parents i. The parents were often not present for planned visits and frequently did not attend meetings. ii. They were sometimes confrontational with practitioners working with them. iii. They would not always accept advice regarding the care of the children. iv. Agencies demonstrated perseverance in trying to engage with the parents but did not always follow organisational protocols for non-engagement. Serious Case Review concerning Child K; Overview Report     Page 30 of 38  v. The parents did not consistently engage with the GP Practice when their children had medical appointments.  The GP Practice appears not to have had a robust mechanism in place to deal with children not brought to appointments or to have identified them as possible neglect, despite the children being subject to Child Protection Plans.  6.8 Drift and Delay i. There was considerable drift and delay from Children’s Social Care.  Problems were exacerbated by frequent changes of social worker and scarce records.  7. Action Taken by Agencies Since the Events Considered in this Serious Case Review  7.1 The Teaching Hospitals NHS Foundation Trust reports that a robust system has now been put in place to ensure that on receipt of the self-referral documentation, the maternity administrator will generate a letter to the GP practice.  This letter informs the GP about the referral to Maternity Services and requests that the GP “notify the Maternity Service of pertinent medical history, medication and safeguarding concerns that can assist the midwifery and obstetric teams.”  Notwithstanding this letter, the Maternity Service does not always receive an appropriate response from the GP practice.  (See Paragraph 4.3.2 and Recommendation 6)  7.2 Children’s Social Care has significantly changed its procedures relating to PLO.  At the time the decision to commence PLO was authorised by the service manager in consultation with Legal Services. The tracking process lay with the service manager/team manager and social worker. All decisions for PLO need to go through Legal Gateway Panel for authorisation and their progress is tracked by the Panel.  Pre-birth risk assessments are managed more tightly and the Pre-birth Protocol is clear about the need for early Initial Child Protection Conference so that there is an interagency decision. (See Paragraphs 4.2.2 and 4.2.3)  7.3 Children’s Social Care has made changes to address the issue of people having difficulty making contact with individual social workers.  This includes systems that allow managers to override voicemails and access email accounts if staff are absent from work.  In addition, a duty system is now in place in each social work team so that practitioners can contact the duty worker if the allocated staff member cannot be contacted.  However, practitioners from other agencies are not confident that that these changes have resulted in significant improvements.  It is suggested that Children’s Social Care should ensure that partner agencies are informed that there is now a duty system in each locality team and that the duty officer can be contacted if there are difficulties contacting the named worker.  (see Paragraph 4.3.12 and Recommendation 6)   7.4 The ‘Signs of Safety’ model is now used within the local authority and partners.  This is a strengths-based approach to child protection casework that provides opportunities Serious Case Review concerning Child K; Overview Report     Page 31 of 38  for a more focused approach to setting and achieving goals.  Relevant staff have been trained to use the ‘Signs of Safety’ model but work is required to ensure that its effective use is embedded in practice.   8. Recommendations   8.1. Individual agencies have already made changes to practice which address some of the learning from this review and these are described in section 7 of this report.  Agencies have also made single agency recommendations within their individual reports.  These are attached at as appendix 2.  The Lead Reviewer makes the following additional recommendations to the Safeguarding Children Board and individual agencies:   1. The Safeguarding Children Board should seek assurance from partner agencies that practitioners are being provided with appropriate knowledge and skills that will help them identify people who are risk of developing mental health problems and know what action to take when they have concerns.   2. The Safeguarding Children Board should make links with the church where the mother presented in a distressed state to support the church in providing robust and appropriate safeguarding training to all staff and volunteers and to ensure that staff and volunteers at the church know who to contact if they have any safeguarding concerns.  3. The Safeguarding Children Board should ensure that relevant learning from this review is disseminated to organisations, such as faith establishments, that are likely to encounter people at times of crisis.  4. The Safeguarding Children Board should seek information from Children’s Social Care about the impact of the substantial practice changes reported in Section 7 and Appendix 2 of this report.  5. The Safeguarding Children Board should seek assurance that Signs of Safety is being appropriately embedded across the partnership.  6. Children’s Social Care should ensure that partner agencies are aware of the changes made to contact arrangements for social work staff and the action that should be taken if someone is unable to make contact with the allocated worker within a reasonable timescale.  7. The Clinical Commissioning Group and the Teaching Hospitals NHS Foundation Trust should develop a referral form to be used by GPs when referring women for terminations.  This should include information relating to any other children the woman has and whether they are subject to Child Protection or Child in Need Serious Case Review concerning Child K; Overview Report     Page 32 of 38  processes.  It should also provide information about any identified mental health risks for the woman being referred.  8. The Safeguarding Team for the Clinical Commissioning Groups should recommend to all GP Practices that they have a process in place to respond to letters received from Maternity Services which request the “pertinent medical history, medication and safeguarding concerns that can assist the midwifery and obstetric teams” in the case of women who self-refer to Maternity Services in connection with their pregnancy. i. The Teaching Hospitals NHS Foundation Trust should undertake an audit of compliance during 2019 and present the results to the health safeguarding group.  9. The Safeguarding Team for the Clinical Commissioning Groups should recommend to all GP practices that they use the Clinical Commissioning Groups’ ‘Was Not Brought’ policy when children are not brought to appointments.    10. The Safeguarding Team for the Clinical Commissioning Groups should recommend to all GP practices and to NHS Trusts using SystmOne, that all locum doctors should be given access to the Safeguarding template on SystmOne.  11. The Head of Prevention and Early Help within Children’s Services should have regard to the recommendations made within the Action for Children report (see Appendix 2) to inform the operation of children’s centres now managed by the Local Authority.   Serious Case Review concerning Child K; Overview Report     Page 33 of 38  Appendix 1 – Key Lines of Enquiry  The key lines of enquiry considered within the agency reports:   1. Describe and analyse the way in which organisations, identified as part of the review, interacted and worked with Child K and his immediate family and with each other. Consider these interactions in the organisational contexts and of the policy and procedural frameworks that applied at the time. In addition, the author should analyse the impact on the family, intended and unintended, of these interactions with professionals and organisations. 2. Were single and multi-agency assessments and interventions child focussed, accurate and acted upon? Did agencies recognise and assess risk in respect of Child K? Please detail each individual risk that was identified and how each was assessed. 3. Describe and analyse the parenting capacity of Child K’s parents. In particular did agencies consider historical information with regards to the parents of Child K which could have identified potential harm or concerns around their parenting of the child? (Including history of mental health, medical conditions and interest in faith aspects) 4. Was the parenting capacity of Birth Father assessed effectively? What influence and risks did he present to Mother, Child K and his sister? 5. What, in this case, reassured practitioners that Child K and his sister were safe and well? Were any signs of abuse missed by practitioners? 6. Did agencies have any knowledge or concern that either parent was misusing drugs.  If so, what was the response and was it appropriate?   7. What can we learn from our response to Child K and his family and from the engagement with the Mother of Child K and extended family in fully understanding vulnerability, harm, risk and effective interventions? 8. Explore whether Mother and father/ or extended family were able to withhold concerns or deceive agencies, why this was able to happen and whether there are lessons that can be learnt. 9. Explore if agencies recognised and assessed risk in respect of Child L in relation to contact with Child K’s mother and being present at the time of the death of Child K. 10. Explore whether agencies responded in a timely manner to the incident leading up to the death of Child K. 11. Were appropriate assessments and measures in place to protect vulnerable adults and children within the home of Child K?  12. Was professional practice informed by appropriate and effective supervision? 13. Was professional practice and supervision informed by research and evidence based practice? 14. Were single and multi-agency communications and information sharing appropriate, accurate and acted upon?  How well was information shared, understood and responded to between agencies?  Include consideration of communication between practitioners working with both the immediate and the extended family. 15. Determine whether the National, Regional and Local policies, procedures, thresholds and practice expectations of the agencies in use were followed during this period. 16. Consider whether there are any common themes from previous serious case reviews or critical incident reviews and the effectiveness of agency’s actions in relation to these. Serious Case Review concerning Child K; Overview Report     Page 34 of 38  Appendix 2 – Recommendations from Agency Reports  Action For Children Number Recommendation i.   The Operational Director for Children’s Services in the local authority should ensure that Action for Children workers holding case work responsibilities have access to monthly case file supervision as already required by Action for Children’s Supervision Policy in order to ensure manager oversight, track progress against outcomes selected, and offer an opportunity for reflective case discussions. ii.  Ensure that on all occasions, historical information should be obtained to give the service a thorough understanding of the case history, as a minimum the record of the last Child Protection Case Conference discussion and the Safeguarding Plan should be sought if not readily shared by the referrer, in line with Action for Children’s existing policies. If not made available, then steps to escalate this to senior managers within the local authority should be taken.  iii.  The Service Manager should ensure that all staff within Children’s Centres have practice discussion sessions on working with mental health issues and use the online learning materials available in Action for Children to this end. iv.  If Action for Children is requested to undertake work contrary to that set out in a Child Protection Plan or any other legal arrangement such as license following release from custody, work should be undertaken only after agreement with a responsible manager in the local authority. The Operational Director should ensure that in cases where agreement cannot be reached, Action for Children’s existing escalation procedure should be followed. v.  The Head of Safeguarding should develop a flowchart to indicate the nature of key child protection processes and expectations of all agencies within these and incorporate into the Safeguarding Framework.  District Care Foundation Trust Number Recommendation i.  HV teams need to review the process of how they are notified of movements within the area by GPs ii.  HV teams need to ensure that they are involved in safeguarding meetings with GP practices.  iii.  HV record templates need a prompt to ask parents about their own experience of childhood/being parented iv.  HVs need to record relevant adults in the groups and relationships in records of children on CP plans and consider completing a genogram Serious Case Review concerning Child K; Overview Report     Page 35 of 38  v.  HVs need to take/create opportunities to use routine enquiry in regards to domestic abuse  vi.  HVs need to consider opening records for fathers (with their permission) if they are present at visits vii.  HVs need to transcribe information from texts sent and received from parents into the records viii.  Consideration needs to be given as to how the Care Foundation Trust monitors safeguarding supervision compliance  Teaching Hospitals NHS Foundation Trust Number Recommendation i.  Improved partnership information sharing between heath partners in relation to sharing of historical safeguarding information. ii.  Improved inter-agency information sharing between professionals where there is on-going Children’s Social Care involvement. iii.  Recognition of the impact and information that all professionals working with families hold when completing multi agency assessments, including the consideration and invitation to child protection conferences/review process.  Children’s Social Care Number Recommendation 1 Assessments should cover childhood experiences of the parents and relevant history and the impact this may have on parenting  2 Assessments need to identify with families using the Signs of Safety model what we are worried about and what is being assessed so that families are clear what they need to change or improve.  3 Team Managers and Practice Supervisors will be reminded of the requirement for regular monthly supervision for all social workers, that is recorded on case files (more frequently for newly qualified staff) 4 Children’s Social Care will offer and encourage all families to accept a family group conference or family network meeting at the start of the pre birth assessment process or parenting assessments to ensure that wider family members are consulted with as part of the process. 5 Contract of expectations/written agreements should not be used routinely but only used in exceptional circumstances as a very short term measure where Signs of Safety planning needs to be reinforced.   6. Assessments of parent’s ability to supervise contact safely should take into account the impact on them and the reality of this in practice.  Serious Case Review concerning Child K; Overview Report     Page 36 of 38   Clinical Commissioning Group Number Recommendation i.  CCG Clinical Leads should design a clinical template to aid GPs in completing a thorough maternal post-natal check. The template should include contraception advice, incorporate the Whooley questions and GAD2, and contain links to guidance on assessment and management of postnatal depression. ii.  CCG Safeguarding Children team to raise awareness of the assessment and management of peri-natal mental illness by incorporating this subject into level 3 safeguarding children training.  iii.  To aid information sharing between health  partners in relation to sharing of historical safeguarding information (see Teaching Hospital Foundation Trust recommendation i) the CCG suggests partnership work with Teaching Hospital Foundation Trust to modify the Teaching Hospital Foundation Trust Maternity referral form  to include prompts for maternal mental illness, child safeguarding concerns, CSC involvement. When a woman self-refers to midwives, midwives and GPs should have an accepted method of communication to share any history of mental illness and any safeguarding concerns. iv.  When there is a change in practice management a handover should take place, which includes passing on current safeguarding policies and record of staff training. How to do this: Feedback to the GP Practice. How to measure this: Check practice policy in place following this feedback. v.  The GP Practice to have a robust system in place to ensure locum GPs and all new staff members are manually enabled to view entries in the safeguarding children template. How to do this: feedback to the GP Practice.  How to measure this: Check practice policy in place following this feedback.  Housing Providers Number Recommendation i.  There were four recommendations for housing providers ii.   iii.   iv.    Legal Services Number Recommendation i.  The use of a shared /inter agency electronic record system which could enhance and improve communication. The shared record system could contain a basic log of Serious Case Review concerning Child K; Overview Report     Page 37 of 38  actions and interventions that have been carried out so that professionals are aware of each other's actions. This could provide real time information on the progress of cases particularly those without court deadlines. It would not rely on services having to respond to email or telephone requests for updates or instructions and would highlight inactivity and or assist in prioritising those cases where interventions are required.   Police Number Recommendation i.  That the Force consider how to ensure that PPOs are fully aware of all available information from the incident logging database about the RSOs they manage prior to completing risk assessments and management plans; ii.  That the Force audit attendance at domestic abuse incidents to ensure that Force policy re completing full research on involved persons is being complied with and if not considers what remedial action is required to achieve this;       