Death of a 3-month-old baby boy, presented to hospital unconscious and not breathing, in January 2013. Baby F's father was arrested on suspicion of murder and bailed without charge. Baby F's parents were both Polish and had been living in the United Kingdom for 6 years; both had two older children from previous relationships who were all residing in Poland at the time of the incident. Issues/lessons identified include: access to interpreter services and the impact on communication between parents and services; difference in cultural approaches to possible non-accidental injuries between hospital and police staff; the inability of professionals to identify when a strategy meeting is required; and where opinion of cause of injury is unknown or conflicting, professionals should proceed as if injuries are inflicted. Makes various interagency and single agency recommendations, covering children's services and health services.
      
 Title:  Serious case review: overview report V4: Baby F. LSCB: Rochdale Borough Safeguarding Children Board Author: Graham Yip Date of publication: 2013  This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC.  This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above.                          1      Rochdale Borough Safeguarding Children Board  Serious Case Review   Overview Report V4  Baby F            Chair LSCB: Jane Booth Chair SCR:  David Hunter Author SCR: Graham Yip                                                      Date: September 2013          2     CONTENTS Section         Page Number 1. Introduction                       3  2. Serious Case Review Process (SCR)                                                      3   2.1 Decision to hold an SCR                                                              3 - 4  2.2 Membership of the Overview Panel                                              4  2.3 Terms of Reference                                                                     5 - 6  2.4 Documents Reviewed                                                                   6  2.5 Family Involvement                                                                       6 - 7  2.6 Parallel Process                                                                    7  2.7 Media Interest                                                                               7      2.8 Genogram                                                                                      7        3. Family Background                                                                                    7 - 8 4. Overview of what was known                                                                     8 - 15 5. Commentary on IMRs                                                                                15 - 22            6. Critical Analysis against Terms of Reference                                             22 - 40 7. Lessons Learned                                                                                        40 - 43 8. Conclusions                                                                                                43 - 44 9. Recommendations                                                                                      44  Single Agency                                                                                             44 - 46  Multi-Agency                                                                                   46 - 48                 Appendix A Genogram                                                                                         3    1. Introduction. 1.1 The principal family members referred to in this report are:  Baby F .   White British/Polish.    Deceased  Birth Mother.      Mother of Baby F.  White Polish  Birth Father.   Father of Baby F.  White Polish  1.2 Baby F, a boy, was born in North Manchester General Hospital in autumn 2012.                     Both parents are Polish nationals who have been resident within the Rochdale area for some 6 years. Following his birth, Baby F and his parents lived at Address 1.  1.3      At 1528hrs, Saturday 19th, January 2013, Greater Manchester Police (GMP) received a 999 call from North West Ambulance Service [NWAS] informing them that  a three month old baby was unconscious and not breathing at Address1. 1.4 Baby F was taken to North Manchester General Hospital Accident and Emergency Department, before being transferred to the Royal Manchester Children’s Hospital, where he received specialist intensive medical treatment. It was very strongly believed by medical professionals that the injuries to Baby F were inflicted and therefore non-accidental. 1.5 Birth Father had been alone with Baby F immediately prior to the incident when Baby F had become unconscious and unresponsive.  On Friday 25th, January 2013 both Birth Father and Birth Mother were interviewed under caution by Officers from GMP. Both parents were legally represented and had the services of an official interpreter  1.6      On Wednesday 30th, January 2013, following discussions between health professionals and the parents of Baby F over the serious condition over their son, Baby F was extubated, and was certified dead at 22.55hrs.   1.7     To date the Home Office Pathologist who undertook the post mortem examination of Baby F has deferred his decision regarding cause of death until the outcome of additional specialist medical examinations have been undertaken  1.8       On Friday 8th, February 2013 Birth Father was arrested and interviewed by officers from GMP on suspicion of the murder of Baby F. Birth Father was legally represented and had the services of an official interpreter. Birth Father was subsequently bailed without charge until Monday 28/10/2013.  2. Serious Case Review [SCR] Process 2.1 Decision to hold a SCR  2.1.1 On 28/2/13 Rochdale Borough Safeguarding Children Board Serious Case Review Screening Group was convened to consider whether a Serious Case Review should be undertaken. The Panel took into account the following:  The circumstances of Baby F death.  Medical evidence available.  Suspicions that Baby F had been the subject of abuse.   4    2.1.2   The panel concluded that the criteria for undertaking a Serious Case Review had been met. A decision was therefore made to recommend that a Serious Case Review be undertaken. 2.1.3.   On 25/3/13, the recommendation of the Serious Case Review Screening Group was approved by the Independent Chair of the Safeguarding Board. 2.1.4    On 26/3/13, Ofsted were informed of the decision to undertake a Serious Case Review. 2.2 Membership of the SCR Overview Panel [The SCR Panel]  2.2.1 The Panel consisted of:    David Hunter                      Independent Chair   Detective Inspector                         GMP  Acting Head of Safeguarding Children      Pennine Care NHS Foundation                         s                                                                 Trust  Designated Doctor                     Heywood, Middleton and Rochdale              Clinical Commissioning Group               [HMR CCG]  Designated Nurse                      HMR.CCG.  Head of Safeguarding                                 RMBC  Children’s Services Manager                      RMBC  Interim Head of Service Care for Children  RMBC  Business Manager                       RBSCB    Administrator                        RBSCB  Cultural Advisor                                           Lay Member  Principal Solicitor (Advisor to Panel)          Rochdale Metropolitan Borough               Council [RMBC]  Senior Solicitor   (Advisor to Panel)            RMBC   (From 30/7/13)  Graham Yip                                   Independent Author  2.2.2   The RBSCB was satisfied that the Independent Chair and Author had the appropriate experience and independence to undertake their respective roles. 2.2.3 The Panel met on 6 occasions, and attendance was initially variable, an issue addressed by the Independent Chair of the SCR.  2.2.4   Following quality assurance by the CIG, the Overview Report, Executive Summary and Multi-Agency Action Plan were scrutinised by RBSCB on 19/09/2013, where after a thorough debate the documents were approved for submission to the Department for Education. 5    2.3 Terms of Reference 2.3.1 Terms of Reference 2.3.1 The following terms of reference were agreed at the Panel’s first meeting on 08/05/13.  Purpose  The purpose of this Serious Case Review is to:   Establish whether there are lessons to be learned from the case about the way in which local professionals and agencies work together to safeguard children;  Identify clearly what those lessons are, how they will be acted upon and what is  expected to change as a result and as a consequence;  Improve inter-agency working and better safeguard children.  Working Together to Safeguard Children 2010 Chapter 8.5   Timeframe   The period under review is: From your agency’s first contact with any of the core family members, to Baby F’s death on 30.01.2013.  Agencies will also consider any contextual information outside of this time frame  in  relation to the core family members who are listed below.  Such information should  be included as a synopsis at the start of the narrative section of their IMRs.   Core Family Members   Baby F  Birth Father   Birth Mother    Specific Terms of Reference  1. How did agencies respond to Birth Mother’s pregnancy?  2. What steps did agencies take to discover the family’s background and what influence did any findings have on their assessment and decision making?  3.  What were agencies assessments of the parenting abilities of both parents and how did agencies identify and manage any risks?  4. Was agencies management of risk in compliance with their procedures and those of RBSCB?  5. To what degree, did agencies in gathering information, making assessments and delivering services take account of issues such as: - race and culture [including isolation], language [including interpretation services], age, 6    disability, faith, gender, sexuality and economic status and how did this impact upon agencies assessment and service delivery? 6. What child protection procedures did your agency follow after Baby F was admitted to hospital and were they fit for purpose?   7. To what extent did agencies communicate effectively and work together to safeguard and promote the continued wellbeing of Baby F?  8. What lessons have agencies learned from this Serious Case Review?  9. Provide examples of good and poor practice where evident.    2.3.2  Other Considerations  The Overview Report will consider whether the death of Baby F was predictable  and/or  preventable.  2.4 Documents Reviewed  Individual Management Reviews [IMR] 2.4.1 IMRs were submitted from the agencies listed below:  Greater Manchester Police  Rochdale Borough Council Children’s Services  Central Manchester University Hospitals NHS Foundation Trust  Pennine Care NHS Foundation Trust  Pennine Acute Hospital Services NHS Trust  GP Service  Other Documents  2.4.2 Information was also received from:  Health Overview Report  Minutes of Strategy Meeting held on 22/1/13 2.5 Family Involvement  2.5.1    In line with the expectations of Working Together (2010), early consideration was       given by the panel to seeking a contribution to the Serious Case Review from family members. The panel agreed that the family members who should be invited to contribute should be Birth Mother and Birth Father. The panel was keen to establish the parent’s views in respect of the support they had received from different services in helping them to look after their baby, and whether language barriers impacted upon the support they received from different services.  7    2.5.2    The Independent Chair of the Serious Case Review panel has written to the parents of Baby F, in Polish, introducing himself, and informing them that a Serious Case Review is being undertaken and what the purpose and process of a Serious Case Review is. In addition the letter also sought the parent’s involvement within the SCR process. 2.5.3    Given the ongoing criminal investigation the Chair of the panel sought the advice of the Greater Manchester Police Senior Investigation Officer, with regards to meeting with the parents of Baby F.  The Police advice was that a meeting with the parents of Baby F could potentially compromise any future criminal proceedings.  2.5.4   The panel accepted the Police advice and as a result concluded that it would not be helpful to contact the parents of Baby F in these circumstances. 2.5.5   The panel agreed that following the Police investigation and any potential future court proceedings, further consideration would be given to contacting the parents of Baby F, to see if they would be willing to make a contribution to the SCR at that stage. The panel agreed that that if this was the case, and new information was received which could lead to further learning, the Panel would reconvene to consider how best the learning could be taken forward, including the possibility of an addendum to the Overview Report.   2.6       Parallel Processes 2.6.1 Greater Manchester Police have commenced a criminal investigation to determine                             how Baby F died.  Birth Father was arrested on suspicion of murder, and subsequently given Police bail.  At the time of this report he remains on Police bail. 2.6.2    HM Coroner for Rochdale has opened and adjourned the Inquest.         2.7 Media Interest 2.7.1 There appears to have been no reports in the media of the death of Baby F or the  police investigation. This is very likely to change if Birth Father is charged and/or                   when the inquest takes place.  2.7.2   Any subsequent media interest will be handled by RBSCB. 2.8 Genogram 2.8.1 This appears at Appendix A 3. Family Background. 3.1 Birth Mother and Birth Father are both Polish nationals, who have been married for some 6 years. They came to the United Kingdom in November 2006. The couple settled in a part of the Greater Manchester area, within a well established and large community of Polish and other East European nationalities. 3.2.      Both Birth Mother and Birth Father each have two children from previous relationships in Poland, three of whom are of adult’s age and one is a teenager. All four reside in Poland and are not subject of this Serious Case Review.  8    3.3. Birth Father is employed as a Production worker. Birth Mother runs her own small business. They have resided as a couple at Address 1 since September 2012.  3.4       Following the death of Baby F, Birth Father was arrested by Greater Manchester Police on the Suspicion of Murder of Baby F. He was subsequently given Police bail. At the time of this report he remains on Police Bail. 3.5       Prior to the incident of Saturday 19th, January 2013, neither parent was known to Children’s/Social Services in the United Kingdom. The panel initially requested that enquiries be undertaken in Poland to establish if either parent were known to the Polish Children/Social Services.  However as the SCR progressed, the requirement for this action to be completed diminished.  3.6  Although present within the United Kingdom since 2006, English is an additional language to both parents, a fact recognised by most agencies dealing with the family. 3.7       Birth Mother discovered she was pregnant with Baby F in January 2012.  3.8       Baby F was born in autumn 2012, at North Manchester General Hospital, without any complications 4. Overview of what was known  4.1 Introduction 4.1.1 The combined chronology which is attached as Appendix B to this report, details the relevant contact incidents between Baby F, his parents and each respective agency. With the exception of the Police IMR, each IMR and the Health Overview Report includes a full detailed chronology and narrative containing all the information regarding the agency’s involvement with Baby F. GMPs chronology is embedded within the narrative section of the Police IMR. This Section will therefore focus on highlighting the key events and contacts with the family. Section 6 will critically analyse these events and contacts. 4.2 Period up to the Birth of Baby F 4.2.1 The first contact between the family of Baby F and agencies, at which the existence of Baby F was identified occurred on 5th, January 2012, when Birth Mother presented herself to a Midwife at the local children’s centre in Langley, Middleton. 4.2.2  It was estimated that Birth Mother was in the early stages of pregnancy. It was recorded at this appointment that Birth Mother did not speak English and was accompanied by a family friend, not further described, who translated for her. The Midwife at the children’s centre formally referred Birth Mother onto Maternity Services, and an appointment was made for a booking interview with a request for an interpreter to be present. 4.2.3 On 1st, March 2012, Birth Mother was seen by her General Practitioner. The GP made the relevant referrals for ante natal care for Birth Mother and her unborn child. There was no mention of the Doctor being a Polish speaker, or of an Interpreter or English speaking friend being present at this appointment.  4.2.4    On 19th, March 2012, Birth Mother attended at North Manchester General Hospital for a maternity booking appointment. An Interpreter was present.  A full obstetric and 9    medical history was taken. The existence of two “children”, residing in Poland by a previous relationship, was identified. Due to Birth Mother’s obstetric and medical history she was referred to Consultant Obstetrician, to review her medical condition and to discuss mode of delivery. 4.2.5    On 26th, March 2012 Birth Mother attended at North Manchester General Hospital following her involvement in a Road Traffic Collision.  Medical examinations and further attendances at the Early Pregnancy Unit at NMGH over the following days established Birth Mother had suffered only minor injuries.  4.2.6    From 2nd April 2012 to 17th, September 2012, Birth Mother continued to receive ante natal care from the Community Midwife and Consultant Obstetrician. At all key times the services of an interpreter were utilised.  4.2.7    Baby F was born at NMGH. The baby weighed 7.3lbs.  Birth Father and an Interpreter were present during the relevant periods.  4.2.8    During the ante natal period of Birth Mother there were no potential safeguarding issues identified. 4.3 Period from Date of Birth October 2012 to Saturday 19th, January 2013. 4.3.1    Baby F was born and continued to thrive on the post natal ward.  Staff on the post natal ward described how Birth Mother “was delighted with her baby and observed her taking and sending photographs of Baby F to her family in Poland”.  4.3.2    Whilst on the post natal ward midwifery staff noted that on one occasion communication with Birth Mother was difficult due to the language barrier, whilst other staff spoke of being able to hold limited conversations in English with Birth Mother.   4.3.3    Birth Mother and Baby F were discharged home from NMGH. 4.3.4    Between the period 13/10/12 – 26/10/12 the Community midwife visited or saw Baby F and his mother on 4 occasions. On each occasion the community midwife noted that Mother and baby were doing well. It was recorded that the community midwife provided Birth Mother with routine advice about care of herself and the baby and contact numbers for registering the Baby F with a General Practitioner and Children’s centre. The health records are unclear, but it would appear that no interpreter was present during these visits.   4.3.5    On 26/10/12 Birth Mother and Baby F were discharged by the community midwife into the care of the Health Visitor. 4.3.6    On 25/10/12 Health Visitor 1 (HV1), undertook a primary birth visit at the home address of Birth Mother and Baby F. It was recorded that there had been no contact between the Heath Visiting Service and Birth Mother during the ante natal period, due to the failure of the existing administrative systems that did not ensure that all routine notifications of pregnancy are forwarded by the Ante Natal Booking Clinic to the Health Visiting Team. Ante Natal Contact is a requirement of the Universal Service offer in the Health Visitors Service specification.  10    4.3.7    During the primary birth visit the Health visitor screened Birth Mother for post natal depression. No concerns were identified. The Health visitor also completed the Common Assessment Framework check list in respect of Baby F.  4.3.8    The Birth Father was not present during the visit, and no assessment was made about his background and role within the family. The genogram for the family was not completed.  4.3.9    No interpreter was present during the primary birth visit.  Birth Mother was present with Baby F. An unidentified ‘male friend’ was present in the house. Birth Father was out at work. The Health Visitor recognised that Birth Mother was a Polish speaker, but felt that she could converse with her, particularly with the assistance of the ‘male friend’, who was fluent in English.    4.3.10  Following the primary visit the Health visitor, in accordance with the Health Visiting Service specification, assessed the family for the Universal Offer.              Explanatory Note             The Health Visiting Service is commissioned to provide social and emotional well being advice and/or intervention to children and families in their early years of life in accordance with 4 progressive levels of Service. 1. Communities. 2. Universal Offer – to lead and deliver the Healthy Child Programme.( 2009) 3. Universal Plus Offer –to provide and coordinate tailored packages of additional care to vulnerable families 4. Universal Partnership Plus – intensive multi agency targeted care packages.      HMR Community Healthcare clearly identifies that where English is an additional            language within a family, the family should be assessed as requiring the Universal Plus offer. 4.3.11  On 28/11/12 the Health Visitor contacted Birth Father and Birth Mother by      telephone to update them on the routine blood screening test results for Baby F.  The Health Visitor spoke to both parents on the phone. She was advised that Baby F was well and the parents had no concerns. The Health Visitor informed the parents that there would not be any further visits or calls and that should they require any further advice or support, they should take Baby F to the baby clinic. No interpreter was involved in this telephone conversation as the Health Visitor felt there were no communication difficulties.  4.3.12  On 9/12/12 Birth Mother and Baby F attend the GPs surgery for a post natal examination. Both mother and child were viewed as having no health problems. The GP received the consent of Birth Mother to have Baby F vaccinated. The first vaccinations were administered on this date.  There was no evidence from the health records that the GP was a polish speaker, or used or considered using the services of an Interpreter. 4.3.13  On 16/1/13 Birth Mother took Baby F to the GPs surgery to receive his second set        of vaccinations.  11    4.4 Period from 19/1/13 – to date of Death  4.4.1 At 1528hrs, North West Ambulance Service contact Greater Manchester Police to inform them that they are dealing with an incident of a 3 month old child, unconscious and not breathing at Address1. Attempts are made by passing neighbours and arriving paramedics to resuscitate Baby F   4.4.2    At 1550hrs.Baby F arrived via ambulance at the Accident and Emergency Department of North Manchester General Hospital. On arrival waiting medical professionals recorded that Baby F had ‘no pulse rate or respiratory effort’. Baby F was given drugs and fluids for resuscitation and was intubated without complication. 4.4.3    Doctor 10 (DR10), a Polish speaking Doctor within the A&E department, took a history of what had occurred from Birth Father. It was recorded that Birth Father informed the doctor that Baby F took a feed at 1400hrs, after that he went sleep. When Baby F woke at 1500hrs, the father placed him in his arms whilst he prepared a milk feed. Baby F then developed a sudden cough and shortness of breath. He became floppy, limp and was not breathing.  4.4.4 At 1609hrs, 19/1/12 Detective Sergeant 1 (DS1) and Detective Constable 1 (DC1) attend at the hospital. They spoke with an A&E Consultant 1 (A&EC1). They subsequently record on the Police incident log that “no suspicious circumstances and no requirement for a scene”.  4.4.5    At 1812 hrs 19/1/13 DS1 updated the Police incident log with the following” The child is to be transferred to a neo natal paediatric unit for further treatment and CT scan when his condition has stabilised . The Doctor stated that he believed that the child’s condition was due to an infection” 4.4.6    At 1819hrs 19/1/13, DS1updated the Police incident log with the following” Consultant Paediatrician 1 (CP1) examined the child and stated that there were no signs of any external marks or injuries other than what had been received from medical treatment” The Police incident log at this time also recorded the information that Detective Chief Inspector 1 (DCI1) had been appraised of developments by DS1. A decision was made to remove Police Officers from the scene at Address 1.  4.4.7    Following resuscitation Baby F was investigated further with blood tests, chest X ray and a Computerised Tomography (CT) scan. Blood tests showed that Baby F had suffered a cardiac arrest. The X ray showed Pulmonary Oedema (swelling of the lungs), but no fractures. The CT scan showed Right extradural and subdural haemorrhage and Left sub arachnoid haemorrhage. The CT scan was undertaken at 1835hrs.  4.4.8   At 1838hrs Police Constable 1 (PC1), who was at NMGH on an unrelated incident, was approached by medical staff treating Baby F and requested the details of the CID officer dealing with the incident involving Baby F. The Officer recorded in his Police notebook” Poss (possible) non accidental” 4.4.9    At 1855hrs 19/1/12 CP1 telephoned Children’s Services Emergency Duty Team regarding Baby F’s injuries and his belief that they were potentially non-accidental.  At approximately the same time a similar request was made to Greater Manchester Police to attend the hospital. 4.4.10  Between 1859hrs and 1909hrs two entries were made on the GMP incident log they recorded the following information “…from the doctors, this injury is non accidental.  12    PC2 will re-start the scene. DC2 is aware and will contact the hospital shortly”, this followed by the following entry “… child has come back from CT scan and the injury shows a severe inter cranial bleed” 4.4.11  EDT Social Worker 1 (SW1) responded to the call from CP1 and attended NMGH. 4.4.12  DC2 attended the Hospital. Prior to doing so she liaised with the duty DCI1, who advised that she should attend with a member of the Divisional Public Protection Investigation Unit (PPIU). None were available at that time.  4.4.13  Upon attending the Hospital DC2 and SW1 spoke with CP1. SW1 made a verbatim note of the account of Baby F’s medical history and condition. Within her notes SW1 recorded the sentence “There is no evidence at present to suggest Baby F has been subject of NAI – nor is there evidence to state he has not”. 4.4.14  What is termed a ‘multi agency meeting’, by the GMP IMR author, was held between CP1, SW1 and DC2.  The meeting was not a formal strategy meeting as defined in Rochdale Borough SCB safeguarding procedure or Working Together 2010.  4.4.15  The meeting was timed by the Police at 1900hrs, whilst CP1 in a statement to Police after the death of Baby F recorded the meeting as taking place at 2000hrs. The SCR Panel would have expected that a written record of what occurred at this ‘multi agency meeting’, what actions or decisions were agreed and whether those actions/decisions had been circulated to all relevant agencies, would have been made. The SCR Panel requested sight of any formal record of this meeting. It was subsequently established no formal record of this meeting was made.  4.4.16  The verbatim notes made by SW1 were forwarded as part of a referral email to Children Services First Response team. The notes made by SW1 were not shared with any other agency.  4.4.17  At 2000hrs, 19/1/13 CP1 made the following entry on the PAHT case notes” Discussed with Social Services. Explained that Non accidental injury has to be ruled out”  4.4.18  At 2145hrs, Saturday 19th, January 2013 Baby F arrived at the Paediatric Intensive Care Unit (PCIU) at Royal Manchester Children’s Hospital (RMCH), following transfer from NMGH. 4.4.19  At an unknown time on Sunday 20/1/13 CP1, NMGH made a written Child Protection Referral to Children’s Services on Baby F’s admission to hospital and his concerns that the brain injuries maybe non- accidental in nature. This was written confirmation of the verbal referral of 19/1/13. 4.4.20  At 0840hrs and 0848hrs, 20/1/13, DC3 sent 2 emails to Children’s Services EDT providing a summary of what had occurred to date, an overview of the family history and an update on the medical condition of Baby F. The email timed at 0840hrs concluded with the reference “the injury was non accidental”. The subsequent email timed at 0859hrs, 20/1/13 requested a joint visit to the Hospital.  4.4.21  At 1310hrs, 20/1/13 another, what the Police IMR author refers to as a ‘Multi agency meeting’ was held at RMCH. DC3, DR12, EDT SW2 and SW3 were present. The meeting was not a formal Strategy Meeting as defined in RBSCB Multi - Agency safeguarding procedures. The SCR Panel would have expected that a written record of what occurred at this ‘multi agency meeting’, what actions or decisions were agreed and whether those actions/decisions had been circulated to all relevant 13    agencies, would have been made. The SCR Panel requested sight of any formal record of this meeting. It was subsequently established no formal record of this meeting was made.  4.4.22  At approximately 1325hrs, Sunday 20/1/13, DC3, DR12, EDT SW2 and SW3 met with Baby F parents in the presence of an interpreter at RMCH. A medical update on Baby F was provided to the parents. It was agreed that that the parents of Baby F would have supervised contact with Baby F. The parents agreed to that decision. The SCR Panel would have expected that a written record of what occurred at this meeting, what actions or decisions were agreed and whether those actions/decisions had been circulated to all relevant agencies, would have been made. The SCR Panel has requested sight of any formal record of this meeting. It was subsequently established no formal record of this meeting was made   4.4.23  At 1740 DC3 was contacted by Staff Nurse 3 (SN3) regarding the supervision arrangements for Baby F. DC3 was informed that Nurses would not be responsible for the supervision of the parents. SN3 confirmed that DR12 had not documented any decision regarding the supervision of the parents of Baby F.  4.4.24  At 1750hrs, Sunday 20/1/13 DS2 contacted SN3 to inform her that GMP would not be supervising the parents visits to Baby F.  DS2 records his rationale in his policy book -“I explained that the consultant had said that there would be supervised access but had not requested police assistance. I also outlined that the parents had had unsupervised access for a prolonged period of time since the child was admitted to hospital” He further added “ Decision made not to PPO the child as there was no immediate risk to the child . EDT SW (Emergency Duty Team Social Worker) was in agreement and involved in the decision making”              Explanatory Note.             Section 46 of the Childrens Act 1989, creates a power for Police officers to remove and accommodate children in cases of emergency. Although it is not an actual order , the exercise of this power has become known as the  ‘Police Protection Order’.             The main provision of the Section allows a constable who has reasonable cause to believe that a child would otherwise be likely to suffer significant harm, he may            (a) remove the child to suitable accommodation and keep him there; or            (b) take such steps as are reasonable to ensure that the child’s removal from any       hospital, or other place, in which he is then being accommodated is prevented.           4.4.25  At 1940hrs, Sunday 20/1/13, DC3 received a telephone call from Paediatric Registrar 3 (PR3), who expressed concerns over why Baby F had not been made subject of a Police Protection Order, and queried why the Police were treating the incident as “an injury with an unknown cause whereas the hospital were treating it as a non accidental injury”  4.4.26  In response to PR3 telephone call, DC3 contacted DS2 and made the following entry in her daybook- “No changes to be made as yet. Police have no grounds to PPO the child as the cause of injury has not been ascertained”.            4.4.27  At a time to be established on Sunday 20/1/13, but believed between 1725 and 2010hrs, PR3 completes a Child Protection Proforma. Within the document he 14    recorded the following information ‘Baby F is to be treated as a child with a non accidental injury until proven otherwise’             Explanatory Note.             A Child Protection Proforma is an internal Health document used by examining Doctors as a medical checklist where NAI is suspected. The document is retained on the medical notes of the child, and the information is used to inform all medical reports to other agencies. 4.4.28   At 1310hrs, Monday 21/1/13 Children Services Team Manger 1 (SWTM1) reviewed the information gathered by EDT in respect of Baby F. SWTM1contacted DC3 by telephone for an investigative update.  Following that conversation the following entry is recorded on ICS as her management decision – “Baby F is three months old, he has been found with Birth Father at home unresponsive. He (Baby F) has had a heart attack and was later found to have a brain bleed. No trauma evident and organic reasons are being explored. The Police are taking the lead as of yet no Child Protection concerns are established. Home conditions are good and previous care of baby F appears to have been appropriate”   4.4.29  At 0700hrs, Tuesday 22.1/13 DS3 an experienced PPIU supervisor came on duty. The officer reviewed the incident involving Baby F, and obtained medical and Children’s Services update. The officer identified that a formal strategy meeting in accordance with established Child Protection policies and procedures had not been undertaken.  She arranged for an urgent Strategy Meeting to be undertaken at 1200hrs Tuesday 22/1/13 at RMCH. This is the first time any professional in this matter had made mention of a Strategy Meeting, as defined by the Children Act 1989. 4.4.30   At 1200hrs, Tuesday 22/1/13, DS3, Investigative Support Officer 1 (ISO1), SW4, SWTM1, SGN2 and CP2 attended the strategy meeting. CP2 states in her expert opinion that the injuries sustained by Baby F were as a result of being violently shaken, but that being dropped could not be ruled out. A number of actions were allocated to partner agencies.  4.4.31  At the Strategy Meeting it was agreed that that Children’s Services would assume the role of main point of contact for information sharing regarding developments in Baby F condition and the investigation. It was further agreed that a Section 47 Enquiry would commence. The SCR Panel have been given access to the ICS record of this strategy meeting. 4.4.32  An action from the Strategy meeting held on 22/1/13 was that Children Services would provide to the PICU and the Safeguarding Children’s Team the outcome of discussions regarding the supervision of Baby F parents. 4.4.33  At 1915hrs, Wednesday 23/1/13, following discussions, Children’s Services and the Police met with the parents of Baby F. An interpreter was present. The reasons for parental supervision were explained to the parents and it was agreed that they could visit Baby F between 0900hrs- 2000hrs.  4.4.34  On Thursday 24/1/13 following discussions with SWTM1 and CP2 supervised contact that afternoon and evening were suspended.  4.4.35  On Friday 25/1/13 Children’s Services Service Manager 1 (SM1) spoke with CP2 by telephone. It was agreed that supervised contact between Baby F and his parents would cease. SM1 made the following record” Following prior discussion SW4 and 15    SWTM1 have had with CP2; CP2 agreed Birth parents presented little or no risk to Baby F on the ward, she agreed Birth parents should be treated with dignity in their last hours with Baby F and agreed Children’s services were taking appropriate action. Children’s Services has assessed Birth Parents as behaving entirely appropriately and were very loving and supportive to Baby F. Baby F was not expected to live very long. It was agreed supervision of contact would be ceased”. Children Services record that the Police “were spoken to” about the decision. 4.4.36  At 1252hrs, Friday 25/1/13 Birth Father was interviewed by Police under caution. His solicitor and an interpreter were present throughout. Birth Father provided a detailed account of his background and the events of 19/1/13. He denied causing Baby F any harm. 4.4.37  At 1847hrs, Friday 25/1/13 Birth Mother was interviewed by Police under caution. Her solicitor and an interpreter were present throughout. Birth Mother provided a detailed account of her background, pregnancy and Baby F habits and demeanour. She recalled the events of 19/1/13. She denied causing Baby F any harm. 4.4.38  At  2255hrs, Wednesday 30/1/13, Baby F died at RMCH. 4.4.39  On Friday 8th, February 2013, Birth Father was arrested on suspicion of the murder of Baby F. He was interviewed in the presence of his solicitor and an interpreter. He denied the offence maintaining he did not harm Baby F. He has been given Police bail. At the time of this report he remains on Police bail 5          Commentary on the IMRs  5.1      Rochdale Children’s Services IMR   5.1.1   Rochdale Council Children’s Services have provided a chronology and Individual     Management Review for this Serious Case Review.   5.1.2.  The report has been prepared by an Independent Consultant with experience of   Serious Case Reviews. The author has had no operational responsibility in the case or any direct involvement with Baby F and his family and as such met the criteria for independence.   5.1.3    The report was countersigned by the Assistant Director, Childrens Services, RMBC.   This individual had no direct knowledge or involvement of the services provided to Baby F or his family and as such met the criteria for independence.   5.1.4    The IMR draws on both written records and direct interviews with 2 members of staff and telephone interviews with 5 members of staff.  The IMR author responded to requests for further information, and with the assistance of SCR Panel members made a number of significant amendments , which led to the production of a more critically focused and pertinent IMR .   5.1.5    Rochdale Council Children’s Services Department had no contact with Baby F or his family until the events of the 19th, January 2013. From that date to the date of Baby F death on 30th, January 2013, Children’s Services had continued contact with Baby F and his family. . 5.1.6    The IMR is open and critical in its analysis of the service provided and has identified   key areas for improvement. The IMR author has highlighted weaknesses in individual practise, non adherence to existing child protection policies and procedures and the 16    importance of timely and accurate record keeping. These issues are subject of appropriate scrutiny, but additional critical analysis around the limited explanations offered by staff for individual failings would have enhanced the learning opportunities within the IMR. The commentary on the role of EDT staff and the access they have to the ICS computerised system, was extremely helpful, bring clarity to what had been a confused and conflicting picture.   5.1.7    There is evidence within the IMR of staff reflective learning.   5.1.8    The lessons learned and recommendations are compatible with the analysis    5.2.      Greater Manchester Police IMR  5.2.1   Greater Manchester Police have provided a chronology and Individual Management            Review for the Serious Case Review.              5.2.2   The report has been prepared by a Detective Inspector from the forces Major Crime  Review Unit. The author has had no operational responsibility in the case or any  direct involvement with Baby F and his family and as such met the criteria for  independence.  5.2.3   The Report was countersigned by the Force Review Officer who had no direct  knowledge or involvement of the services provided to Baby F or his family.    5.2.4    The IMR author has not prepared a comprehensive chronology as required by Section 8.9 Working Together to Safeguard Children 2010 and RBSCB Multi agency procedures. The chronology consists of two entries, which does not accurately reflect the interactions that GMP had with the family of Baby F or other agency partners. The IMR author has provided an explanation that the chronology reflects the only two recorded incidents reported to Police which involved Baby F and his family. The author adds that contents of additional incident logs and associated documents are detailed in the narrative section of the IMR to avoid repetition.     5.2.5    The IMR authors view is supported by the Force Review Officer who undertook the quality assurance of the IMR. The Force Review Officer quotes the under mentioned principle from the North West Safeguarding Steering Group Learning and Development Framework:              "The approach taken on learning and reviewing should be proportionate to the scale and complexity of the issues being examined."     5.2.6    The Force Review Officer states that he believes that within its current format the GMP IMR adheres to the aforementioned principle, and that any further work  in relation to the chronology is duplication for its own sake and adds nothing to the learning outcomes.             5.2.7   The SCR Panel noted the point but felt the IMR would have benefitted from a full     chronology.    5.2.8   The IMR draws on both written and computerised records and direct interviews with                  7 members of staff. The author responded to advice and feedback from the panel and consequently included additional information and analysis to strengthen the report.  17    5.2.9    Prior to the events of the 19/01/2013 GMP had no involvement with Baby F.  However between August 2008 and August 2010, GMP had contact with the Birth Father on 4 occasions as a victim of crime (Theft of Motor Vehicle), or as a complainant in incidents of Anti Social Behaviour.  5.2.10  The IMR is open and critically analyses the failure of Police Officers to follow existing Child protection procedures and policies particularly in relation to the requirements of calling a strategy meeting, and the need to accurately record and share with colleagues the decisions and actions agreed at such meetings.   5.2.11  The IMR would have benefited from greater analysis of the reasons why officers, including senior officers and those in specialist public protection roles, did not identify that a strategy meeting was required in accordance with established child protection policies.  5.2.12  The IMR contains evidence of officer’s reflective learning within their decision making processes and acknowledgments that if faced with similar circumstances they would adopt a different approach.   5.2.13  The IMR author highlights the clear non adherence to established child protection procedures in respect of the requirements to ensure that strategy meetings are called, as a significant learning episode for staff. However the IMR contains no recommendations.   5.2.14 The IMR author provides a commentary that the issues identified within this SCR are similar to issues identified in two previous SCR. (Child K 2011, a Tameside LSCB SCR, and Child W 2012, a Manchester LSCB SCR) Those SCRs made respective recommendations to GMP in respect of how to conduct inter agency strategy meetings, and the requirement for GMP to devise a standard method of how to record the discussions, actions and outcomes of strategy meetings. The IMR author then lists a host of training initiatives that GMP have undertaken since 2012/13 to address those recommendations. As a result the IMR author concludes that there is no new learning from this SCR and no requirement for recommendations.   5.2.15  The Force Review Officer concurs with the IMR author that the IMR does not need recommendations, believing that duplicating recommendations for its own sake within the SCR has little merit when work has been undertaken and is ongoing to finalise the same issues.  5.2.16 The SCR Panel believe that there are significant areas of learning around strategy meetings, which while similar to previous ones, are not identical and for that reason makes its own recommendations for GMP.  5.2.17  The panel accept that GMP has instigated training and awareness events to spread the learning from previous SCRs to staff. However the findings from this review, which examined events from early 2013, suggest that GMP’s initiatives are not yet fully embedded in practice. The SCR Panel’s recommendations should not be seen as a duplication of effort, rather a catalyst and a recognition of what still needs to be achieved. 5.3        Pennine Care NHS Foundation Trust IMR – (Health Visiting Service)  5.3.1 Pennine Care NHS Foundation Trust have provided a chronology and Individual             Management Review for this Serious Case Review. 18      5.3.2 The report has been prepared by a Registered Nurse and Health Visitor, with                            extensive experience of Child safeguarding. The author has had no operational             responsibility in the case or any direct involvement with Baby F and             his family and as such met the criteria for independence.  5.3.3    The report was countersigned by the Acting Head of Safeguarding Children for the    Trust.  This individual had no direct knowledge or involvement of the services provided to Baby F or his family and as such met the criteria for independence.  5.3.4    The IMR draws on both written records and interviews with 6 members of staff The IMR author responded to requests for further information and made a number of amendments to the IMR in the light of feedback from the Panel.  5.3.5    There is evidence within the IMR of staff reflective learning, most notably the Health Visitor who undertook the primary visit.  5.3.6    The Health Visiting Service had two contacts with Baby F and his family. A primary    visit on 25/10/12, when Baby F was seen in the presence of his mother and an unknown male. The second contact was via telephone on 28/11/12.  5.3.7    The IMR provides a comprehensive and detailed review of the service provided. It is an open and reflective IMR, which provides an overview of the expected standards and a commentary on the individual practice against those standards. It recognises missed opportunities in service provision and offers credible explanations for those individual and organisational failings  5.3.8   The IMR author has made use of appropriate research to emphasise the learning evident within the IMR.  5.3.9   The IMR is of a high standard and evidences an organisation willing to learn. The lessons learned and the recommendations flow from the critical analysis.  5.3.10  The SCR Panel have noted that many of the recommendations within this IMR have already been implemented.   5.4 Heywood, Middleton and Rochdale Clinical Commissioning Group .General Practitioner [GP] IMR 5.4.1    Heywood, Middleton and Rochdale Clinical Commissioning Group have provided a chronology and Individual Management Review for this Serious Case Review.  5.4.2 The report has been prepared by the Designated Safeguarding Nurse. The author                 has had no operational responsibility in the case or any direct involvement with Baby F and his family and as such met the criteria for independence.  5.4.3   The report was countersigned by the NHS HMR CCG Board Lead for Safeguarding             This individual had no direct knowledge or involvement of the services provided to                          Baby F or his family and as such met the criteria for independence.  19    5.4.4    The IMR draws on both written records and a direct interview with 1 member of staff The IMR author responded to requests for further information and made a number of amendments to the IMR in the light of feedback from the Panel.  5.4.5    General Practitioners within HMR CCG had contact with Baby F, or his parents on 10 occasions starting in 2009 when Baby F’s parents registered with a GP surgery.  5.4.6   The IMR is open and critical in its analysis. It provides a critical account of the GP services provided to the family. It rightly highlights the complete absence of the use of interpreting services by General practitioners in this case. This is a significant issue when dealing with patients who have English as an additional language, and the considerable impact that such omissions can have when attempting to build up a robust family history. An explanation is sought from the Lead GP for safeguarding who explains that GPs have difficulty in accessing Interpreter Services within the Rochdale Borough.  5.4.7    The IMR author utilises excellent reference material to assist her critical analysis in quoting Lord Lamings 2003 recommendation   - “It is not appropriate for friends, relatives or other practitioner colleagues to be used to interpret for the patient”.  5.4.8   The IMR makes 2 recommendations which flow from the author’s critical analysis and identification of lessons learned. However the significance and importance of General Practitioners not using interpreter services/ or not being able to access interpreter services for patients cannot be underestimated in terms of the safeguarding agenda. As a result the SCR Panel have inserted an additional recommendation.   5.5 Central Manchester University Hospitals NHS Foundation Trust (CMFT) IMR 5.5.1    CMFT has provided a chronology and Individual Management Review for this Serious Case Review.  5.5.2 The report has been prepared by the Named Nurse Safeguarding Children. The author has had no operational responsibility in the case or any direct involvement with Baby F and his family and as such met the criteria for independence.  5.5.3    The report was countersigned by the Medical Director. This individual had no direct knowledge or involvement of the services provided to Baby F or his family and as such met the criteria for independence.  5.5.4    The IMR draws on both written/computerised records and interviews with 2 members    of staff. The IMR author responded to requests for further information and made a number of amendments to the IMR in the light of feedback from the Panel.  5.5.5    CMFT had contact with Baby F and his family from 19/1/13 to the date of his death     30/1//13  5.5.6.   The IMR report is comprehensive and detailed. It has a clear focus on understanding why established safeguarding policies need to be adhered to, and the potential vulnerabilities of not doing so. The IMR is both open and critical in its analysis phase.  5.5.7    The lessons learned and recommendations are compatible with the analysis.  5.6       Pennine Acute Hospitals NHS Trust IMR 20    5.6.1    Pennine Acute Hospital NHS Trust have provided a chronology and Individual Management Review for this Serious Case Review.   5.6.2 The report has been prepared by a Consultant Midwife. The author has had no operational responsibility in the case or any direct involvement with Baby F and his family and as such met the criteria for independence.  5.6.3    The report was countersigned by the Head of Safeguarding. This individual had no direct knowledge or involvement of the services provided to Baby F or his family and as such met the criteria for independence.  5.6.4    The IMR author responded to requests for further information and made a number of amendments to the IMR in the light of feedback from the Panel.   5.6.5    The IMR draws on both written/ computerised records and interviews with 2 staff members.  5.6.6    There is no evidence within IMR of staff reflective learning.  5.6.7    The Pennine Acute Hospital NHS Trust, had contact with Birth Mother from January 2012, when Birth Mother utilised the Maternity and Midwifery services, and an additional contact when Baby F was admitted to the Accident and Emergency department of NMGH on 19/1/13.  5.6.8   The IMR is open in its approach, and provides an overview of the expected standards the respective health services provide. It recognises and highlights missed opportunities, but fails to critically analyse and reflect upon those missed opportunities. The IMR fails to provide credible explanations for individual and organisational failures.  5.6.9    There is an absence of relevant lessons learned, and the IMR makes no single agency recommendations. The SCR Panel believe that there are significant areas of learning within the Pennine Acute Hospital IMR which should be translated into single agency recommendations.   5.6.10  The SCR Panel have included a number of recommendations within the section ‘Recommendations’     5.7 Health Overview Report 5.7.1    The commissioning Health Overview Report for HMR CCG is produced in accordance with Working Together to Safeguard Children 2010, Chapter 8 – 8.30, and compiled using the agreed template and guidance designed and developed by the North West Designated Professionals in 2010. The template was subsequently agreed by the RBSCB. 5.7.2    The purpose of this report is to add value to the learning from health services and to review and evaluate the practice of all involved health professionals , including GP’s and providers commissioned by the CCG, with a particular focus on how effectively health organisations interacted together. The overview report will consider whether additional recommendations could and should be made, and if so, how from a commissioning perspective these changes will be brought about.  21    5.7.3    The Health Overview Report author has established her independence and expertise necessary to undertake the task. 5.7.4    The report was countersigned by the Executive Nurse, NHS, HMR, CCG.This individual had no direct knowledge or involvement of the services provided to Baby F or his family and as such met the criteria for independence.  5.7.5    The IMR draws on the Individual Management Reports submitted by the Health        Agencies involved with this SCR, and conversations with IMR authors and panel members   5.7.6    Overall the HOR author reports that the healthcare provided to Baby F and his family from all health services was appropriate and followed expected health practice.  5.7.7    The author identified to two themes which emerged following an examination of the Health family information:   Interpreter Services. The use of Interpreter services is not clear across Provider health services. Whilst policy and procedures exist, there is evidence of a clear disparity of the use of interpreters in the community setting by health practitioners and their use in the acute hospital settings.  There is evidence that family and friends of the family were being used as interpreters. This has been identified as a practice which falls below expected standards. This could be justified during the emergency clinical assessment of Baby F during the first 24hrs of his hospital admission, but there were other circumstances identified when this was not appropriate the cases of GP services there was no evidence that the use of Interpreters was considered.   Information Sharing. There is clear evidence of delays in information being shared between maternity and Health Visiting Services in respect of Routine Notification of Pregnancy and the Mothers Discharge.  5. 7.8    The HOR lists the recommendations made by each of the Health agencies who have submitted an IMR as part of the SCR process. The recommendations are commensurate to the HOR findings. 5.7.9   The HOR author provides a relevant commentary on the absence of recommendations within the Pennine Acute Hospitals Trust IMR. 5. 7.10   The HOR author makes one additional health recommendation within the HOR.  5.7.11  In summary the HOR is a good document which has added value to the individual health submissions.  6. Critical Analysis against the Terms of Reference. 6.1 Introduction  The terms of reference appear below in bold lettering followed by the Overview     Panel’s critical analysis, some of which is appropriate to more than one term. Where this happens, a best fit approach has been taken.   22    6.2.     How did agencies respond to Birth Mother’s pregnancy? 6.2.1    Overall those agencies within the SCR who responded to the health care      requirements of Birth Mother’s pregnancy did so in an appropriate and professional manner. All Birth Mother’s clinical and medical requirements were met. 6.2.2    There is evidence within the IMRs of the Health Agencies that health professionals involved with Birth Mother’s pregnancy recognised the requirement to utilise interpreter services, particularly during the antenatal phase of Birth Mother’s pregnancy. 6.2.3   The Health Visiting IMR author highlights the fact there is no evidence of notification of Birth Mother’s pregnancy to the Health Visiting Service from the Ante Natal Booking Clinic. As a result there was no contact between the Health Visitor and the Birth Mother in the ante natal period.  6.2.4    Good Practice Guidance (Department of Health, Healthy Child Programme 2009), acknowledges that positive outcomes for children can often be determined in the ante natal period. 6.2.5   This was a missed opportunity to undertake an assessment of the parents during the ante natal period. It may have led to a greater understanding of the parent’s social history and the identification of any additional needs, in particular language barriers. This point is both recognised and accepted by the IMR author and the Health Overview Report author. 6.2.6   The Health Visiting Service IMR highlights that routine notifications are not received for every pregnancy from the ante natal clinic, and when received details such as expected date of delivery are often missing. In addition it is highlighted that staff within the Health Visiting service fail to escalate such administrative errors to line managers. Appropriate recommendations are contained within the IMR to address this issue. 6.2.7   The issue of routine notifications from the ante natal clinic to the Health Visiting Service has not been recognised within the Pennine Acute Hospitals IMR. There are no recommendations contained within the Pennine Acute IMR. The SCR Panel will address this issue under SCR Panel recommendations. Recommendation 33 6.3       What steps did agencies take to discover the family’s background and what influence did any findings have on their assessment and decision making? 6.31     Prior to the incident on 19/1/13, which initiated this Serious Case Review only the Health professionals involved had opportunities to collect information on Baby F and his parents. It is recognised that an effective social history of a family will help in the identification of need, and how agencies can best organise service provision to cater for those needs. 6.3.2   The GP IMR provides the first examples of what will be a recurring theme within this Overview Report. Birth Father and Birth Mother are Polish nationals for which English is an additional language. When the parents first registered at a GPs surgery in 2009 the requirement for an interpreter was recognised, yet not responded to. On that occasion a medical history of both parents was obtained by the GP, utilising the parents to act as each other’s interpreter.  6.3.3    In November 2012, Birth Mother, Birth Father and Baby F re-registered at a General Practitioner surgery. The family completed a standard information form for new 23    registrations with the GP. The form was taken away by Birth Mother and Birth Father. The completed form provided a more detailed family history providing details of their arrival in the United Kingdom and details of Birth Mother’s two children who were resident in Poland. It did not provide the same information for the Birth Father. The document was not translated into Polish. The panel questioned how accurate and comprehensive the information provided was. 6.3.4   The GP IMR and Health Overview Report author has clearly articulated within both reports that GPs missed opportunities to provide a more detailed assessment of the family. The IMR author makes sensible recommendations to resolve those concerns. 6.3.5    On 5/1/12 Birth Mother attended at the Children’s Centre, Middleton, where the Midwife assessed Birth Mother as being 7 weeks pregnant. A family friend attended with Birth Mother. The midwife acknowledged on this first meeting with Birth Mother that English was an additional language and that the services of an interpreter would be required to ensure that she had a full understanding of her condition and the care available and provided to her. The Pennine Acute IMR records that an interpreter was present with Birth mother throughout her ante natal care by the maternity Service. This is an example of good practice. 6.3.6    The Booking in Midwife obtained from Birth Mother a wealth of personal and family medical history which could have an impact upon her pregnancy and the health of the unborn baby. However the midwife failed to ask Birth Mother questions around the role of the Birth Father and Domestic Violence. The omission is rightly documented within the Pennine Acute IMR, and an explanation provided. However the SCR Panel believe a specific recommendation is required within the IMR. This will be addressed under SCR Panel recommendations. Recommendations 23 and 24. 6.3.7    An explanation was offered that the Midwife did not have an opportunity to speak with the Birth Mother alone. The Good Practice Guidance (Department of Health 2012) does support not asking the individual in the presence of another person. However the guidance also states that there is a need for opportunity to be created at a later time to ask this question of all pregnant women during the antenatal period. Did the fact that an independent interpreter was present with Birth Mother at subsequent ante natal appointments prevent that happening? If so, what is the advice to staff on how to seek information about Domestic Violence from women who have English as an additional language and require the services of an interpreter? 6.3.8    The panel reflected on the issue of whether the presence of an independent interpreter with Birth Mother at subsequent ante natal appointments adversely affected the midwifery staff s ability to ask the relevant questions about Domestic Violence. The IMR author has not within the IMR made any single agency recommendations. This will be addressed under SCR Panel recommendations. Recommendation 23.  6.3.9    Birth Mother gave birth to Baby F in October 2012. Birth Father and an interpreter were present with Birth Mother at NMGH. 6.3.10  Following the Birth of Baby F and the subsequent post natal care at the hospital, the panel noted the stark difference in the provision of interpreter services to Birth Mother. Whereas those staff providing ante natal care clearly identified the need to provide Birth Mother with interpreting services those engaged in providing post natal and community care singly failed to recognise this important issue.  24    6.3.11  The Pennine Acute IMR provides commentary on the fact that whilst on the post natal ward, the Sister in charge believed that Birth Mother’s English was of sufficient standard to understand “instructions, information and advice”. In addition between 13/10/12 and 26/10/12 the Community Midwife saw or visited Birth Mother and Baby F on 4 occasions. No interpreter was present during these visits. The Community midwife reported that “she could hold limited conversations with Birth Mother about key aspects of her care and felt that Birth Mother understood what she was saying to her”. 6.3.12 The panel were concerned as to how the Ward Sister and Community Midwife came to their respective decisions about Birth Mother’s fluency in English. Decisions that are in clear contradiction to what is recorded on Birth Mother’s ante natal record. The SCR Panel queried whether ante natal patient records are forwarded in their entirety to staff providing post natal care. The Pennine Acute Hospital IMR does not contain any recommendations. The issue of ensuring post natal staff recognise the need to utilise Interpreting Services will be subject of a SCR Panel recommendation. Recommendation 34. 6.3.13  On 25/10/12  a Health Visitor undertook a primary visit with Birth Mother and Baby F at address 1.Unbeknown to the Health Visitor, Birth Mother’s discharge notification pack included information that Birth Mother required the services of an interpreter. The IMR Author reports that it is not uncommon for the discharge notification packs from Maternity Services to Health Visiting teams to be subject of delay. The IMR author makes appropriate recommendations within the IMR to address this issue. 6.3.14  The primary visit was therefore undertaken without the services of an interpreter. An ‘unknown’ male was present in the house who spoke fluent English. This male has never been identified, nor has his relationship to Birth Mother or Birth Father established. This is worrying given the well documented dangers of hidden males (Brandon et al 2010; Ofsted 2010, Ofsted 2011)  6.3.15  The assessment undertaken by the Health Visitor recorded the family’s ethnicity and recorded that Birth Mother had 3 children living in Poland. The Review has established that Birth Mother has 2 children living in Poland. The SCR Panel do not believe that Birth Mother provided inaccurate information, as she would know how many children she had. It highlights the fact that inaccurate information was recorded on such a fundamental issue, and is clear evidence of the requirement to provide interpreting services for those patients who have English as an additional language. 6.3.16 The Health Visitor did not complete a genogram which would have aided a fuller assessment. The Birth Father’s history was not explored and only his name and date of birth was recorded. The IMR author comments upon this weakness and links the omission to a previous recommendation within a SCR. The IMR author makes appropriate recommendations to address this issue. 6.3.17 The Health Visiting IMR author views this primary visit as incomplete. A view shared by the SCR Panel. The assessment failed to take due cognisance of English being an additional language for the family. As a result the family were assessed as requiring the Universal Offer of support, when the assessment should have assessed them as requiring Universal Plus Offer, in accordance with the Health Visiting Service Specification. 6.3.18  Had the family been assessed correctly they would have received a second home visit by the Health Visitor some 6 weeks after the primary visit. This could have provided a more opportune occasion for a more detailed assessment of the family 25    and their needs to be undertaken, especially as the Health Visitor would have now been in possession of the invaluable information that Birth Mother required the use of an interpreter. This was a missed opportunity.  6.3.19  Within the Health Visiting IMR the author provides a helpful contextual overview of the organisational changes that were occurring within the Health Visiting Teams during 2012/13 which provides an explanation as to how service delivery was being prioritised.  6.3.20  Following Baby F admission to Hospital, his medical needs were appropriately assessed and catered for. 6.3.21  All agencies within the SCR have been able to describe the systems that are in being to collect information about the family composition and circumstances to assist the assessment making process. Despite this, relevant agencies have highlighted the missed opportunities that existed to obtain greater detail that would allow a clear family history to emerge. The importance of securing a clear family history is recognised as the first step in understanding and recognising potential vulnerabilities in children.  6.4      What were agencies assessments of the parenting abilities of both parents and how did agencies identify and manage any risks? 6.4.1    Prior to the incident on 19/1/13, health agencies contact with Baby F and his Birth Mother were very favourable. It is acknowledged by health agencies that assessments undertaken may have been more rigorous and complete, but there were no indications that Birth Mother was not coping, or Baby F was in any way vulnerable.  6.4.2    When Birth Mother attended at the ante natal clinic at the Children’s Centre on 5/1/12, Birth Mother was in terms of the Department of Health definition, an ‘older mother’, being aged over 27years. The panel are aware that Birth Mother has two grown up children in Poland the youngest being born almost two decades ago meaning that her maternity experiences were not current. The SCR Panel were concerned that there appeared to be no assessment of the Birth Mother’s age or the impact of being an older mother in a different country/culture than her previous pregnancies, in respect of her health and emotional wellbeing.  6.4.3   Significantly, neither the Community Midwife nor the Health visitor who undertook the primary visit saw the Birth Father or would appear to have discussed and explored with the Birth Mother the role Birth Father was undertaking in parenting Baby F.  6.4.4    It is a matter of record that Serious Case Reviews undertaken across the Country have persistently identified that all sources of information should be used to inform assessments and that there is a failure to take men into account in assessments. (Brandon et al 2010; Ofsted 2010, Ofsted 2011). The SCR Panel felt it would have been advantageous had investigations been undertaken to establish Birth Father’s role and influence. 6.4.5    On his admission to RMCH Hospital, CMFT staff initiated Manchester Safeguarding Children Board, multi agency protocol – Supervision of parents of Children and Young People in Hospital (October 2008) “and the “Guidance for inter agency working between health staff and the Police in Child Protection Investigations in severely ill or injured children Central Manchester University Hospitals NHS 26    Foundation Trust (CMFT), produced January 2012 by CMFT and Greater Manchester Police”. This is viewed by the panel as good practice 6.4.6    It is evident that there was detailed discussion between all agencies around the need to balance the parent’s wishes to be close to their dying son, with the need to safeguard Baby F, albeit this came several days after his admission to hospital. The requirement for parental supervision was agreed. The panel took cognisance of the fact that RBSCB does not have a ‘Parental Supervision of Children In Hospital’ policy parental supervision in hospital policy, but expressed concern that once a decision to have the parents of Baby F subject of parental supervision, that supervision should have been put in place as a matter of urgency. In this case Baby F was in the presence of his unsupervised parents for 95 hrs before supervisory staff were in place. The SCR Panel view this as poor practice. 6.4.7   The decision to remove the requirement for the parents of Baby F to be supervised when visiting their son on 25/1/13 was appropriate, sensitive and compassionate without any significant compromise to his safety.   6.5       Was agencies management of risk in compliance with their procedures and     those of RBSCB?  6.5.1    It is evident from the individual Health IMRs and the Health Overview Report, that overall, clear assessments of risk were undertaken in respect of Baby F. Those assessments were undertaken promptly and were compliant with established procedures. 6.5.2   There were two areas of procedures within health that caused the SCR Panel a little concern. Within the Pennine Acute Hospital IMR it is acknowledged that Birth Mother was not asked by the booking midwife questions regarding Domestic Violence/Abuse. It is acknowledged within the IMR and an explanation given. However it is within the knowledge of SCR Panel members that this omission has been highlighted in a previous Single Agency Report – case of DS. The IMR author would appear not to have established that point or made a suitable recommendation to highlight the issue. 6.5.3   The second procedure relates to the primary visit undertaken by the Health Visitor to Birth Mother and the absence of an assessment of the Birth Father, his background, and his role within the family. The IMR author helpfully acknowledges that this important aspect of assessment of family need has been subject of a recommendation within a previous SCR (Children Q and R in 2012). The panel were reassured by the IMR author’s appraisal of the issue, the presence of an appropriate recommendation, and the information of forthcoming governance meetings to discuss the work undertaken to address this issue. 6.5.4   Staff within the Royal Manchester Children’s Hospital responded to the potential risk of harm to Baby F by initiating the guidance within Manchester Safeguarding Children Board, multi agency protocol – Supervision of parents of Children and Young People in Hospital (October 2008) “and the “Guidance for inter agency working between health staff and the Police in Child Protection Investigations in severely ill or injured children Central Manchester University Hospitals NHS Foundation Trust (CMFT), produced January 2012 by CMFT and Greater Manchester Police”.  6.5.5    It has become evident during this SCR that Rochdale Borough Safeguarding Children Board, does not have Parental Supervision of Children In Hospital policy.  27    6.5.6    It was clearly a source of great frustration to hospital staff that despite repeated requests to Children’s Services and the Police to act within the guidelines established within these two documents, no timely response was achieved. The SCR Panel agreed that this state of confusion is a direct result of professionals failing to recognise the requirement to call a strategy meeting in accordance with established RBSCB child protection policies. 6.5.7    Prior to the 19/1/13 Children Services had no contact with Baby F or his family. The Police had come into contact with the father of Baby F, but only as a victim of a crime and a witness to incidents of anti social behaviour. Following Baby F admission to hospital with unexplained injuries, both agencies responded promptly to those reports 6.5.8    By 1900hrs, 19/1/13 sufficient information was in possession of the Police and Children Services about the nature of Baby F injuries and the potential risk that maybe posed to him by either or both his parents, for a strategy meeting  to be convened in accordance with existing child protection policy and guidelines . 6.5.9    Meetings did take place between the Police, Children Services and Health Professionals at 2000hrs 19/1/13 and the following day at 1310hrs 20/1//13. These meetings did not constitute a strategy meeting. The failure to convene a strategy meeting in these circumstances is a fundamental failure to adhere to a key child protection policy. It is highlighted by the SCR Panel as an example of poor professional practice.  6.5.10  Both the Childrens Services and the Police respective IMRs acknowledge that a strategy meeting should have  been convened on the evening of 19/1/13 , and the failure to do so meant that existing child protection procedures were not adhered to. 6.5.11  The SCR Panel were confused and concerned by the entry within the Children Services IMR at Paragraph 8.6. - “EDT staff can access ICS to see records but cannot input into the system. As a Strategy Meeting has to be triggered by the entry to the ICS record the EDT team cannot record having organised or held one”.  This was a view expressed by staff to the IMR author.  However the SCR Panel sought and obtained absolute clarity from the Interim Head of Service Care for Children, that this situation was not the case. At present all RMBC childcare sessional workers working within EDT can read and write to ICS. However Agency staff who work on an ad hoc basis within EDT have read access only to the ICS. Confirmation was received by the SCR Panel that the EDT Social Workers who were on duty during the relevant periods of this SCR had full access to the ICS system. The SCR Panel were informed of the ongoing work within EDT to have all staff trained to both read and write to the ICS system.  6.5.12 The SCR Panel are clear in their opinion that a strategy meeting was required by the evening of 19/1/13. The meeting, and the subsequent meeting on 20/1/13, do not amount to strategy meetings in accordance with RBSCB child protection policy. As a result the SCR Panel believe that in this respect Children Services and GMP, they did not effectively manage the risks posed to Baby F in compliance with existing RBSCB Child Protection policy and procedures. 6.6      To what degree did agencies in gathering information , making assessments and delivering services take account of issues such as ; - race and culture(including isolation), language ( including interpretation services), age, disability, faith, gender, sexuality and economic status  and how did this impact upon agencies assessment and service delivery? 28    6.6.1   All agencies recorded the fact that Birth Mother and Birth Father were White Polish nationals, who spoke English as an additional language. 6.6.2    With the exception of the GP IMR, all agencies recognised that Interpreting services would be required when dealing with the Birth Parents. The author of the GP IMR rightly highlights the situation that no attempts were made by GPs to access interpreting services for the birth parents, which led on one occasion to the unacceptable situation of the respective parents being used as interpreters for each other. The apparent reluctance of GPs to utilise interpreting services is addressed within the IMR recommendations. 6.6.3    During Birth Mother’s pregnancy with Baby F, Maternity Services providing ante natal and labour services, recognised that English was an additional language to Birth Mother and promptly ensured that interpreting services were in place for future visits by the Birth Mother .This provides clear evidence of a service recognising and responding positively to the diversity needs of a service user.  6.6.4    In terms of the provision of interpreting services to Birth Mother there is a stark contrast between the service provided by the ante natal service to that provided by the post natal and community midwife service. At no time during Birth Mother’s contact with either service are interpreting services utilised. Staff within those agencies made assumptions, based on unknown criteria, that Birth Mother could speak and understand English to a satisfactory level.  The SCR Panel can find no evidence that staff within the post natal and community midwife service undertook any exercise to ensure that Birth Mother understood the information being communicated to her. 6.6.5   The SCR Panel questioned how there could be such a distinct difference in the service provision in respect of interpreting services between the ante natal service and the post natal and community midwife service. The issue is not addressed within the Pennine Acute Hospitals IMR, but will be subject of a SCR Panel recommendation. Recommendation Number 34. 6.6.6   The Health Visitors IMR provides evidence of how a failure to recognise the cultural needs of a family can have a direct result on assessment of need and service provision. The family were assessed for the Universal offer. The Health Visiting Service specification identifies that where English is an additional language the assessment should be one of Universal Plus services.  6.6.7    Following Baby F admission to Hospital it is evident to the SCR Panel that all agencies involved recognised the language barriers faced by the parents of Baby F. Health professionals at the Royal Manchester Children’s Hospital utilised the CMFT Interpretation and Translation services and applied the CMFT interpretation Policy (March 2012) 6.6.8    Although agencies recognised the language barriers faced by the parents of Baby F, there were occasions when agencies recognition of those language barriers differed. Within the Children Services IMR, a commentary is provided of how Social workers attending the strategy meeting on 22/1/13, recognised the need to ensure that interpreting services were utilised to ensure that the parents of Baby F fully understood the implications of the Child Protection and Investigative processes that were being undertaken by the respective agencies. It was perceived by Social Workers that Police Officers present at the strategy meeting did not agree with that assessment of the parents vulnerabilities. As a result appropriate challenges were made between agencies, and the matter was escalated to senior management for 29    resolution. The use of respectful and appropriate challenge is viewed by the SCR Panel as an essential part of good interagency working.    6.6.9   The provision of interpreting Services does not guarantee that the information being provided has been processed and understood by the distressed family members, particularly when the information is of such a sensitive and emotive nature. There are clear examples within the CMFT IMR and Children Services IMR of how Health and Social Work professionals recognised this issue and sought to establish the parents understanding of what was happening to their son. This is viewed as good practice 6.6.10 The Children Services IMR provides additional evidence of support to the parents of Baby F in ensuring that they had an understanding of the legal and child protection processes that were in being. This included providing the parents with a list of solicitors who provided a foreign language service. In addition Children Services staff recognised the religious needs of the family and facilitated contact with the Hospital chaplain. This is viewed as good practice. 6.7      What child protection procedures did your agency follow after Baby F was admitted to hospital and were they fit for purpose? 6.7.1    When Baby F was taken to the accident and emergency Department at North Manchester General Hospital, the focus of all health professionals was on the welfare of the child and efforts to sustain his life. 6.7.2    Greater Manchester Police were the first agency to respond to investigate the circumstances surrounding Baby Fs injuries rather than his immediate medical requirements. The immediate response is in keeping with established Police procedures. Police Officers are sent to the address to secure the premises and any potential crime scene. Duty CID officers are despatched to the hospital to commence the investigation, and specialist officers from the Forces Public Protection Investigation Unit are contacted and made aware of the incident. In addition two Detective Chief Inspectors are made aware of the ongoing incident.  6.7.3    GMP have not submitted as part of the Serious Case Review process a comprehensive chronology, and therefore the Overview Author is confined to assessing Police activity and decision making activity against the narrative contained within the IMR submitted by GMP. 6.7.4    DS1 and DC4 arrive at the NMGH at 1609hrs, some 19 minutes after Baby F was admitted to the hospital. The officers speak to A&EC1 .At 1735hrs DS1 updated the Police Incident log  ( FWIN 1446 19/1/13), with the following entry:           “...full update to follow, no suspicious circumstances and no requirement for a scene”. 6.7.5    At 1812hrs DS1 provides a more detailed entry on the incident log:    “...from consultation with A&EC1, he stated that the prognosis of the child was hopeful as although on a respirator the child was trying to breathe himself and had a pulse on arrival at the hospital. The child is to be transferred to a neo-natal paediatric unit for further treatment and CT scan when his condition has stabilised. The doctor stated that he believed that the child’s condition was due to an infection”.            6.7.6.    As a result of DS1 conversation with A&EC1, DS2, PPIU, makes the following untimed entry into his daybook sometime after 1600hrs, 19/1/13; 30               “Informed from the C.I.D. that the child with the injury re FWIN 1446 19/01/13 has been examined by consultants at the hospital and the diagnosis is biological not an injury and that police attendance is no longer required; not being treated as suspicious by hospital staff. No further involvement required by the PPIU at this time 6.7.7   As a result of these logs, and after consultation with DCI1, the secured scene at Address 1 was released and Police investigations were ceased. 6.7.8.   Due to the absence of a comprehensive Police chronology, the Police IMR is not explicit as to what the focus of initial Police activity was. There is no mention of treating this incident as a “Non Accidental Injury”, or Criminal assault. The fact that a potential ‘crime scene’ was established and protected is indicative of a cautious approach to a suspicious incident. However that cautious approach was allowed to drift. At this stage of the incident the SCR Panel formed a view that the Police decision to accept a preliminary medical explanation, without the benefit of test results and the result of a CT scan, of which they had knowledge of, was premature. 6.7.9    It was within the experiences of all SCR Panel members that children can present at Hospitals with no visible injuries, yet have sustained life threatening internal injuries. 6.7.10  The SCR Panel also commented on the actions of A&EC1 the A and E Consultant who initially provided the information to Police Officers that a possible cause of Baby F condition was an infection. Although the Doctor agreed that a CT scan should be undertaken, the SCR Panel raised the issue of what safeguarding training is provided to A and E staff. A&EC1’s initial professional judgement may have been that the Baby F condition was as a result of an infection, (sepsis), but felt that he should have inserted into his opinion the safeguarding caveats in respect of undertaking a differential diagnosis to eliminate injuries linked to child abuse. 6.7.11 The conversation between the Police and A&EC1 highlights different cultures in medicine and policing in respect of injuries to children. The Police mindset in this incident is almost one of wanting an unequivocal diagnosis of NAI before taking investigative action. Medical diagnosis of NAI is difficult in babies, and A&EC1 mention of Sepsis undoubtedly wrong footed the attending Police Officers. The SCR Panel speculated how inquisitive the initial Police Officers who attended the Hospital had been. Did they specifically ask A&EC1 how the injuries could have been inflicted? If they didn’t ask, it is the opinion of the panel that they should have done. There appeared to be reluctance amongst those Police Officers and Social Workers attending at the Hospital within the first 48hrs to ask relevant questions of medical staff in respect of possible causes for injury.  6.7.12  Baby F underwent a CT scan at 1835hrs, 19/1/13. The results showed that he had ‘Acute right extradural and subdural haemorrhages and quantilateral left subarachnoid haemorrhages’.  6.7.13  At 1838hrs, PC1 is at NMGH on an unrelated matter when he is approached by medical staff treating Baby F, requesting that the CID are contacted in relation to the medical condition of Baby F. An entry timed between 1859hrs and 1909hrs, on the following comment is placed on the Police Incident log:            “... from the doctors, this injury is non-accidental. PC2 will re-start the scene. DC2 is aware and will contact hospital shortly”            31    6.7.14  At 1855hrs 19/1/12 CP1 rings Children’s Services Emergency Duty Team regarding Baby F admission to hospital. The Emergency Duty Team Social Worker SW1 takes the call and makes her way directly to NMGH. 6.7.15  DC2, an Officer with limited safeguarding experience attended the Hospital. Prior to doing so she contacted DCI1 who suggested that she should attend with a member of the PPIU. The officer sought that assistance. However PPIU staff go off duty at 2000hrs each day. The SCR Panel were surprised that a specialist unit tours of duty did not go beyond 2000hrs.This is subject of a recommendation under SCR Panel recommendations. Recommendation number 27. 6.7.16  The SCR Panel queried whether DC2 sought additional advice from her immediate supervisors or DCI1, on discovering that no PPIU staff were available to accompany her to the meeting. It is clear from DCI1 initial instruction that he believed a ‘specialist’ was required at the meeting. It can only be a matter of speculation, but would the presence of a member of the PPIU team at the meeting on 2000hrs 19/1/13 have made a significant difference in respect of the requirement to convene a strategy meeting?    6.7.17  At this stage in the proceedings the medical evidence indicates that Baby F has suffered significant harm, the Police have recorded within their incident log that Doctors believe this to be a NAI, and Police have re- established crime scene security measures at Address1. Section 47 Children Act 1989 procedures should also have been followed and a strategy meeting called.  6.7.18  At approximately 2000hrs, Saturday 19/1/13, what is termed a ‘multi agency’ meeting within the Police IMR is held at NMGH. DC2, SW1 and CP1 are present. Despite the information that at this stage is known about the injuries to Baby F, and the comments from CP1 that “ NAI could not be ruled out”, neither the Police nor Children Services initiate the existing RBSCB Child protection policies and procedures in respect of calling a strategy meeting. The SCR Panel felt that this was a significant oversight by both agencies, a fact recognised and accepted by both the respective agencies. 6.7.19  Rochdale Borough Safeguarding Children’s Board Child Protection Procedures states:              “2.4 Strategy Discussions Involving the Children’s Social Care    Department, the Police and Other Agencies   2.4.1. Whenever the Police or Children’s Social Care have reasonable cause to suspect that a child is suffering, or is likely to suffer, significant harm there should be a strategy discussion between them and other agencies or professionals, as appropriate, in particular any referring agency. Where a medical examination may be needed, the relevant paediatrician/doctor should be included in the strategy discussion.   2.4.2. A strategy discussion will take place, whenever a referral and an Initial Assessment (or new information on any case open to Children’s Social Care) indicates that a child is suffering, or is likely to suffer, significant harm.   2.4.3. A strategy discussion may take place at a meeting, or by telephone. Any information shared, or decisions reached, and the basis for those decisions, should be clearly recorded by all parties to the discussion.  2.4.4. The strategy discussion should be used to:  32     a) share available information;   b) decide whether Child Protection Enquiries under section 47 of The Children Act 1989 should be initiated, or continued if they have already begun;   c) decide whether or not any enquiries/investigation are to be carried out jointly by Children’s Social Care and the Police;   d) discuss how to proceed in a way which will not place the child or others at further risk (e.g. where there is domestic violence);   e) plan how enquiries should be carried out, and by whom;   f) discuss arrangements for any necessary medical treatment;   g) agree what action is needed immediately to safeguard the child, and/or provide   interim services and support;   h) decide on the most appropriate timing of parental involvement;   i) determine what information about the strategy discussion will be shared with the family, unless such information sharing may place a child at risk of significant harm or jeopardise Police investigations into any alleged offence(s)                       General   2.5.1. Those conducting Child Protection Enquiries regarding any individual child should always consider the need for protection of any other children in the alleged abuser’s home, extended family, work or community life.”   6.7.20  The aforementioned extract from RBSCB Child Protection policy and procedures was in being during the time of this incident. In July 2013, The Greater Manchester Safeguarding Partnership produced almost similar guidance for LSCBs within the Greater Manchester area, and Paragraphs 5.56 – 5.60 Working Together 2010, provided similar guidance to practitioners.   6.7.21  There can be no doubt that the staff, who attended the meeting at 2000hrs, 19/01/13, at NMGH, did so with the best of intentions. However the meeting that took place failed to address key concerns that would develop into significant issues over the next 2/3 days. These included who was the lead agency, arrangements for supervised visits and the communication issues with the parents of Baby F.  6.7.22 The lack of a strategy meeting meant that full consideration was not given to all the child safeguarding /protection issues, and that Police and Children’s Services activity was not carried out under the protection and accountability of the formal strategy meeting. The framework of policy and procedures are there to protect the child, but also the agency professionals working with and for that child. 33    6.7.23  The SCR Panel recognised the initial confusion and uncertainties that existed when Baby F was first admitted to Hospital, but the strategy meeting is the framework for working and delivering outcomes around that uncertainty.  6.7.24  The SCR Panel can find no minutes of the meeting held at 2000hrs 19/1/13. What does exist are notes made by SW1 and an updated Police incident log made by DC2. The SCR Panel felt that neither written record established and recorded the fact that this was a NAI investigation. Indeed there is almost a suggestion that there are more plausible medical reason for the injuries sustained by Baby F. These record entries may well have influenced other colleagues thought processes.  6.7.25  Baby F was transferred to the PICU AT Royal Manchester Children’s Hospital late on Saturday 19/1/13. 6.7.26  On the morning of Sunday 20/1/13, following consultation between DCI1 and DCI2. It was agreed that DS2 from the PPIU would assume control of the incident. Despite receiving an up to date briefing it is unclear from the Police IMR whether GMP are actively dealing with this incident as a NAI. The panel raised concerns that despite the input of two DCIs and a D/S Sgt from the PPIU, there was no recognition that a strategy meeting should have been called the previous night, and no suggestion, direction or advice that Police staff should initiate a strategy meeting on that Sunday. The issue of guidance to staff on conducting strategy meetings is addressed under SCR Panel recommendations. Recommendation Number 25. 6.7.27 At 1310hrs, Sunday 20th, January 2013 another ‘Multi agency meeting’ is held at RMCH. DC3, DR12, EDT SW2 and SW3 are present. This was another missed opportunity to adhere to the existing RBSCB Child protection procedures and policies.  6.7.28  The two missed opportunities to call a strategy meeting by the Police and Children Services are viewed as significant failings by the SCR Panel. What occurred later that afternoon provides cogent and compelling evidence of why professionals to need to adhere to existing child protection policies and procedures. 6.7 29  At 1740 20/1/13 DC3 is contacted by SN3 regarding the supervision arrangements for Baby F. DC3 is informed that Nurses will not be responsible for the supervision of the parents. SN3 confirms that DR12 has not documented any decision regarding the supervision of the parents of Baby F. This confusion and lack of clarity emanates from poor record keeping and communication with those who attended the meetings and those tasked with undertaking relevant actions. 6.7.30 At 1750hrs, Sunday 20/1/13 DS2 contacted SN3 to inform her that GMP would not be supervising the parents visits to Baby F.  DS2 records his rationale in his policy book -“I explained that the consultant had said that there would be supervised access but had not requested police assistance. I also outlined that the parents had had unsupervised access for a prolonged period of time since the child was admitted to hospital” He further added “ Decision made not to PPO the child as there was no immediate risk to the child . EDT SW (Emergency Duty Team Social Worker) was in agreement and involved in the decision making”.            6.7.31 The SCR Panel present this as yet another example of where an opportunity was missed to initiate a strategy meeting. Health professionals are clearly concerned over the issue of supervised visits. The Police are unaware of who was tasked to provide staff for those unsupervised visits. There was no consideration of calling a strategy meeting in person or by telephone to resolve this pressing issue. Within the Police 34    IMR it is recorded that DS2 decision making was ratified by DCI2. The SCR Panel felt that this was additional evidence that guidance around how to manage strategy meetings is required within GMP. 6.7.32 The SCR Panel were concerned about the arrangements for the supervised visits of the parents of Baby F. The panel can find no record of the rationale for the supervised visits, who was to undertake the responsibilities of the visits and whether the parents of Baby F had been consulted in any way. Clearly a decision had been undertaken to supervise the parents, but some 4 hrs after the 1310hrs meeting, with the parents present at his bedside, no supervision was in place.  This was an unacceptable situation and potentially placed Baby F at risk of further injury. 6.7.33  At 1940hrs, Sunday 20/1/13, DC3 received a telephone call from PR3, who expressed concerns over why Baby F had not been made subject of a Police Protection Order, and queried why the Police were treating the incident as”an injury with an unknown cause whereas the hospital were treating it as a non accidental injury”  6.7.34  In response to PR3 telephone call, DC3 contacted DS2 and made the following entry in her daybook- “No changes to be made as yet. Police have no grounds to PPO the child as the cause of injury has not been ascertained”. The SCR Panel are in agreement that the Police were right not to initiate powers under Section 46, Childrens Act 1989, but not for the reason provided by DC3. 6.7.35  The SCR Panel once again regard this conversation as another missed opportunity to call a strategy meeting. Concerns are being voiced by a Health professional around Police action and the status of the Police investigation. The Police response to the Doctor is somewhat muted Some 24 hrs after Baby F had been admitted to hospital the Police are unable to confirm that their investigation is one based on a NAI.   6.7.36  During the events of Sunday 20/1/13, the timings cannot be accurately established, CP1 at NMGH, completes and submits a child protection referral in respect of Baby F. The referral raises concerns that the injuries to Baby F are non accidental in nature. The concern raised by a health professional should have instigated a strategy meeting in accordance with established child protection policies. The failure to do so is regarded by the SCR Panel as poor practice. 6.7.37  At 1310hrs, Monday 21/1/13 SWTM1 reviews the information gathered by EDT in respect of Baby F. SWTM1 contacts DC3 by telephone for an investigative update.  Following that conversation the following entry is recorded on ICS as her management decision – “Baby F is three months old, he has been found with Birth Father at home unresponsive. He (Baby F) has had a heart attack and was later found to have a brain bleed. No trauma evident and organic reasons are being explored. The Police are taking the lead as of yet no Child Protection concerns are established. Home conditions are good and previous care of baby F appears to have been appropriate”   6.7.38  The SCR Panel viewed the review of the case undertaken by SWTM1 as not being effective. A call was made to the Police, and medical information was received from the Police. There was no attempt to corroborate what medical information had been obtained from the Police by direct contact with the health professionals who were caring for Baby F. Limiting the information gathering to a conversation with a Police Officer, was a significant failing, and a missed opportunity to acquire the holistic overview of Baby F’s medical condition, and safeguarding requirements.  An effective 35    review of this case must surely have raised the issue of a failure to adhere to existing RBSCB child protection policies and procedures in respect of calling a strategy meeting. In addition there is no mention of the issue of parental supervised visits.  Some 24hrs after the 1310hrs, meeting of Sunday 20/1/13 supervised visits have still not been commenced. The SCR Panel view this episode as another missed opportunity to call a strategy meeting and continued poor practise in respect of absent parental supervision.  6.7.39  At 0700hrs, Tuesday 22/1/13 DS3 an experienced PPIU supervisor paraded for duty. The officer reviewed the incident involving Baby F, and obtained medical and Children’s Services update. The officer identified that a formal strategy meeting in accordance with established Child protection policies and procedures had not been undertaken.  She arranged for an urgent strategy meeting to be undertaken at 1200hrs the same day at RMCH. This is the first time any professional in this matter has made mention of a Strategy meeting. Within DS3 policy book the following entry is found “Reviewed case, concerns by myself in relation to a possible NAI, Treat as such unless proven otherwise”. The SCR Panel recognise the leadership displayed by DS3, but would highlight that it took 4 days for a GMP Officer to recognise and succinctly sum up the nature of this investigation.  6.7.40  At 1200hrs, Tuesday 22/1/13, a formal strategy meeting in accordance with RBSCB policies and procedures was held at RMCH. At this meeting CP2 provided expert medical opinion that the injuries to Baby F were as a result of being violently shaken, but that being dropped could not be ruled out.  6.7.41  Within Children’s Services IMR, at the strategy meeting, held on 22/1/13, it was agreed that that Children’s Services would assume the role of main point of contact for information sharing regarding developments in Baby F condition and the investigation. The SCR Panel expressed the view that following the confirmation of a NAI injury that the Police should have assumed lead status.  6.7.42  An action from the Strategy meeting held on 22/1/13 was that Children Services would provide to the PICU and the Safeguarding Children’s Team the outcome of discussions regarding the supervision of Baby F parents. The SCR Panel noted that despite discussions unsupervised visits continued. 6.7.43  At 1915hrs, Wednesday 23/1/13, following discussions, Children’s Services and the Police met with the parents of Baby F. An interpreter was present. The reasons for parental supervision were explained to the parents and it was agreed that they could visit Baby F between 0900hrs- 2000hrs. The SCR Panel noted that the parents of Baby F agreed to the time constraints placed on visits to their son. In light of the emotional stress that the parents must inevitably have been suffering, did they fully comprehend and understand what was being asked of them and was it appropriate to ask them? 6.7.44 The panel queried whether, at this time, due consideration had been given to the needs, emotional and physical, of the parents to be with their son during his last few days of life. Supervised visits consisted of 11hrs of access. The SCR Panel were concerned that the hours of supervision had been formulated for the benefits of agencies and not for the wellbeing and best interests of the parents and Baby F. Was consideration given to having interpreters present for 24 hours day, which would have afforded the family more time to spend with their son?  6.7.45 On Thursday 24/1/13 following discussions with SWTM1 and CP2 supervised contact that afternoon and evening were suspended. The SCR Panel remain unclear as to 36    what the decision making process was for this decision, who was involved and where are those decisions documented. The SCR Panel regard this as another example of poor record keeping.  6.7.46  On Friday 25/1/13 SM1 spoke with CP2 by telephone. It was agreed that supervised contact between Baby F and his parents would cease.  The SCR Panel are in agreement that the decision to review parental supervision in this matter was good practice. 6.7.47  However the SCR Panel were concerned as to how the decision making around parental supervision was undertaken. There is a clear record of Health and Children’s Services involvement, but no mention of whom within the Police Service agreed the decision. There is no mention of this decision within the Police IMR and in the absence of a comprehensive chronology from the Police it is not possible to check what is recorded on Police systems. The SCR Panel consider this an additional example of poor record keeping.  6.7.48  The issue of supervised parental visits to Baby F is has been a significant feature of this SCR. Hindsight has shown that had agencies initiated a formal strategy meeting on 19/1/13, the issue of supervised visits would have been agreed as part of the strategy meeting agenda.  6.7.49  Without the benefit of a formal strategy meeting, health professionals at the RMCH rightly referred to the two existing policies which provide guidance and advice regarding parental supervision. These policies are “Manchester Safeguarding Children Board, multi agency protocol – Supervision of parents of Children and Young People in Hospital (October 2008) “and the “Guidance for inter agency working between health staff and the Police in Child Protection Investigations in severely ill or injured children Central Manchester University Hospitals NHS Foundation Trust (CMFT), produced January 2012 by CMFT and Greater Manchester Police”.  6.7.50  The CMFT IMR presents evidence of concerned Health professional s seeking the support of colleagues from the Police and Children’s Services to implement the supervised visits under the auspices of the aforementioned policies. The confusion that existed prior to the Strategy meeting of 22/1/13 remained in place until the decision to remove parental supervision was formally agreed on 25/1/13. 6.7.51  The SCR process has established that Rochdale Borough Safeguarding Children Board is not a signatory to either of these two policies. This will be addressed as a SCR Panel recommendation. Recommendation Number 41. 6.7.52  The Police IMR acknowledges that there were missed opportunities to call a formal strategy meeting on the evening of 19/1/13 and the morning of 20.1.13. However the IMR does not analyse why the officers involved did not instigate a strategy meeting and why more Senior Officers who are clearly aware of the Baby F incident fail to recognise the need to call a strategy meeting in accordance with existing child protection policies.  This includes two senior officers holding the rank of Detective Chief Inspector and a Detective Sergeant posted within the PPIU. This will be addressed as a SCR Panel recommendation. Recommendation Number 25. 6.7.53 The Children Services IMR acknowledges that there were missed opportunities to call a formal strategy meeting on the evening of 19/1/13 and the morning of 20/1/13. The IMR provides limited explanations as to why Social workers failed to recognise the need to call a strategy meeting in accordance with existing child protection policies.  37    The limited explanations provided by some of the staff involved would have benefited from greater critical analysis in order to maximise the learning opportunities from this SCR. This will be addressed as a SCR Panel recommendation. Recommendation 29. 6.7.54 The Children Services IMR recognises that as a result of the failure to convene a timely strategy meeting there were inappropriate time delays in addressing the pressing issue of parental supervision. The IMR author highlights Children’s Services approach to this issue as a good practice example. However there is no explanation or analysis as to how a child, identified as requiring parental supervision, is unsupervised with those parents for some 95 hrs before supervisory staffs are in attendance. (2145hrs, 19/1/13 – 1915hrs, 23/1/13). This will be addressed as a SCR Panel recommendation. Recommendation 41. 6.7.55  When Baby F was taken to North Manchester General Hospital on 19/1/13 and following his subsequent transfer later that day to the PICU at Royal Manchester Children’s Hospital, he was the subject of expert medical treatment, and the outcome for Baby F would not have changed. However the SCR Panel are clear in their belief that Baby F’s  welfare was potentially compromised by the non adherence to existing child protection policies, particularly in relation to the absence of a reasoned decision making process on whether /how to provide adequate parental supervision arrangements for Baby F. 6.8      To what extent did agencies communicate effectively and work together to safeguard and promote the wellbeing of Baby F? 6.8.1    Overall the health family shared information well and worked effectively with other agencies. There were a number of exceptions.  6.8.2    The SCR Panel noted that those services providing antenatal care to Birth Mother quickly identified the need for interpreting service and ensured that those services were in place for Birth Mother at subsequent appointments. Yet correspondingly ,following the birth of  Baby F, those tasked with providing post natal care and community midwife care, provided no interpreting service to Birth Mother at all. The SCR Panel questioned how effective the communication channels were between ante natal and post natal services.  6.8.3   It is highlighted within the Health Visiting IMR and the Health Overview report that there are delays in the Health Visiting Service receiving discharge notification packages from Maternity Services and that the detail contained within the packages can be of variable quality. 6.8.4    In this case information within the Notification package contained relevant information that Birth Mother required the services of an interpreter. That information was not known to the Health Visitor who undertook a primary visit to Birth Mother. As a result the Health Visitors assessment of the family dynamics and parenting ability was limited due to the lack of interpreter involvement. The Health Visitor assessed the family as requiring the Universal Offer, when the Health Visiting Service specification  identifies that were English is an additional language for a family, the assessment should be one of Universal Plus Offer. 6.8.5    Both the Health Visiting IMR author and the Health Overview author have indicated that work is inbeing to rectify these issues as part of the Healthy Child Programme. As a result no formal recommendation has been made within the Health Overview 38    report. However the SCR Panel have initiated a SCR recommendation in respect of this ongoing work. Recommendation Number 33. 6.8.6    Following Baby F admission to hospital on 19/1/13 there is some evidence of effective communication and multi agency working. However there are examples of poor communication and ineffective multi - agency working. Notably, the hospital messages about the potential NAI nature of the injuries to Baby F were fairly consistent after about 1900 hours on Saturday 19/1/13, post the CT scan of Baby F. Those messages were not effectively transmitted between GMP and Childrens Services, as evidenced by the Childrens Services managers note on the Monday that there were no concerns re cause of injuries. 6.8.7   The SCR Panel have been critical of the lack of adherence to RBSCB child protection policies in respect of arranging Strategy meetings. However the SCR Panel take full cognisance of the fact that those agencies did meet on the evening of 19/1/13 and thereafter. Information was exchanged and the wellbeing of Baby F was at the centre of multi agency discussions and activity, albeit the supervision issues were not adequately dealt with.    6.8.8    There are examples of significant lapses in communication which led to interagency disagreements. Decisions regarding the parental supervision of Baby F parents were not communicated effectively to health professionals caring for Baby F, who felt, with some justification, that existing policies directed towards the supervision of parents with children in hospital were not being correctly adhered to.  6.8.9    Health professionals despite being present at meetings on 19/1/13 and 20/1/13 did not believe that the Police and Children Services were treating the injuries to Baby F as NAI, despite the medical evidence present. This led to an exchange of phone calls on 20/1/13 between the Police and Health professionals. 6.8.10  There is evidence within the Children Services IMR of appropriate challenges following inter agency disagreement.   6.9       What lessons have agencies learned from this Serious Case Review            See section 7.  6.10     Provide examples of good and poor practice where evident? 6.10.1  The following examples of good and poor practice have been extracted and condensed from contributory reports and are presented by agency. 6.11     GMP 6.11.1  Good practice is identified within the leadership displayed by DS3, in reviewing   the case of Baby F, and implementing the requirement to convene a strategy meeting in accordance with established child protection procedures.  6.11.2  Poor practice is identified in the failure of staff to recognise the need to initiate a strategy meeting in accordance with established child protection procedures.  6.12.    Rochdale Children’s Services 39    6.12.1  Good Practice has been identified in the areas of Information gathering at the commencement of the incident. When all agencies involved worked quickly and effectively to gather information about Baby F and his parents. 6.12.2  Good practise was also identified in the daily review of the requirement to maintain parental supervision for the parents of Baby F, following the strategy meeting of 22/1/13  6.12.3  The recognition of the cultural, language and faith needs of the family of Baby F by Social Workers is highlighted as good practice. 6.12.4  The effective and appropriate use of challenge by Social Workers in this SCR is highlighted as good practice.  6.12.5  Poor practice was identified in the failure of staff to recognise the need to convene a strategy meeting in accordance with established child protection procedures.  6.12.6  In addition the incidents of poor record keeping by Social Workers, particularly on the ICS system is highlighted as poor practice.  6.13     Pennine Care HHS Foundation Trust IMR – (Health Visiting Service)  6.13.1   No examples of good practice are highlighted. 6.13.2  Poor Practice was identified in the current weaknesses within the administrative systems to marry up Discharge Notifications with Health Visitor Primary Pack. 6.13.3    The decision not to utilise interpreting services for a family, for whom English is an additional language was a breach of existing policy and is viewed as poor practice. 6.13.4   The limited assessment undertaken to establish the family dynamics of Baby F’s family, particularly in relation to the role of Birth Father is viewed as poor practice.  6.14  Heywood, Middleton and Rochdale Clinical Commissioning Group .General Practitioner [GP] 6.14.1  No examples of good practice are highlighted. 6.14.2  Poor Practice was identified by the reluctance of GP’s to utilise interpreting services for a family, for whom English is an additional language  6.14.3  The failure to ensure that a robust family history was obtained for the family of Baby F is viewed as poor practice. 6.15    CMFT. 6.15.1  Good practice was identified in recognising the cultural and language requirements for the family of Baby F. 6.15.2  The adherence to existing Parental Supervision policies is viewed as good practice. 6.15.3  The recognition that this incident should be treated as NAI at an early stage is viewed as good practice. 40    6.15.4  Good Practice has been identified in the area of Information sharing amongst agencies during Baby F period in hospital.  6.15.5  No examples of poor practice are highlighted.  6.16      Pennine Acute Hospital NHS Trust  6.16.1   No examples of good practice are highlighted. 6.16.2  Poor Practice was identified by the reluctance of post natal to utilise interpreting services for a family, for whom English is an additional language   7. Lessons Learned 7.1 Introduction 7.1.1 The following lessons which are judged particularly relevant to the terms of reference have been extracted and condensed from contributory reports and are presented by agency.  7.2 GMP  7.2.1 GMP report that no new learning has been identified during the course of the SCR. 7.3 Rochdale Children’s Services  7.3.1   The substantive lesson is that EDT staff did not recognise when a Strategy Meeting    was needed. 7.3.2    In cases of conflicting or unsure medical opinion as to the cause of serious injuries in   children, professionals should proceed as if the injury was inflicted.  7.3.3   The importance of clear and timely communication between Children’s Services and hospital staff to ensure a prompt and appropriate response to children who require protection.  7.3.4   In conducting Child Protection inquiries, whenever possible, managers and social workers should contact medical staff directly and not take decisions based on third party information.   7.3.5    Social work managers and staff should ensure records are kept of all telephone calls between agencies. Social work managers and staff must ensure the accuracy of records. 7.3.6   When Senior Managers intervene directly in a case they should ensure a record of the intervention is added to the record  7.3.7    Children’s Services Senior Managers should ensure there is effective communication between the EDT and First Response Team  41     7.4      Pennine Care HHS Foundation Trust IMR – (Health Visiting Service)   7.4.1     There is a need to review the process of receiving notifications of pregnancy     from Pennine Acute NHS Trust and the quality of information contained within them.    7.4.2     There is a need for an ante-natal pathway or guidance in the HMR borough that details the requirements for the transfer of care from the midwife to the health visitor. Ante-natal guidance to be updated to include promotion of and the importance of involving birth fathers.    7.4.3      There is a need for mothers’ discharge notifications following delivery to be received in a timely manner in the Primary birth packs.    7.4.4      There is a need to consistently use interpreters where English is a parent’s second language in order to complete an effective assessment of the need for the appropriate level of health visiting services. Interpreting policy needs to be in place    7.4.5      That the use of genograms to record family and household structures must be completed within the HV records. Recommendations about an audit of record-keeping and findings need to be implemented across PCFT.   7.4.6       There is a need to ensure comprehensive, structured assessment at the primary visit; this should as a matter of routine include Birth fathers. The pre-CAF checklist needs to include the domains of parenting and wider family and environmental factors.   7.4.7       Babies under one year are a vulnerable group and there is a need to ensure that health visitors understand their responsibility in relation to any interim guidelines to deliver the universal health visiting service.    7.4.8       Consideration needs to be given to the importance of prevention of Shaken Baby Syndrome and the education of parents. This should be reviewed at regional level.   7.4.9       All staff need to escalate failures in processes to managers so that action can be taken.   7.5 Heywood, Middleton and Rochdale Clinical Commissioning Group .General Practitioner [GP]  7.5.1 The need for GPs to actively engage in building robust family histories of their patients 7.5.2 There is a need to review the procedures for the use of interpreters within GP surgeries.   7.6 CMFT. 7.6.1 In light of this review the existing Manchester Safeguarding Children Board, multi agency protocol – Supervision of parents of Children and Young People in Hospital (October 2008) “requires urgent review. Its initial review date was 2009 42     7.7 Pennine Acute Hospital NHS Trust  7.7.1 The assessment of Birth Mother’s interpreting requirements should have been assessed more fully by staff providing post natal services. 7.8       Health Overview Report 7.8.1    The use of Interpreting Services is not clear across providers of health services. 7.8.2    Highlights the continued delays in information sharing between Maternity Services and Heath Visiting Services. 7.8.3    A recognition that that frontline health practitioners continue to demonstrate a lack of ‘professional curiosity’, when undertaking assessments of the role males play in the care of children.   7.9 SCR Panel 7.9.1    A significant finding of the SCR is the inability of professionals to identify when a strategy meeting is required. Within a matter of hours of Baby F being admitted to hospital, a CT scan identified the presence of significant trauma injuries. At that stage professionals had sufficient information to hand to identify that this was a child protection case that required the convening of a formal strategy meeting. The lesson learned is that recognising and initiating a strategy meeting would have provided professionals with the framework to undertake all the necessary and relevant actions in a reasoned, comprehensive and proportionate manner, avoiding the potential for significant issues to be overlooked.    7.9.2    The mindset of professionals to Baby F’s medical condition appeared to be overly influenced by a desire to have a definitive opinion from health professionals that his injuries were NAI. The lesson is that by adopting this ‘wait and see’ approach, Baby F was exposed to potential additional harm because his parents had unsupervised access to him for a significant period.  7.9.3    There are examples within the SCR of the failure of agencies to identify the requirement to utilise interpreting services for service users for whom English is an additional language, often in breach of existing policy and procedures. The lesson for professionals is to embed the culture of utilising interpreting services into everyday practice so that assessments that are undertaken in respect of family history and required service provision are as accurate as possible. 7.9.4    Although RBSCB are not signed up to the Manchester Safeguarding Board policy on parental supervision, there is a policy of treating each case of parental supervision on an individual case basis. Within this SCR the issue of parental supervision of the parents of Baby F lacked focus, clarity and leadership, prior to the convening of a strategy meeting on 22/1/13. The learning from this SCR is the requirement to have a written policy which clearly identifies all the administrative and logistical requirements of undertaking such supervision.   7.9.5    There are several examples within the SCR were professionals failed to maintain accurate records of meetings held, decisions made and actions agreed. Significantly where computerised information systems are in being, it is essential that they are populated with timely and accurate information. The lesson for professionals is that 43    the failure to maintain and record information accurately can lead to confusion, ineffective assessments of need and poor decision making, all of which potentially compromises the health and wellbeing of children. 8.         Conclusions 8.1       At no time during Birth Mother’s pregnancy with Baby F, or any period of his short life prior to 19/1/13, did any Agency identify the existence of any safeguarding concerns in respect of Baby F. 8.2.     The circumstances which led to the hospitalisation of Baby F, and his subsequent death, remain the focus of a Police criminal investigation. The exact cause of his death has yet to be determined by the Home Office Pathologist in this matter. 8.3       Rather uniquely for a Serious Case Review, the concerns of agencies involved in this matter are triggered on Baby F’s admission to NMGH and his subsequent transfer to the RMCH on 19/1/13. At this time Baby F is receiving expert medical attention. However Baby F’s wellbeing was potentially compromised by the inability of professionals to put in place timely and effective parental supervision arrangements. 8.4      The SCR was therefore focused on a post incident event. With a focus on whether Agencies followed established Child protection policies and procedures  8.5       At the crux of this  review has been has been the issue of how responding individuals from Agencies failed to instigate strategy meetings in adherence with established Child Protection Procedures of RBSCB and their own respective agency. 8.6     Individual professionals from all agencies involved in this incident were subject of managerial oversight, yet inappropriate decision making persisted. Managers have a responsibility to ensure that their staff work within established frameworks. Moreover   tangible managerial grip must be an integral element of managerial oversight.   8.7    Failing to identify and recognise when a strategy meeting is required is a serious mistake which goes to the heart of child protection.  8.8   The framework of policy and procedures are there to protect the child, but also the agency professionals working with and for that child. Failing to recognise the requirement for a strategy meeting or seeking appropriate supervisory advice, can lead individuals professionally vulnerable.  8.9    All agencies have accepted that there were individual failings, and many professionals involved with Baby F and his family have as part of the SCR and learning process, reflected on their decision making processes.  8.10   However there is a need to balance and put into a perspective what occurred in the 48hrs following Baby Fs admission to hospital on 19/1/13.  Adherence to the existing child protection procedures relating to strategy meetings was not achieved, but professionals undertook pragmatic decisions and actions to safeguard Baby F and provide support to his family. At all times professionals had Baby F’s wellbeing at the heart of their decision making. Sadly even if the requirement to undertake a strategy meeting and timely and effective parental supervision had been adhered to, the outcome for Baby F would not have altered.   44    8.11   Cause/effect: Preventable/Predictable            An important question for the SCR Panel, the RBSCB and for the wider community is whether the death of Baby F could have been predicted or prevented.              Prior to the events of 19/1/13, agencies in contact with Baby F and his parents did not have a single child protection or safeguarding concern. What occurred on the afternoon of Saturday 19/1/13 is the subject of a criminal investigation. This report provides the supporting analysis that Baby F’s death was not predictable and therefore could not have been prevented by the professionals involved with him.   9.      Recommendations 9.1    Single Agency          Greater Manchester Police          No Recommendations.                 Rochdale Children’s Services  1       Adoption of Parental Supervision of Children In Hospital Policy.  2      Children’s Social Care staff Inc EDT staff to understand the importance of compliance   with procedures and accurate recording 3       Children’s Social Care staff Inc EDT staff to comply with the requirement to convene, chair and record the outcomes of strategy meetings or discussions in all cases where there is reasonable cause for concern that a child is at risk of significant harm.            Pennine Care HHS Foundation Trust IMR 4       The process of routine notification of pregnancy to health visitors from Pennine Acute    NHS Trust be reviewed. 5       The community boroughs review and benchmark their progress towards the pathway for the transition of care from the midwife to HV. 6      Existing universal and safeguarding guidance on the content of health visiting ante-natal contacts be updated and harmonised across the community boroughs to include Birth fathers.  7     Existing guidance on Primary visits be updated and harmonised to include the assessment and promotion of the Birth fathers role. 8     The system of receiving and processing mothers’ discharge notifications is reviewed to ensure timely receipt by health visitors. 9      PCFT should agree guidance for the use of interpreters. 45    10     The findings of the lessons from the Trust’s Safeguarding Record-keeping Audit (when completed) be disseminated to and embedded with services. 11     The Draft Interim Guidance for the delivery of the Universal Pathway, HMR Health Visiting Service be completed, approved and disseminated to the HV teams. 12     All staff to be reminded to use the Incident Reporting system according to PCFT criteria and escalate failures in processes to managers.         Heywood, Middleton and Rochdale Clinical Commissioning Group General Practitioner (GP) 13.  There is a need review the availability of Interpreter services to GP practices across       the Rochdale Borough  14    The content of the new patient registration form requires further review to ensure that GP practice has information to inform clinical assessment of each patient registered.                Central Manchester University Hospitals NHS Foundation Trust (CMFT)  15   That Medical and Nursing staff working on the Paediatric Intensive Care Unit are made aware of, and can access the MSCB Supervision of Parents of Children and Young People in Hospital – Multi-agency Protocol and the Guidance for inter-agency working between health staff and Police in Child Protection Investigations in severely ill or injured children, Central Manchester University Hospitals NHS Foundation Trust 16.  That the MSCB Supervision of Parents of Children and Young People in Hospital –  Multi-agency Protocol is reviewed and updated in light of the learning from this IMR         Pennine Acute Hospital NHS Trust IMR         No Recommendations               Health Overview Report  17   All health services commissioned to provide health care need to provide assurance that practitioners have access to the use of interpreters for all patients for whom English is an additional language.  9.2  SCR Panel/ Multi-Agency          Single Agency Recommendation.         HMR CCG.   18   HMR CCG should provide information to the RBSCB on the extent to which GPs are    accessing Interpreter Services for patients, whose first language is not English.   46           Pennine Acute Hospitals NHS Trust  19   Pennine Acute Hospitals NHS Trust to reinforce to all midwives and community care staff of the requirement to ensure that all assessments  as a matter of routine should include the role of the Birth Father  and any other males associated with the family.               GMP 20   GMP to reinforce to all operational officers of the need to recognise when a strategy meeting is required in accordance with established Child Protection procedures. 21   GMP to reinforce to all operational officers engaged with child protection duties, of the need to ensure that when dealing with a suspected NAI incident, in the absence of a definitive medical diagnosis, the default position must always be the requirement to initiate a strategy meeting in accordance with established Child Protection procedures. 22   GMP should undertake a review of the shift pattern performed by staff within the PPIU. 23   GMP to reinforce to all operational officers, of the need to provide and maintain accurate records of meetings, decision making and interactions with key individuals and partner agencies.                Childrens Services 24   Children Services to reinforce to all Social Workers, engaged with child protection duties, of the need to recognise the legal framework in which they operate and to identify when a strategy meeting is required in accordance with established Child Protection procedures. 25    Children Services to reinforce to all Social Workers, engaged with child protection duties, of the need to ensure that when dealing with a suspected NAI incident, in the absence of a definitive medical diagnosis, the default position must always be the requirement to convene a strategy meeting in accordance with established Child Protection procedures. 26   Children Services to provide guidance to all Social Workers, engaged with child protection duties, of the need to provide and maintain accurate records of meetings, decision making and interactions with key individuals and partner agencies, on the ICS record of the respective child.        Multi Agency/SCR Panel recommendations.  27    Rochdale Borough Safeguarding Children Board to arrange a timely, reflective          learning event in relation to Baby F’s case. This event to involve all the          key practitioners, using the principles outlined in the Munro report to          maximise reflective learning.  28     Pennine Care NHS Foundation Trust and Pennine Acute Hospitals NHS Trust should provide information to the RBSCB on the progress of work being undertaken to improve information sharing between Maternity Services and the Health Visiting Service, in relation to the issues of routine notifications of pregnancy and the timely and accurate provision of discharge notifications.  47    29     Pennine Acute Hospitals NHS Trust should provide information to the RBSCB on the extent to which Community Midwifery Services are accessing Interpreter Services for patients, who have English as an additional language.   30      Pennine Care NHS Foundation Trust should provide information to the LSCB on the extent to which the Health Visiting Service are accessing Interpreter Services for patients, who have English as an additional language.   31     GMP and Rochdale Children Services to provide information to the RBSCB on the progress they have made in re- enforcing to all operational staff of the need to recognise when a strategy meeting is required in accordance with established Child Protection procedures.  32     GMP to provide to the RBSCB a report on the Forces intentions in respect of the production of a comprehensive chronology, as part of the IMR process.   33     Midwifery Services, Pennine Acute Hospitals NHS Trust to provide information to the RBSCB on how staff approach the issue of domestic violence./abuse when dealing with patients who are constantly accompanied during medical appointments.   34     All partners engaged with RBSCB, to provide evidence to the RBSCB of the presence of an Interpreter’s policy which caters for those people who have English as an additional language.   35     All partners engaged with RBSCB, to provide confirmation that their staff receive guidance on how to work effectively with Interpreters.  36     Children Services to provide information to the RBSCB on the progress made to adopt the Manchester Safeguarding Children Board, multi agency protocol – Supervision of parents of Children and Young People in Hospital (October 2008), and what guidance is provided to Social Workers on how to discharge the logistical requirements of parental supervision.  37     Children Services to undertake a review of the commissioning, oversight and authorising aspects of the Individual Management Review process.  38     GMP to provide information to the RBSCB on the progress of the training programme initiated by the Force to raise awareness of the role , responsibilities and management of Strategy Meetings in respect of Child Protection investigations.               48    Appendix A    