Death of a 5-week-old baby girl in February 2011, from a non-accidental head injury. Child L and her family were only known to universal services. Father was arrested and charged with murder and Section 18 Wounding Offences Against the Person Act 1861 in connection with fractured ribs, which occurred 7-10 days prior to Child L's death. Mother was charged with attempting to pervert the course of justice. Review concludes that Child L's death could not have been prevented however it recognises a failure of professionals to take a full history from father or to record whether or not he was present at appointments. Makes various interagency and single agency recommendations covering Barnsley Safeguarding Children Board, midwifery and other health services.
      
 Title:  Serious case review: concerning Child L: overview report. LSCB: Barnsley Safeguarding Children Board Author: Peter Ward 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.                             Barnsley Safeguarding Children Board  Serious Case Review Concerning Child L  Overview Report   Author of Overview Report – Peter Ward, Independent Social Work Consultant  3rd February 2012    Page 2 of 46 Table of Contents    Page 1 Introduction 3 1.1 Purpose of the Review 3 1.2 Circumstances leading to decision to carry out a Serious Case Review 3 1.3  Delay in the Decision to Carry Out this Review 4 1.4 Terms of Reference of the Review 5 1.5 Contributors to the Review and Methodology 6 2 Details of Family 8 2.1 Family Composition 8 2.2 Relevant Family Information 8 2.3 Information provided for this Serious Case Review by Mother & Father 9 2.4 Action Taken as a result of the information provided by Mother and Father 11 3 Summary of Agencies Involvement 13 3.1 Description of Agencies Providing IMRs and Reports 13 3.2 Chronological summary of agency involvement  14 4 Analysis 17 4.1 Introduction 17 4.2 Chronological Analysis 18 4.3 Analysis by Terms of Reference 21 4.4 Consideration of Significant Adults 32 4.5 Analysis of IMRs 33 5 Conclusions 35 6 Recommendations 38 Appendix 1 Genogram 40 Appendix 2 Integrated Action Plan 41 Appendix 3 Abbreviations 45 Appendix 4 References 46   Page 3 of 46 1. Introduction  1.1 Purpose of the Review  1.1.1    This Serious Case Review (SCR) was commissioned in compliance with regulation 5(1) (e) and 5(2) (a) & (b) (ii) of The Local Safeguarding Children Boards Regulations 2006 which came into effect on 1 April 2006. In accordance with the guidance issued in Chapter 8 of ‘Working Together to Safeguard Children’ (HM Government 2010), this Overview Report has been undertaken by an Independent Author and completed in accordance with the terms of reference set out in section 1.4 of this report.  1.1.2 Working Together to Safeguard Children 2010 states that an SCR should be undertaken when a child dies and abuse or neglect is known or suspected to be a factor in the death. The purpose of this Review is to:  � establish what lessons are to be learned from the case about the way in which local professionals and organisations work individually and together to safeguard and promote the welfare of children; � identify clearly what those lessons are, both within and between agencies, how and within what timescales they will be acted on, and what is expected to change as a result; and  � improve intra- and inter-agency working and better safeguard and promote the welfare of children. (Working Together to Safeguard Children 2010, 8.5)  1.1.3 Consequently this report is not intended to be a judicial opinion or to apportion blame but to consider, with the benefit of hindsight, the above three points.  1.2 Circumstances leading to decision to carry out a Serious Case Review  1.2.1 Child L was born in January 2011 and lived with both her parents.  She died in Hospital in February 2011 aged five weeks.  1.2.2 On an evening in February 2011 Child L was reported to have been found “floppy” and not breathing by her parents.   An ambulance was called and basic life support was commenced by Child L’s father..  This was continued by the paramedics who transferred Child L to the Emergency department at Barnsley District General Hospital (BDGH).  Full cardio pulmonary resuscitation was provided in the Emergency Department and Child L regained a regular heart rhythm.  Child L was ventilated and stabilised whilst in the department and specialist transfer was arranged to Sheffield Children’s Hospital (SCH).    1.2.3 There was no evidence of external injuries to Child L and an ophthalmology examination was normal.  However, a Computerised Tomography (CT) scan, carried out at SCH showed that Child L had suffered bleeding into the skull which had compressed the brain.  Following a Magnetic Resonance Imaging (MRI) scan it was determined that Child L had suffered irrecoverable brain injury.  Consequently paediatric intensive care was withdrawn and Child L passed away during the evening.  1.2.4 The initial post mortem indicated that non accidental injury (NAI) was a likely cause of death and the full post mortem results, which were received some months later after forensic examination, confirmed this.  As a result of the full post mortem  Page 4 of 46 results, a meeting of the Serious Case Review Sub Group of the Barnsley Safeguarding Children Board was held on 29 July 2011, and a decision was made to recommend that a Serious Case Review be undertaken in accordance with Chapter 8 of Working Together to Safeguard Children – A guide to inter-agency working to safeguard and promote the welfare of children (DCSF 2010).  The Chair of the Barnsley Safeguarding Children Board accepted this recommendation on 22 August 2011.   1.3 Delay in the Decision to Carry Out this Review  1.3.1 Child L died in February 2011 and the decision to carry out an SCR was taken six months later in August 2011.  On the face of it this is a significant delay and therefore the Independent Overview Report Author (IORA) has sought information as to the reason for it.  It is stated within the IMR from SCH that whilst Child L was at BDGH and SCH, professionals were alert to the possibility of an NAI but there were no clear pointers to this and other diagnoses were also considered.  The Police and Social Care were made aware of Child L’s condition shortly after she arrived at BDGH and again when she arrived at SCH.  Professionals from both services spoke to Father and Mother whilst Child L was at SCH.  Staff from SCH informed the Police of Child L’s death immediately and contacted Social Care at the start of daytime working hours on the morning after Child L’s death.   1.3.2 Because there was uncertainty about the cause of Child L’s death, additional pathological investigations were undertaken.  On 31 May 2011 the Police received a report which stated that there was evidence of Child L having suffered fractured ribs seven to ten days prior to her death.  This report was forwarded to the Neuro Pathologist for expert opinion as to whether these injuries were likely to have been caused by an NAI.  The Neuro Pathologist concluded his report on 25 June 2011 and this report demonstrated the rib fractures and head injury to be non accidental.  Subsequently, in July 2011 Mother and Father were arrested on suspicion of murder.  The SCR panel met on 29 July 2011 to consider whether the case met the criteria for an SCR and the Chair of the LSCB decided, on 22 August 2011, that a SCR should be undertaken.  1.3.3 There appears to have been a gap of approximately 5½ weeks between it being brought to the attention of the Local Safeguarding Children Board (LSCB) that neglect and/or abuse had probably been a factor in Child L’s death and the decision being taken to carry out an SCR.  This is one week longer than the timescale in paragraph 8.22 of Working Together to Safeguard Children 2010 which was due to the limited availability of Panel members as it was the middle of summer and several key people, including the Chair of the Board, had annual leave during this period.    1.3.4 Although it was uncertain, for several months, whether Child L’s death had been caused by an NAI, Social Care took immediate action in respect of Father’s three older children.  Arrangements were put in place for contact between Father and Mother and the children to be supervised and Social Care undertook an assessment of the family.  An Initial Assessment was started the day after Child L died, and was completed two weeks later.  A Core Assessment was then started and was completed in May 2011. Social Care considered the assessment to be very positive with all family members being very cooperative and helpful although it was also very distressing for everyone. The closing comment in the assessment  Page 5 of 46 was that the family should be allowed to get back to normal family life and there was no further role for social care. The matter was discussed with the Safeguarding Unit and it was felt at that meeting that nothing could be found to say the death was suspicious, therefore the assessments were concluded.  Once the Core Assessment was completed Social Care involvement ceased and there was a period of unsupervised contact.  The decision to re-implement supervised contact was made in July 2011 following information from the Police that Child L’s death was believed to have been caused by an NAI and a home visit was made to sign a written agreement.  1.4 Terms of Reference of the Review  1.4.1 The period of the Review was determined by the SCR Panel to cover the period from the notification of Mother’s pregnancy in June 2010 to the date of Child L’s death in February 2011.  In addition education, police, health and social care agencies reviewed their records, for Child L, her parents and her half-siblings, for a five year period to ascertain whether there had been any previous concerns which might justify expanding the review to take in a longer time period and/or Child L’s half siblings.  All agencies reported that they had not been aware of any concerns in relation to any of the family during that five year period.  No issues emerged in respect of domestic violence, mental ill health or child protection and the Police and Social Care had no contact with the family at all during the period in question.  1.4.2 The following Terms of Reference were agreed at the beginning of the review: 1. Construct a comprehensive chronology of involvement by the organisation and/or professionals in contact with Child L and her family.   2. Summarise the decisions reached, the services offered and/or provided to Child L and her family and any other actions taken.   3. Consider if practitioners were aware of and sensitive to the needs of Child L in their work, had the relevant knowledge about potential indicators of abuse or neglect and what to do if they had concerns about a child’s welfare.   4. Did the organisation have in place Policies and Procedures for Safeguarding and promoting the welfare of children and were able to act on concerns relating to a child’s welfare.   5. What were the key relevant points/opportunities for assessment and decision making in this case in relation to Child L and her family?  Do assessments and decisions appear to have been reached in an informed and professional way?   6. Were appropriate services offered/provided or relevant enquiries made in light of any assessments?   7. Was practice sensitive to the racial, cultural, linguistic and religious identity and any issues of disability relating to Child L and her family and were they explored and recorded?   8. Were Senior Managers or other organisations and professionals involved at points in the case where they should have been?   Page 6 of 46  9. Was the work consistent with each organisation’s and Barnsley Safeguarding Children Board Policy and Procedures for Safeguarding and promoting the welfare of children and with wider Safeguarding standards?   10. Were there organisational difficulties being experienced within or between agencies?   11. Did any resourcing issues have an impact on the case?   12. Consider the decision making process around the request for a scan for Child L and the impact of this process.   13. Establish if the recommendation for Child X SCR for Health Visitors to document all other persons present at a visit has been enforced and embedded.   1.4.3 At a subsequent SCR Panel Meeting held on 13 October 2011 it was decided that number 13 of the above Terms of Reference was too narrow and it was replaced with the following:  13. Establish whether there are any overlapping issues between this review and the Child X Serious Case Review and, if so, what has been done to address the issues.  1.5 Contributors to the Review and Methodology  1.5.1 Peter Ward, the IORA, has a background in social care and has worked in management and front line social work.  He is qualified to degree level in social work and has a post-graduate diploma in management studies.  He is now the Director of Arrow Social Care Consultancy Limited and, as such, undertakes investigations and other consultancy work on an independent basis.  Since 2005 he has been involved in several Serious Case Reviews as an Overview Report Author, Individual Management Review Author or Panel Chair.  His appointment is in accordance with the guidance at 8.33 in Chapter 8 of ‘Working Together to Safeguard Children 2010’ which states that: “The overview report should be commissioned from a person who is independent of all the local agencies and professionals involved and of the LSCB(s).  The overview report author should not be the chair of the LSCB, the SCR sub-committee or the SCR Panel.”  1.5.2 The chair of the Barnsley Safeguarding Children Board (BSCB) is Simon Hart.  The independent chair of the SCR Panel for this SCR is Diane Hampshire who is employed by NHS Leeds as Head of Safeguarding Children and Adults and is the Designated Nurse for Safeguarding in NHS Leeds.  As such Ms Hampshire has considerable experience of Safeguarding Children and of the SCR process but is independent of all the local agencies and professionals involved and of BSCB.  Her appointment is in accordance with the guidance at 8.16 in Chapter 8 of ‘Working Together to Safeguard Children 2010’ which states that: “The Chair of the SCR sub-committee should be an experienced person and could be the independent Chair of the LSCB, or a member of the LSCB. The Chair of any SCR Panel should not be a member of the LSCB(s) involved in the  Page 7 of 46 SCR, an employee of any of the agencies involved in the SCR or the overview report author. The SCR Panel Chair can be the independent LSCB Chair, someone from another LSCB which is not involved in the SCR or from an agency which is not involved in the case.”  1.5.3 In addition to the chair the following people were members of the SCR Panel: � Assistant Executive Director, Safeguarding Health and Social Care, Barnsley Children Young People & Families (CYP&F) � Head of Children’s Social Care, Barnsley CYP&F � Head of Safeguarding and Welfare, Barnsley CYP&F � Assistant Director, NHS Barnsley � Designated Nurse Safeguarding Children, NHS Barnsley  � Medical Director and GP Representative, NHS Barnsley  � Designated Doctor Safeguarding Children, Barnsley Hospital NHS Foundation Trust (BHNFT) � Public Protection Unit Manager, South Yorkshire Police � Solicitor, BMBC Legal � Area Manager, Education Welfare, Barnsley CYP&F  1.5.4 The SCR Panel met on 13 October 2011, 16 November 2011, 22 December 2011 and 1 February 2012 in connection with this SCR.  The IORA was not a member of the SCR Panel but attended the Panel meetings in connection with writing the Overview Report.    1.5.5 The SCR Panel received and considered Individual Management Reviews (IMRs) the following agencies: � BHNFT � Primary Care, NHS Barnsley  � Sheffield Children’s NHS Foundation Trust (SCNFT) � South West Yorkshire Partnership NHS Foundation Trust (SWYPFT) � NHS Barnsley (the Health Overview report)  1.5.6 The Serious Case Review Panel received and considered reports from the following agencies:  � Yorkshire Ambulance Service (YAS)  1.5.7 The authors of the IMRs are all independent in accordance with the guidance at 8.33 in Chapter 8 of ‘Working Together to Safeguard Children, 2010’ which states that: “Those conducting management reviews of individual services should not have been directly concerned with the child or family, or have been the immediate line manager of the practitioner(s) involved.”  1.5.8 A comprehensive integrated chronology of agency involvement and significant events for the period covered by the review has been compiled from the chronologies provided within the IMRs.  This has been analysed by the SCR Panel.   1.5.9 The IORA undertook this review by making reference to the terms of reference, IMRs and other reports listed above and through discussions at SCR panel meetings and face to face, telephone and email communication with IMR authors and SCR Panel members.     Page 8 of 46 1.5.10 In addition the SCR Panel considered which family members should be involved in the review and how and when to involve them.  The Panel decided that Child L’s Mother and Father should both be invited to contribute to the review and this was done by way of a face to face meeting with the IORA and the Independent Chair of the SCR Panel (hereafter referred to as the Panel Chair).  This meeting took place in December 2011, whilst Mother and Father were both subject to Police bail but before they had been charged with any offences.  Prior to the meeting, the IORA consulted with the SCR Panel representative and the Senior Investigating Officer from South Yorkshire Police to ensure that the meeting would not impact upon possible criminal proceedings.   1.5.11 In writing this Overview Report, the IORA has been mindful of the revised approach to the evaluation of SCRs described by the National Director, Development and Strategy for Ofsted in a letter dated 14 December 2011 to Directors of Children’s Services and LSCBs.  2. Details of Family  2.1 Family Composition    2.1.1 Child L Born January 2011, Died February 2011  Relationship to Child L  Referred to as Ethnic Origin Mother  Mother  White British Father  Father  White British Half sibling  L2 White British Half sibling  L3 White British Half sibling  L4 White British Mother of L2  Adult 1 White British Mother of L3 & L4  Adult 2 White British  2.1.2 A genogram of the above family is included as Appendix 1 of this Overview Report.  2.2 Relevant Family Information   2.2.1 Child L lived with her mother and father throughout her short life.  She was the first child of Mother but Father already had three children from two previous relationships.  All three children lived with their mothers throughout the time that Child L was alive.    2.2.2 The SCR Panel considered which members of the family should be part of the review.  Agencies identified all contacts they had had with the three siblings over the period covered by the review and found these contacts to be few in number and not to have had any Safeguarding dimension.  Because of this, the SCR consider that any possible benefit of including the siblings in the review was outweighed by the possible negative impact on their privacy.  2.2.3 Father and Mother informed the IORA and Panel Chair that prior to the death of Child L, L3 and L4 had visited the family home on a daily basis and stayed overnight at weekends.  Therefore during Child L’s lifetime L3 and L4 had seen her on a regular and frequent basis.  Father and Mother had also maintained frequent contact with L2 although this had been less regular than with the younger children.   Page 9 of 46 Following the death of Child L, Social Care requested that all contact between Mother and Father and the children should be supervised.  In the case of L2 supervision is provided by Father’s parents and in the case of L3 and L4 by their mother or Mother’s parents.  When the IORA and Panel Chair met Father and Mother they expressed their unhappiness with the need for contact to be supervised because it made it much more difficult to arrange.  2.2.4 It appears that Mother and Father have supportive families with whom they have frequent contact.  In addition to the support being given with regard to supervision of contact Mother’s mother was present at Child L’s birth and when she died whilst Mother’s father and maternal aunt and uncle were also present when Child L died.    2.2.5 The family are white, British with English as their first language, which is typical of the area in which they live.  Little information is recorded about the family’s religion although there is a record of Mother stating that she was not religious.  There are no records to indicate that either parent had a disability and Child L had not been diagnosed as having any form of disability at the time of her death.    2.2.6 The family lived in an area of deprivation which was hit very hard by the loss of the mining industry in the latter part of the 20th century.  Despite continued regeneration projects unemployment and child poverty remain, with approximately one third of the working age population claiming benefits from the Department of Work and Pensions and nearly 12% being in receipt of Disability Living Allowance.  However both Mother and Father were in employment and none of the agencies involved had documented concerns regarding the home environment or the family’s financial situation.    2.2.7 Father has been charged with the murder of Child L and also with Section 18 Wounding Offences Against the Person Act 1861 in connection with her fractured ribs.  Mother has been charged with attempting to pervert the course of justice.  Neither parent has yet stood trial in connection with these charges.  2.3 Information provided for this Serious Case Review by Mother and Father   2.3.1 In their meeting with the IORA and the Panel Chair, Father and Mother were largely positive about the services they received during Mother’s pregnancy and in the weeks following the birth of Child L.  Mother had received care from Barnsley midwives but attended ante natal clinics and gave birth in a neighbouring hospital.  She felt that this had worked well and she described the midwife who delivered Child L as “brilliant, very supportive and professional”.  2.3.2 Mother acknowledged feeling a little upset at times, including her first meeting with the health visitor but she said that she had not been depressed and she made this clear to the health visitor.  Mother’s only slightly negative comment about the care she received was that she felt that the health visitor and midwife gave slightly different advice about feeding.  However this was not a significant problem and she felt reassured by the comments the health visitor made about feeding.  2.3.3 Both Mother and Father said that Father had been present during some of the appointments with health staff but had not been present for them all due to his work.  Father felt that he had been included and said he felt able to ask questions when necessary.  For example he said that he asked about jaundice.  Mother said  Page 10 of 46 that both Father and her mother had been present at Child L’s birth and she felt that she could not have done it without Father there.  2.3.4 Mother and Father were complimentary about the way they had been treated at BDGH following Child L’s collapse in February 2011.  They found it particularly helpful that a nurse stayed with them most of the time and kept them informed of what was going on.  Similarly they found it helpful that Embrace staff explained what was happening, made them aware that Child L would be going for a scan when they arrived at SCH and came to wish the family good luck once their role had finished.  Mother and Father also commented that the police officers present at the hospital introduced themselves and Mother and Father were told that it is usual for the police to be present in such circumstances.  At SCH Mother and Father again appreciated being given information; they commented that they were able to stay at their daughter’s bedside and the nurses explained what tests were being done and the machines that were being used.    2.3.5 Mother and Father are, however, unhappy with one aspect of how they were treated during the morning when they were in SCH with their daughter.  A doctor came to see them and Mother and Father took an instant dislike to him because of the way he spoke to them.  Social Care and the police were at the hospital and Mother and Father felt as though people were ‘pointing the finger at them’ as being responsible for Child L’s condition.  The police said that they wanted to go to the house and asked for the keys which they were given; Social Care said that they could not see Father’s other children without supervision and the doctor discussed ‘shaken baby syndrome’.  Mother and Father had no problem with letting the police have their house keys but feel that it was wrong for people to talk to them in the way they did at that time, whilst their daughter was dying.  Father feels that Social Care have ‘cocked up’ in the past, by not protecting children, so were reacting in this way with them.  It appeared that he was referring to Social Care generally rather than making a comment specifically about Barnsley Social Care.  Mother and Father understand that children get injured and agencies have a job to do but strongly feel that this was not the time to be talking to them in that way.  2.3.6 Mother and Father also expressed a number of concerns regarding the services they have received since their daughter died.  They remain on police bail and because of this Mother has been suspended from her job which has resulted in a reduction in their income.  They are also unhappy that all contact with Father’s children has to be supervised as it is difficult to arrange this, particularly with L2.  Mother and Father were due to answer bail three days after their meeting with the IORA and Panel Chair and were hopeful that they would be told that criminal proceedings were not going to be pursued and that they would be able to get their lives back in order.  2.3.7 Mother and Father were unclear what Social Care’s involvement was at the time of the meeting because, although contact had to be supervised, they said they had not seen a social worker since July or August 2011 and they had had a letter from Social Care saying that everything was back to normal and a card saying sorry and wishing them luck for the future.   They were upset about this card as they felt they had been badly treated by Social Care and they ripped it up.  Mother and Father also made the point that, although they were abiding by the requirement for contact to be supervised, no-one was monitoring this.   Page 11 of 46 2.3.8 In terms of support, Mother said that the midwife visited and offered to refer her for bereavement counselling.  A letter was sent with an appointment but Mother misread this and thought the appointment was on a Thursday when it was in fact two days earlier on the Tuesday.  Consequently she missed the appointment.  Mother intends to phone up to rearrange this.  Shortly after the death of Child L the health visitor offered to refer the family to the bereavement health visitor but nothing has come of this.  In addition, Mother’s GP offered her medication to cope with the bereavement; but she did not want this.  2.3.9 Father said that work have been very supportive of him; they have given him time off if necessary and have offered him counselling.  He has a different GP to Mother and the GP did not know that Child L had died.  He has not been offered counselling by the GP.  2.3.10 Father’s other children have not been offered any external support but have been supported by the family.  2.3.11 Mother and Father feel that they should have been given information about what support is available to them.  However they consider themselves lucky in the sense that they have very supportive families, including both Mother and Father’s parents and the mothers of Father’s older children.  Therefore they have managed without bereavement counselling.    2.3.12 Mother told the IORA and Panel Chair that she is pregnant again and is due to give birth in 2012; she has mixed emotions about the pregnancy.  She is under the care of the same hospital as before and feels that they are being very supportive and are offering whatever tests she wants to have.  She is also having additional midwifery appointments and expects to see the social worker for a pre-birth assessment.    2.4 Action Taken as a result of the information provided by Mother and Father   2.4.1 It is notable that Father and Mother did not make any significant criticisms about the services provided to them prior to their arrival at SCH after Child L had sustained the injuries that led to her death.  Therefore the comments they made that might require attention from agencies related almost exclusively to issues outside the timescale and scope of this SCR.  Nevertheless it was important that the SCR Panel took their comments seriously and considered what action to take in respect of their comments.  Consequently at the Panel Meeting on 22 December 2011 the SCR Panel discussed the issues raised by Mother and Father and the following actions were then taken:  2.4.2 The Designated Nurse confirmed that there is in fact no bereavement health visitor, only a bereavement midwife.  However, the Designated Nurse has contacted the health visitor involved with the family and asked her to extend support to them as they had not picked up on the support offered by the bereavement midwife.  The Designated Nurse explained to the Panel that in Barnsley, a pack is given to bereaved parents by the hospital with lots of helpful contacts for agencies in Barnsley and SCH does this for bereaved families in Sheffield.    2.4.3 The SCR Panel were disappointed to learn that Mother and Father had been upset by the timing of police and Social Care involvement whilst they were at SCH and  Page 12 of 46 Child L was dying.  However Panel Members acknowledged that the agencies involved have important roles in respect of protecting children and investigating potentially suspicious events.  Talking to parents in such circumstances is never likely to be easy and there is no good time to do it, however it does have to be done.  All the professionals who were involved with Father and Mother whilst they were at SCH, carry out jobs where they will frequently be dealing with people in difficult emotional circumstances and it is important that they have appropriately training and skills.  Nevertheless Panel Members felt that some people’s ‘soft skills’ are inherently better than others.    2.4.4 The Panel noted that Mother and Father said they had taken a dislike to the doctor who spoke with them on the morning that Child L died and felt that this was an understandable response as the doctor would have been viewed as the person who was effectively “pointing the finger” and suggesting that Child L’s injuries may have been non-accidental.  Nevertheless it was agreed that the Mother and Father’s perceptions would be fed back to the doctor in order that he can learn from this.   2.4.5 The Head of Children’s Social Care within Barnsley CYP&F has checked the social care records and spoken to the social worker involved with Mother and Father and has provided the IORA with the following information: � The social worker clearly remembers sending a condolence card to Mother and Father after Child L’s death. She describes this as saying something like “sorry for your loss” It was most emphatically not an apology but a register of empathy at a time when the prevailing view was that Child L had died a natural death. She thinks it was sent around the end of April or beginning of May 2011, after the initial assessment was complete.  � There is no record of a letter, and the social worker cannot recall sending one. It seems likely that what Mother and Father refer to as a letter, was in fact the initial assessment which does say in the last paragraph of the recommendations section:  “My recommendation is that the family should be allowed to get back to normal family life. It is also important that a safeguarding meeting is held to discuss Mother’s work and make decisions about any possible return to work. Again this needs to happen as a matter of urgency as the current uncertainty is extremely stressful for Mother, Father and the extended family.”  � Although Mother and Father’s recollection was that they had not had a visit from a social worker since July or August 2011 records show that a visit was made in October 2011 to explain the pre-birth assessment process.  At that time the view was taken that contact arrangements were secure and it was not intended that any further action would be taken until the pre birth assessment, unless there were significant changes in the available information. The pre birth assessment commenced in January 2012 and the social worker will have more frequent contact with Mother and Father as this progresses.  2.4.6 It is notable that Mother and Father drew attention to a number of occasions when professionals explained things to them and kept them informed as to what was happening.  They clearly found this to be helpful, even during the last few hours of Child L’s life.  By contrast they have felt unclear about Social Care’s role in recent months and what to expect from the social worker.  This is a useful reminder for all  Page 13 of 46 agencies of the importance of communicating with their service users and providing clear and unambiguous explanations.     3. Summary of Agencies Involvement  3.1 Description of Agencies Providing IMRs and Reports  3.1.1 BHNFT provides a range of in patient and out patient health services within Barnsley and the surrounding area.  The services which had contact with Child L and her family during the period covered by the review were maternity services (antenatal clinic and community midwifery services) in connection with Mother’s pregnancy and the birth of Child L and the emergency department at BDGH in connection with the incident that led to Child L’s death.    3.1.2 Mother chose to give birth and have scans and blood tests in connection with her pregnancy at a neighbouring hospital.  The involvement of this hospital is addressed within the IMR from BHNFT.  3.1.3 The Primary Care IMR considers the family’s contact with General Practice during the period covered by the SCR.  Child L and her mother were registered with one practice and Father with another.  Mother visited the GP in June 2010 when her pregnancy was confirmed.  She had no further contact with the GP, regarding herself, throughout the remainder of the period covered by the review.  Child L was taken to see the GP on one occasion whilst Father had no contact with the GP at all during the period covered by the review.  3.1.4 SCNFT is a dedicated paediatric Trust which provides paediatric medicine and surgery, radiology, transport services and paediatric intensive care on a regional basis.  The only contact that Child L and her family had with this Trust during the period covered by the review occurred after the incident which led to Child L’s death.  She was transferred from BDGH to SCH, the Trust’s hospital, by Embrace, the Trust’s specialist transport service. Once at SCH she was cared for in the Paediatric Intensive Care Unit (PICU) until her death that evening.  Whilst Child L was at SCH she underwent CT and MRI scans and an ophthalmology investigation.  3.1.5 SWYPFT provided health visiting services to the family, with a health visitor visiting the family home twice and Mother and Child L visiting a Children Centre baby clinic once.  SWYPFT had no other contact with the family during the period covered by this SCR.  3.1.6 YAS had only one contact with the family during the period covered by the SCR.  This commenced with a 999 call from Mother during the evening when Child L had stopped breathing.  As a result of this call, a paramedic and an ambulance were dispatched to the family home and Child L was conveyed to BDGH.  Prior to the arrival of the paramedic, staff from the Emergency Operations Centre provided instruction to the parents’ by phone.   3.2 Chronological summary of agency involvement   Antenatal Period; June 2010 to January 2011   Page 14 of 46 3.2.1 Mother’s pregnancy with Child L was confirmed in June 2010 and 11 days later a community midwife carried out an antenatal booking contact.  At this initial contact, screening and dietary advice was discussed and a routine mental health assessment was undertaken which did not indicate any mental health concerns.  No previous obstetric history was reported and no social concerns were documented.  Mother was asked about domestic abuse during the antenatal booking contact and it was recorded that she did not disclose any abuse.  3.2.2 Mother elected to have scans and blood tests and to give birth at a hospital in a neighbouring area.  This decision reflects patient choice and is not an unusual decision for people living in the particular part of Barnsley in which this family lived.   3.2.3 During her pregnancy Mother had six contacts with maternity services in Barnsley and attended the ante natal clinic at the neighbouring hospital on three occasions.  She attended for all appointments and no complications or concerns were noted.  She was given routine health promotion advice about achieving a healthy pregnancy.  This covered issues such as diet, smoking and alcohol.  3.2.4 The community midwife in Barnsley recorded a partial history for Father but he was not asked about drugs and alcohol use or mental health issues. There is no record of when the midwife saw Father although she told the author of the BHNFT IMR that she remembers him being present at some of the antenatal contacts.    Birth of Child L; January 2011   3.2.5 Mother was admitted to hospital in advanced labour and Child L was born that day at 36 weeks gestation.  No concerns were noted.  A paediatric check and hearing screening were conducted the following day and nothing abnormal was detected.  Child L was bottle feeding well on demand.    Postnatal Period; January – February 2011   3.2.6 Mother and Child L were discharged home from hospital the day after Child L was born.  Community midwives from BHNFT then visited them at home on the 3rd, 4th, 6th, 8th and 14th day of Child L’s life.  In total three different midwives visited with the last three visits all being undertaken by community midwife 1, who had also had the majority of antenatal contact with Mother.  A student midwife was also present at the final visit.  Records state that Child L and Mother were both seen at all of these visits but there is no record of whether Father or anyone else was present.  However community midwife 1 told the author of the BHNFT IMR that she remembered Father being present at some of the visits and she took a partial history from him.  3.2.7 During the five postnatal midwifery visits, Mother was given routine health promotion advice about safe sleeping and reducing the risk of cot death, general care and feeding.  Leaflets were provided in support of these topics.  No information was given about ‘Shaken Baby’ syndrome.  The only concern recorded about Child L was slight facial jaundice on the first and second visit.  The only concern recorded about Mother was at the final visit when she reported herself to have been feeling emotional over the last few days.  Support was offered to Mother in respect of this.   Page 15 of 46 3.2.8 Following the final visit from the community midwife Mother and Child L were discharged to the care of the GP and health visitor.  There was no written handover from the midwife to the health visitor but both professionals report that information was passed on verbally, this included information about Mother feeling low emotionally.  Neither professional made a written record of their discussion.  3.2.9 The first visit from the health visitor to Child L was made the day before the last visit from the midwife.  The health visitor carried out a Guthrie screening test1 on Child L and also undertook a routine head to toe examination which gave no cause for concern.  The health visitor recorded that an elderly male had been present with a small child but did not record who these people were.  When the IMR author interviewed the health visitor the health visitor stated that she had not asked the identity of these people but had assumed that the adult was one of Child L’s grandfathers.  The health visitor also informed the IMR author that Father had been present during the visit and had handled Child L appropriately.  The health visitor had been able to discuss the family history and had been told that Father had three older children from previous relationships and also that he was supportive in the home.  None of this information was included in the health visitor’s written record of the visit.  The health visitor did record that Mother reported being low in mood and feeling tearful and the health visitor discussed ‘baby blues’ with Mother and arranged a follow up visit the following week to provide support.  3.2.10 The follow up visit from the health visitor was carried out one week later, as had been agreed, and the health visitor recorded that Mother’s mood was improved and she was in much better spirits.  Nevertheless the health visitor discussed postnatal depression and its potential side effects.  At this visit the health visitor assessed Child L’s feeding pattern and found that she had made an acceptable weight gain to 3.08 kg and was reportedly taking four ounces of milk every four hours.  The health visitor told the author of the SCNFT IMR that Father was not present at this visit and she took this opportunity to ask questions in relation domestic abuse and substance misuse.  Mother did not make disclosures in relation to these questions although the IMR author has written that in cases where disclosures are made this often happens at a later date when the mother’s relationship with the health visitor has developed.  The health visitor also made enquiries of Mother about Father’s other children and was told that they lived with their mothers.  There is no record of how much contact the children had with Father.  The health visitor felt that Mother lacked confidence and the health visitor offered ongoing support for Mother at the six-week visit.  In the event, the six week visit did not take place as Child L died before reaching six weeks of age.  3.2.11 The next contact with the family took place six days later when Mother took Child L to see the GP due to concerns because Child L cried when trying to open her bowels.  This was the only contact that Child L ever had with the GP.  The author of the Primary Care IMR describes the examination that was carried out by the GP and explains that this is a very common presentation in new babies and that a GP would not be expected to focus on anything other than the presenting problem in such a situation.  Records show that the GP examined Child L’s abdomen and provided reassurance to Mother.  The GP reported having no recollection of this consultation when interviewed by the author of the Primary Care IMR and there was no reference in the records to Mother’s mood at the consultation.                                             1 A screening test that is offered to all infants in the first few days of life to test for a number of possible health disorders  Page 16 of 46  3.2.12 Eight days after the GP consultation, Mother took Child L to the Children’s Centre baby clinic where Child L was measured and weighed by a nursery nurse and the health visitor saw Mother who reported that Child L was unsettled on feeds of three ounces every three hours. The health visitor recommended that Mother revert to giving Child L four ounces of milk at each feed as she had done previously.  The author of the SWYPFT IMR explains that the clinic provides an opportunity for staff to observe interactions between parent and child and that babies are weighed naked for the purpose of accuracy and the observation of the child for any medical conditions including possible injury.  No concerns relating to Child L are recorded in the record of this visit.  Admission of Child L to hospital and her subsequent death; February 2011   3.2.13 The day after the clinic visit, Child L was admitted to the Emergency Department at BDGH at 21:17 hours after her parents had called for an ambulance.  Child L’s parents reported that she had appeared well that day and had gone to bed at about 19:00 hours after a feed.  She had woken at approximately 20:30 hours and was crying; she was picked up by Mother and was then reported to have gone “floppy” and stopped breathing.  Father reportedly commenced cardio pulmonary resuscitation (CPR) whilst Mother dialled 999 and requested an ambulance.  YAS received the 999 call at 20:37 hours and dispatched a paramedic and a Double Manned Ambulance to the address.  YAS staff in the Emergency Operations Centre remained on the phone to Mother whilst the paramedic and ambulance were en route to Child L’s home and provided advice to Mother in respect of the CPR.  The paramedic arrived at 20:45 hours, eight minutes after the service received the 999 call and the ambulance arrived three minutes later.    3.2.14 Child L was transferred to the ambulance where resuscitation attempts continued and at 21:01 hours the ambulance left the scene in order to convey Child L to hospital.  A pre-alert call was made to the hospital warning of an impending cardiac arrest.    3.2.15 At 20:50 hours, whilst resuscitation attempts were being made, the Police were informed of the 999 call and at 21:05 hours the police called YAS for an update.  3.2.14 On arrival at BDGH there was possibly an occasional heartbeat which was written up at around 30 per minute by the Paediatric Registrar.  Full CPR was carried out and by the time the Paediatric Consultant arrived around 21:35 hours Child L had a regular heartbeat around 130 per minute and had been intubated by an Anaesthetist.  She had no rash present and on examination by the Paediatric Consultant there were no signs of bruise or injury, she had normal heart sounds, no heart murmur, no signs of heart failure, her fontanel was normal tension, and pupils were 3 mm in size, non-reactive and equal.  Child L was ventilated and stabilised at BDGH and the Transfer Team from Embrace were called to transfer her to the PICU at SCH.  The Consultant from Embrace requested that a CT scan of the head should be undertaken prior to transfer.  Because these events were taking place after 20:00 hours, no consultant radiologist was available on site at BDGH and arrangements for a CT scan had to be made in accordance with the Department of Medical Imaging Policy for Out of Hours Radiology.  Under this policy, BHNFT have a contract with an external Teleradiology service.  If a clinician requires a CT scan a request is made to the Teleradiology Consultant who is  Page 17 of 46 responsible for authorising a radiographer to carry out the scan.  Images from the scan are then transferred to the Teleradiology service which is responsible for providing an electronic written report to the clinician who requested the scan.  In the case of Child L, the Teleradiology Consultant refused the request for a CT scan stating that there was nothing to indicate that it was required, it would not fit National Institute of Clinical Excellence (NICE) guidelines and she could not interpret a CT scan on a baby of this age.  As a result of this response a decision was taken to progress with the transfer of Child L to SCH and to carry out the scan on arrival there.    3.2.15 Child L arrived at SCH at 02:25 hours after an uneventful transfer.  A CT scan was undertaken and she was transferred to the PICU.  During the course of the day various investigations and examinations took place, including an MRI scan and an eye examination and numerous phone calls and assessments were made.  Child L’s parents, maternal grandparents and maternal aunt and uncle were present throughout the time Child L spent at SCH and discussions were held with them.  At 19:55 hours treatment was withdrawn after discussion with Mother and Father and at 20:15 hours Child L died.  3.2.16 Prior to Child L’s transfer from BDGH to SCH, Social Care was contacted to undertake a safeguarding list check and no concerns were reported.  A note in the departure list stated that safeguarding “will need to be sorted out.”  The police and Social Care attended SCH and spoke with Child L’s parents.    4. Analysis  4.1 Introduction  4.1.1 The following analysis commences with a ‘freeform’ analysis of agency involvement in a chronological order.  This is used to identify key issues of practice.  After the ‘freeform’ analysis the IORA provides further analysis with direct reference to each of the 13 Terms of Reference identified by the SCR Panel.  A repeating issue from this review concerns how agencies should work with fathers and other significant adults.  Section 4.4 of this report specifically considers that issue.  Finally there is analysis of each of the IMRs and the Health Overview Report.   4.2 Chronological Analysis  Antenatal Period; June 2010 to January 2011  4.2.1 Through the antenatal period Mother received appropriate services in view of the information that she disclosed to health professionals.  She exercised her right to choose where she gave birth and it appears that the interface between the hospital and midwives in Barnsley was managed appropriately.  No information came to light to cause any concern for any of the staff who came into contact with Mother.    4.2.2 With hindsight, one apparent shortfall in the practice of staff during this period was the failure to take a full history in relation to Father or even to record whether or not he was present during the various contacts that the midwifery service had with Mother.  However, this needs to be viewed in the context of the policies and procedures in place at the time of Mother’s pregnancy with Child L.  The maternity  Page 18 of 46 paperwork in use in Barnsley during the period covered by this review, which is national paperwork, does not have prompt fields for questions to be asked of fathers, or other significant adults in the home, relating to issues such as alcohol or drug misuse and mental health.  On a local level, at the time of Mother’s pregnancy with Child L there was no expectation on midwives to take full social histories of fathers or even to document if or when the father was seen by the midwife.  This is an important issue that will be considered in more detail later in the analysis.  4.2.3 The authors of the BHNFT IMR have identified that whilst Mother was provided with a range of health promotion advice both antenatally and postnatally no information was given, either verbally or in writing concerning ‘shaken baby’ syndrome.  The review found that a leaflet used to be given routinely but was discontinued when the information from the leaflet was incorporated into the Personal Child Health Record (Red book).  Furthermore it appears that the practise of discussing this issue has also ceased to be a common occurrence.  The authors of the BHNFT IMR point out that there is no clear evidence that Child L’s injuries were the result of being shaken, but nevertheless, it is good practice for issues around managing crying episodes and the frustration this can lead to to be discussed with both parents during the antenatal period or very soon after the child is born.  The authors of the Health Overview Report consider how information about the risk of shaking a baby is provided to parents in America and support the view of the authors of the BHNFT IMR that action needs to be taken as a result of this review to ensure that suitable arrangements are put in place in Barnsley.  Birth of Child L; January 2011   4.2.4 The review has not identified any significant issues during the time that ML was in hospital for the birth of Child L.   Postnatal Period; January – February 2011   4.2.5 There were five midwifery visits to Mother and Child L in the fortnight following Child L’s birth which appears to have been an adequate number.  These were appropriately used to assess the physical health and wellbeing of Child L and Mother and the emotional health of Mother.  These assessments did not identify any significant issues of concern although at the final visit Mother reported feeling a little tearful.  This was addressed appropriately by the midwife at the time but information was not passed on to the health visitor in writing as it should have been.  4.2.6 The handover from the midwife to the health visitor did not include a written handover although this is required by procedure.  The author of the BHNFT IMR explains that the reason for this omission was that Mother had given birth outside Barnsley and consequently the established discharge form was not included with the documentation provided by the hospital as it would have been if the child had been born in Barnsley.  Given that the author of the BHNFT IMR also states that it is not unusual for pregnant women, living in this particular area of Barnsley, to give birth at the hospital in question, the IORA considers it unacceptable that there is no system in place to ensure that a discharge form is available.  The IORA notes that BHNFT have made a recommendation to address this shortfall.   Page 19 of 46 4.2.7 Although a discharge form was not completed, both the midwife and the health visitor maintain that there was a verbal handover between them.  However there is no written record of this from either of them, which is another shortfall in practice.  Irrespective of whether a handover took place, the health visitor’s first visit to Mother was actually the day before the final visit from the midwife and therefore Mother informed the health visitor that she had been feeling tearful before she informed the midwife.  It is evident from the information provided by the health visitor when she was interviewed in connection with this SCR that her record of her first visit to the family was incomplete.  4.2.8 The authors of the BHNFT and SWYPFT IMRs describe Mother’s feelings of tearfulness as ‘baby blues’.  The authors of the Health Overview Report explain that, according to the Royal College of Psychiatrists in 2011, ‘baby blues’ is experienced by an average of eight out of ten women three or four days after birth and that the feelings tend to disappear within a few days (ten days) after birth.  The authors of the Health Overview Report compare ‘baby blues’ with postnatal depression which, they explain, is an illness which occurs between four and six weeks after birth and initially resembles the symptoms of ‘baby blues’ but is more intense and longer lasting.  The authors of the Health Overview Report point out that when Mother reported feeling tearful to the midwife this was the 13th day after birth.  Given that this is outside the three to ten day period identified by the Royal College of Psychiatrists the authors query whether Mother was simply experiencing ‘baby blues’ but they do not reach any conclusion.     4.2.9 Whilst it may not be possible to categorically diagnose Mother’s feelings of tearfulness as ‘baby blues’ it is the view of the IORA that the most important aspect of this is how professionals responded to Mother.  The health visitor’s response at the first visit was to arrange a further visit one week later.  When Mother reported, at this second visit, that she no longer felt tearful, the health visitor offered ‘listening visits’ if they were required.   The authors of the Health Overview Report explain that listening visits “are an intervention designed to help women who are having mild adjustment problems in the postpartum period, and were developed in the United Kingdom.  In addition to checking on the health of the mother and baby, health visitors also assess the mother’s emotional well being.  If a woman is found to not to be coping emotionally, and she is not severely disturbed, the health visitor offers to provide listening visits.”  The authors quote Serge L, (2007) in stating that “listening visits have been shown to be effective in the U.K.”  It is the view of the IORA that the response from the health visitor was appropriate.  The IORA also points out that when he met with Mother she reinforced that although she had felt a little upset at the times she had not felt depressed and had made that clear to the health visitor.  4.2.10 The absence of any record from the midwife or health visitor about whether or not Father was present at their visits is a further reflection that these services paid insufficient attention to his role in the family and the care of the child.  Such failure to adequately consider the father or other male care giver in a family has been recognised and well documented over a number of years.  For example in pages 51 – 54 of “Understanding Serious Case Reviews and their Impact, A Biennial Analysis of Serious Case Reviews 2005 – 07” Brandon et al (2009) identify a frequent failure by agencies to adequately engage with men in families.  This includes a failure to gather information about their history or to include them in assessments.      Page 20 of 46  4.2.11 Notwithstanding the above comments it should be emphasised that, in this case, Father had no known history that should have caused concern to agencies and therefore, even if he had been assessed and enquiries made, no matters of concern would have come to light.  Cavanagh et al (2007) found, in their study of fathers who fatally abuse their child, that the men are “under-educated, under-employed, with significant criminal histories” there is a strong correlation to violence to women, with 75% being violent towards the child’s mother. Less than 13% were married to the mother of the child.   There is nothing to indicate that any of these factors identified applied to Father or that there were any other indicators that should have given agencies cause for concern.  Furthermore, although Father has now been charged with his daughter’s murder he has not yet stood trial.  4.2.12 With regard to Child L’s visit to the GP 10 days before her death, the author of the Primary Care IMR helpfully explains the accepted pattern by which a GP should conduct a consultation using the Royal College of General Practitioners (RCGP) protocol for a standard medical record.  It is important to understand that such a consultation is reactive to the problems that are being presented.  In this case Child L was presented with a reported history of crying when trying to open her bowel and the author of the Primary Care IMR explains that this is a common presentation in new babies and is not an event that would cause a GP to focus on anything other than the initial problem.   4.2.13 Following Child L’s death it was found that she had suffered fractured ribs around the time of the GP consultation.  In the case of some previous child deaths, including that of baby Peter in Haringey, there has been concern that medical practitioners have failed to identify injuries that it was later found had been present during consultations.  Because of this, IMR authors, the authors of the Health Overview Report, the IORA and the SCR Panel have all given careful consideration to whether the GP should have identified that Child L had fractured ribs at the consultation.  It is the opinion of the medical experts, backed up by research, which is highlighted within the Health Overview Report, that even if Child L had sustained these injuries before the GP consultation there would have been no outward signs to enable the GP to identify them.  Therefore it is the view of the IORA that the GP should not be criticised for failing to identify any injuries to Child L.    4.2.14 Similarly, consideration has been given to whether the nursery nurse and/or health visitor should have identified that Child L had these historic injuries when she was examined at the baby clinic the day before her admission to hospital.  Again the IORA accepts, based on evidence within the Health Overview Report, that it would not be reasonable to expect them to have done so.    Admission of Child L to hospital and her subsequent death; February 2011   4.2.15 In analysing the response from YAS the author of the Health Overview Report concludes that there is nothing to suggest that the care provided to Child L and her family was not of a good standard.  The author explains that the national target response time for immediately life threatening emergencies is within eight minutes and this target was just met as the paramedic arrived exactly eight minutes after the call was received by YAS.   Page 21 of 46 4.2.16 This SCR has not identified any concerns with the medical care that Child L received at either BDGH or SCH with the exception of the refusal to undertake a CT scan whilst Child L was at BDGH.  Furthermore, given this refusal, the decision to transfer her to SCH without further delay is considered appropriate.  Term of reference 12 specifically concerns the issue of the CT scan and therefore it will not be considered in any further detail at this point in the report.  4.2.17 In addition to providing emergency treatment to Child L, hospital staff were responsible for dealing with Child L’s parents, maternal grandparents and maternal aunt and uncle who were present.  It was also necessary for hospital staff to consider possible causes of Child L’s collapse and to liaise with other agencies as appropriate.    4.2.18 Comments made by Mother and Father in their meeting with the IORA and Panel Chair suggest that both hospitals were largely successful in managing the family members in a supportive and sensitive way.  Records make it clear that both hospitals appropriately considered the possibility of NAI and liaised with Social Care and the police as required.  Although Father and Mother felt that there timing of the intervention from Social Care and the police was insensitive, the SCR Panel are of the view that this was probably unavoidable and it is unlikely that it would have been any easier for the family if these organisations had waited until immediately after Child L’s death.  4.3 Analysis by Terms of Reference  1. Construct a comprehensive chronology of involvement by the organisation and/or professionals in contact with Child L and her family.   4.3.1 All agencies who were asked to provide an IMR for this review constructed a comprehensive chronology on a template provided by the Safeguarding Children Unit.  These individual chronologies were integrated into one chronology which the IORA has used to assist in understanding this case.  2. Summarise the decisions reached, the services offered and/or provided to Child L and her family and any other actions taken.   4.3.2 The decisions reached, the services offered and/or provided to Child L and her family and any other actions taken are summarised in section 3 of this Overview Report.  3. Consider if practitioners were aware of and sensitive to the needs of Child L in their work, had the relevant knowledge about potential indicators of abuse or neglect and what to do if they had concerns about a child’s welfare.   4.3.3 Evidence suggests that, prior to Child L’s collapse in February 2011, there were no indicators of abuse or neglect and therefore it is difficult to demonstrate, with certainty that staff would have acted appropriately if such signs had been present.  Nevertheless, the authors of all of the IMRs demonstrate that the staff who had contact with Child L and her family had appropriate, up to date training with regard to Safeguarding Children and knew where to seek support and information if and when they required it.  Information is provided in the Primary Care IMR about appraisal and revalidation processes being undertaken by the PCT to ensure that  Page 22 of 46 GP’s are able to practise safely.  Safeguarding training forms a mandatory part of both these processes.   4.3.4 From the interviews they carried out in undertaking the IMR, the authors of the BHNFT IMR found that the midwife who was mainly involved with the family, and paediatric consultant who dealt with Child L after her collapse, were up-to-date with the required safeguarding training, and showed a good understanding and working knowledge of potential concerns and the appropriate procedures and guidance to be followed should concerns arise.     4.3.5 Similarly the author of the SWYPFT IMR found that the health visitor’s safeguarding training was current and that she knew who to contact regarding safeguarding issues.  The IMR author explained that the health visitor demonstrated her sensitivity by offering ongoing support to Mother due to her low mood and also by not assuming that Mother would be confident with her baby simply because she worked as a child care professional.   4.3.6 Following Child L’s collapse on 16 February 2011 medical and nursing staff at both BDGH and SCH demonstrated that they had knowledge about potential indicators of abuse or neglect and what to do if they had concerns about a child’s welfare.  Staff in the Emergency Department at BDGH took the appropriate action of contacting the Emergency Duty Social Care team to inform them of Child L’s attendance and complete a background check.  The BHNFT IMR makes it clear that practitioners considered NAI as a possible cause but there was no clear evidence at that point and there existed a number of possible differentials that could have led to the collapse.  As it was unclear at this point that practitioners were looking at an NAI a direct referral was not made.    4.3.7 Similarly the IMR from SCNFT explains that NAI was considered and staff considered whether there were siblings who may have been at risk.  Although the diagnosis of NAI was not clear cut, staff from SCNFT appropriately involved the Police and Social Care.  4. Did the organisation have in place Policies and Procedures for Safeguarding and promoting the welfare of children and were able to act on concerns relating to a child’s welfare.   4.3.8 All of the organisations which have provided IMRs for this SCR report that they have in place Policies and Procedures for Safeguarding and promoting the welfare of children.  Furthermore IMR authors found that key professionals involved in working with Child L and her family had ready access to these policies and procedures.  The author of the Primary Care IMR states that in accordance with Barnsley Safeguarding Policies, GP1 has the Barnsley Safeguarding Policies and Procedures available on his desktop, requiring just one click of the mouse to access them.  The authors of the BHNFT IMR state that practitioners interviewed as part of the review knew how to access policies, procedures and guidance.  The author of the SWYPFT IMR wrote that policies relating to safeguarding children are stored electronically on the Trust intranet and the LSCB’s website and that all health visitor bases have access to the internet and intranet.  Finally, the author of the SCNFT IMR wrote that the Trust Policies and Procedures relating to Safeguarding Children are available on the hospital intranet, in the medical  Page 23 of 46 handbook and within Embrace and PICU.  In addition the author stated that the key consultants involved with Child L were aware of these procedures.  4.3.9 No concerns for Child L’s welfare were evident until Mother made the 999 call on the evening of 16 February 2011 and therefore no staff had instigated safeguarding procedures prior to this.  However following the 999 call organisations appear to have acted appropriately.  YAS, BHNFT and SCNFT staff all alerted the police to Child L’s injuries whilst the latter two organisations also involved Social Care.  SCNFT also informed the police and Social Care of Child L’s death.  It is clear that medical staff at both hospitals were alert to the possibility of the injuries being the result of an NAI.  4.3.10 The authors of the BHNFT IMR suggest that the current policy relating to providing information about the dangers of shaking a baby is insufficiently robust.  They make a recommendation to address this.  The IORA is in agreement with the need to strengthen this policy but is not confident that the recommendation and action plan from BHNFT is itself sufficiently robust.  Therefore the IORA makes an additional recommendation about this to the chair of the BSCB.  5. What were the key relevant points/opportunities for assessment and decision making in this case in relation to Child L and her family?  Do assessments and decisions appear to have been reached in an informed and professional way?   4.3.11 Each of the contacts between professionals and family members provided an opportunity for assessment and decision making in this case.  These were: � the initial GP consultation when it was established that Mother was pregnant,  � Mother’s attendances at the antenatal clinic,  � Mother’s antenatal appointments with the community midwife,  � Child L’s birth,  � postnatal visits from the midwife, � postnatal visits from the health visitor ,  � Child L’s visit to the GP with Mother � Child L’s visit to baby clinic with Mother � attendance of YAS staff at the family home after Child L collapsed � the entirety of Child L’s attendance at BDGH and SCH following her collapse.   4.3.12 These occasions have been considered in the chronological analysis in section 4.2 of this report.  Decisions were largely reached in an informed and professional way based on the assessments that were undertaken but there was insufficient consideration of Father.  This could potentially have affected the decisions that were made although, in reality, based on the information that is available about him, it seems unlikely that greater consideration of Father would have led to any significant changes in the decisions made.  4.3.13 The decision taken by the Teleradiology Consultant not to authorise a CT scan of Child L was an incorrect decision based on the assessment of the child’s condition.  This situation is addressed on more detail in the analysis of term of reference 12.  6. Were appropriate services offered/provided or relevant enquiries made in light of any assessments?   Page 24 of 46  4.3.14 During Mother’s pregnancy and delivery and the period that Child L lived at home with her parents, routine health services were provided.  This was relevant in the light of the assessment of the family.  Following the injury to Child L YAS correctly transferred Child L to BDGH and she was appropriately treated there prior to transfer to SCH.  Following transfer, treatment was also appropriate.    4.3.15 Again, the occasion when an appropriate service was not offered was when the Teleradiology Consultant refused to authorise the CT scan whilst Child L was at BDGH.    7. Was practice sensitive to the racial, cultural, linguistic and religious identity and any issues of disability relating to Child L and her family and were they explored and recorded?   4.3.16 Child L’s parents are white, British with English as their first language; Child L herself was white, British and was pre-verbal at the time of her death.  Child L’s grandparents and two of her half-siblings also lived in the neighbourhood.  The vast majority of people in the neighbourhood are white, British, English speakers and many families have lived in the area for generations.  Although the area is one of economic deprivation with high levels of unemployment and invalidity, Mother and Father were both in paid employment and did not have any disabilities or significant ill health.  4.3.17 The agencies involved in this SCR all had information recorded about the family’s ethnic origin.  The authors of the BHNFT IMR comment that Mother reported herself not to have any religious beliefs and that information related to ethnicity and diversity needs were all recorded, as per local practice, as part of the antenatal booking record.  The author of the SWYPFT IMR, however, states that the religious conviction of the family was not recorded and ought to have been as this is basic information.    4.3.18 It was the view of all agencies that the family did not have any specific needs as a result of their racial, cultural, linguistic or religious identity or any issues of disability.  When families are white, British with English as a first language it is very easy to assume that they will not have any special needs relating to these issues.  Care needs to be taken in making such assumptions as even white, British, English speakers can sometimes find themselves living in an area where they feel culturally isolated.  For example, this may occur if they have specific religious beliefs, come from a very different socio-economic background to those of their neighbours or live in an area where the majority of people are not white, British English speakers.  However, in this instance, the IORA believes it is reasonable to assume that the family did not have any specific racial or linguistic needs that might have caused them difficulties in their local neighbourhood.    8. Were Senior Managers or other organisations and professionals involved at points in the case where they should have been?   4.3.19 Prior to the incident that led to Child L’s death, organisations and professionals did not have any particular concerns about this family.  Therefore there were no occasions when one would have expected professional staff to seek child protection supervision or specific management guidance.  Even now, no  Page 25 of 46 information has come to light to suggest that agencies should or could have had safeguarding concerns.    4.3.20 It was appropriate for Child L to be examined by a nursery nurse when she attended the baby clinic in February 2011.  The author of the SWYPFT IMR explains that nursery nurses are fully trained in child development up to eight years of age and they receive training in safeguarding.  It is common practice for nursery nurses to be used at baby clinics and they are directly accountable to the health visitors in the team.    4.3.21 Following Child L’s collapse and admission to hospital, senior medical staff were involved in providing her care and treatment.  During this period there was appropriate liaison between BDGH and SCH and with the police and Social Care.  This is described in the analysis to term of reference 4.   9. Was the work consistent with each organisation’s and Barnsley Safeguarding Children Board Policy and Procedures for Safeguarding and promoting the welfare of children and with wider Safeguarding standards?   4.3.22 It is evident from the analysis concerning Terms of Reference 3 and 4 that work in this case was consistent with the Policies and Procedures for Safeguarding and promoting the welfare of children within each organisation and BSCB and with wider Safeguarding standards.  10. Were there organisational difficulties being experienced within or between agencies?   4.3.23 No organisational difficulties are identified in any of the IMRs with regard to services provided to Child L and her family during the period covered by this review.  However the author of the SWYPFT IMR has identified some difficulties with the organisation’s change over from paper to electronic records that may impact on the management of cases.  A number of recommendations have been made in the SWYPFT IMR regarding SystmOne, the electronic record.  4.3.24 The absence of a written handover from the midwife to the health visitor was an organisational difficulty because it resulted from the documentation pack not including a discharge form because Child L was not born in Sheffield.  There is a recommendation within the BHNFT IMR to minimise the likelihood of this situation arising again.  4.3.25 The IORA does not regard the refusal by the Teleradiology Consultant to carry out a CT scan on Child L as an organisational difficulty.  Instead it appears to have been a potentially serious error of judgement from the individual consultant.  The BHNFT IMR describes action taken by the Trust in respect of this incident.  This is addressed in the response to term of reference 12.    11. Did any resourcing issues have an impact on the case?   4.3.26 This review has not identified that any resource issues impacted on this case; routine appointments took place at appropriate times and there was adequate continuity of staff.  The response to the emergency on 16 February 2011 was also adequate with YAS arriving at the property eight minutes after receiving the  Page 26 of 46 emergency call and a responsive service from BDGH and SCH.  The shortfalls in service delivery that have been identified did not result from resource issues.   12. Consider the decision making process around the request for a scan for Child L and the impact of this process.   4.3.27 It is evident that the Embrace and PICU Consultants from SCNFT wanted Child L to have a CT scan before leaving BDGH in order to assist them in making decisions about her care.  However the scan was not undertaken and the aforementioned consultants from SCNFT decided to transfer Child L to SCH without further delay and undertake the scan when she arrived.  4.3.28 In undertaking this SCR it is important to identify why a scan was not undertaken at BDGH, whether a scan should have been undertaken at BDGH, what the impact was of no scan being undertaken at BDGH and, if necessary, how to minimise the risk of a similar situation occurring in the future.  4.3.29 The author of the BHNFT IMR provides a detailed explanation of the process by which scans are managed out of normal hours and explains that the Trust contract with an external provider to provide a Teleradiology service which authorises and interprets such scans.  The author explains that, according to notes made by the Paediatric Consultant, the reason the scan was not undertaken was that the Teleradiology Consultant on duty that evening refused to authorise a scan on the grounds that the case did not meet NICE criteria and that, in any case, she would not be able to interpret the results on a baby of Child L’s age.  The contact between BHNFT and the external provider does not allow local clinicians from other departments to contact the local Consultant Radiologist and therefore, once the Teleradiology Consultant had made her decision, the Consultants from SCNFT were powerless to arrange for the CT scan to be performed at BDGH.  4.3.30 In considering the Teleradiology Consultant’s reasons for refusing to undertake the scan the author of the BHNFT IMR explains that the out of hours Teleradiology protocol lists indications for CT scan to be undertaken and that this includes a Glasgow Coma Scale (GCS) of 13 or below, of unknown cause.  This is a category into which Child L fell.  The author adds that this is consistent with the NICE guidelines (NICE clinical guideline 56 – Head Injury 2007 page 9) and concludes that the Teleradiology Consultant did not follow these guidelines.  On reading the BHNFT Department of Medical Imaging Policy for Out of Hours Radiology Requests at BDGH, it was clear to the IORA that where a patient meets the standard imaging criteria for a CT scan, the consultant clinician can request the scan directly from the radiographer without needing to talk to the Teleradiology Consultant.  Consequently, in the case of Child L, the protocol would have allowed for the scan to have been undertaken without reference to the Teleradiology Consultant.   4.3.31 The IORA raised this matter with one of the authors of the BHNFT IMR who amended the IMR and explained that it has become accepted custom and practice for Paediatric Consultants to request scans from the Teleradiology Consultant.  Furthermore, the author stated that, even if the Paediatric Consultant contacted the Radiographer directly the Radiographer would, in most cases involving a child, refer the case onto the Radiologist due to concerns about exposing young children and babies to radiation.  The IORA accepts this explanation from the author of the  Page 27 of 46 BHNFT IMR but considers it important that accepted practice should match written procedure.  Therefore the IORA welcomes the statement in the BHNFT IMR that the protocol is being rewritten and will state that all referrals will go straight through to the Teleradiology Consultant.    4.3.32 The author of the SCNFT IMR explains that the CT scan did not need to be interpreted by the Teleradiology Consultant, as it could have been sent to SCNFT via the PAX system, and interpreted by a SCH paediatric radiologist.  The author adds that this was communicated by the Embrace consultant 1 to the Teleradiology Consultant.  Therefore the author of the SCNFT IMR considers that this was not an acceptable reason for the Teleradiology Consultant to refuse the request.  The Teleradiology Consultant was not interviewed for the IMR and therefore it is not possible for the IORA to know whether she was aware that the scan could have been interpreted by the paediatric radiologist at SCH.  The author of the SCNFT IMR has suggested that, as a specialist paediatric service, SCNFT might be able to formalise arrangements to assist radiologists serving BDGH with interpreting scans in young children.  This SCR includes a recommendation that that proposal should be explored further.  4.3.33 Both the BHNFT and SCNFT IMRs consider the potential impact of the scan not being performed at BDGH and the actual impact in this case.   The author of the SCNFT IMR explains that, if Child L had been found on CT scan to have required urgent neurosurgery, then she would have needed to be transferred to neurosurgical care immediately.  Therefore lack of early scanning could have resulted in a delayed operation, and could have affected the outcome.  Alternatively a local scan could have resulted in a decision not to transfer Child L, as a decision might have been made to withdraw care on the basis of dire scan results.    4.3.34 However the authors of both IMRs agree that, in the case of Child L, it is highly unlikely that the absence of a CT scan prior to transfer had any impact on the eventual outcome for Child L.  This was because when the scan was done surgery was not indicated and, Child L’s condition was such that she was highly unlikely to survive.  4.3.35 Although the refusal of the consultant to carry out a CT scan is unlikely to have had an impact on Child L it is important that action is taken to minimise the risk of a similar situation occurring in the future.  It should be noted that this incident was already being addressed by BHNFT prior to the decision being taken to carry out an SCR and the authors of the BHNFT IMR explain that since this incident the out of hours Teleradiology contract has been awarded to a different provider.  The authors describe some of the safeguards that have been put in place to ensure that the contract is more robust than was previously the case.  This includes new monitoring arrangements, random sampling of reports and a two way process of feedback.  In addition the service is now being provided by consultants based in Australia with the result that the service will be delivered during their day time hours.  This will mean that the organisation will have more staff around to offer peer review of requests and image interpretation.     4.3.36 By awarding the contract for out of hours radiology services to a new provider BHNFT have sought to ensure that the inappropriate refusal to carry out a CT scan is not repeated within their trust.  However, an issue remains about how the matter  Page 28 of 46 should be addressed with the organisation that was providing the service at the time of Child L’s admission and the individual Teleradiology Consultant who refused the request. This Serious Case Review has not directly involved the Teleradiology service or the Teleradiology Consultant.  Therefore it is not possible to know whether any action has been taken to minimise the risk of that service or the individual making a similar decision in the future.  The authors of the BHNFT IMR explain that the police have become involved in pursuing a statement from the Teleradiology Consultant and it is understood that this matter will be addressed by the coroner who will decide whether the consultant’s professional body should be notified.  13. Establish whether there are any overlapping issues between this review and the Child X Serious Case Review and, if so, what has been done to address the issues.  4.3.37 Child X died in September 2010 at just seven weeks of age and was the subject of a Serious Case Review commissioned by Barnsley Safeguarding Children Board which was completed in June 2011, approximately four months after the death of Child L.  4.3.38 There are the several similarities between the circumstances of Child X and Child L and these include the following: � Neither child was known to Social Care prior to sustaining the injuries that led to their death. � Both children died as a result of severe traumatic brain injury believed to be the result of an NAI.   � In the case of Child X the father has been convicted of murder and in the case of Child L the father has been charged with murder but has not yet stood trial.   � Both children had been seen by health professionals less than 36 hours before being admitted to hospital with the injuries that led to their deaths. � Post mortem medical investigations have shown that both children had old rib fractures. � Both families were white, British and were not felt to have any particular needs relating to their religion, race, language or ethnicity.  There were no issues of disability.  4.3.39 The IORA for Child X listed a number of factors that are typically found in Serious Case Reviews as follows: � Insufficient focus upon the child and a greater and/or disproportionate focus upon the adults. � Failure by agencies to identify and/or report signs of abuse. � Poor recording by agencies. � Poor interagency communication. � Poor communication with children. � Poor professional knowledge. � Poor application of procedures. � Poor risk and analytic assessments. � Multiple assessments not taking account of the relevance of past history. � The rule of optimism – accepting standards of care which would not be acceptable with other families. � Not recognising the indicators of risk: chronic neglect, older children, domestic violence, mental ill health and substance misuse.  Page 29 of 46 � Lack of management oversight of cases with poorly trained, inexperienced practitioners and managers and insufficient or inadequate supervision.  4.3.40 She commented that these had not applied in the case of Child X and similarly these typical features were not prominent in the case of Child L.  It is therefore reasonable to say that this was not a case where a serious incident could typically be predicted.  The logical extension of this is that there was no reason for organisations or individuals working with this family to have particular concerns for the safety of Child L.  4.3.41 A key difference between the cases was that there had been some earlier concerns in relation to the care of an older child of the mother of Child X and it was also known that the mother of Child X had been the victim of domestic abuse from previous partners.  However in the case of Child L there had been no previous concerns.  4.3.42 With regard to the actions of organisations and professionals, the following issues applied to both cases: � There were no organisational failures or missed opportunities to safeguard either child. � Midwifery and health visiting services did not record the presence of the father at appointments and home visits. � Health professionals who saw the children shortly before they were admitted to hospital could not reasonably have been expected to have identified the existence of rib fractures.  4.3.43 The IORA has examined the Action Plan from the Child X Serious Case Review and found the following three recommendations which are of relevance to Child L’s case.  Information contained within the Child L IMRs and Child X action plan indicates what action has been taken with regard to each of these recommendations.  4.3.44 Recommendation 1 (to BHNFT) - The organisation should reassure itself that the midwifery service routinely ask all women about domestic abuse.  4.3.45 Action was taken in December 2010 to reinforce the need for the midwifery service to ask this question and practice and paperwork has been amended to facilitate this.  An audit was completed in September 2011, in which 100% of records sampled included a record that questions regarding domestic abuse had been asked.  Furthermore, in the case of Child L, records show that Mother was asked about domestic abuse during the antenatal booking contact.    4.3.46 Recommendation 2 (to BHNFT) - A full family history (including social history) should be obtained relating to mother, partner and any members of the household.  This should include previous and present alcohol misuse, substance misuse, mental illness and learning disabilities / difficulties, previous child protection concerns.  4.3.47 The author of the BHNFT IMR has explained that local paperwork has been amended to include the need for a full history to be extended to all significant adults.  This change was made in December 2010, six months after Mother’s booking information was taken and a matter of weeks before Child L was born.  At  Page 30 of 46 the booking appointment a partial history of Father was taken, which at that time was regarded as adequate, although it does not meet the standard now expected.    4.3.48 An additional complication, for the midwifery service, with regard to recording a full history relating to all significant adults is that the national paperwork does not include provision for this.  Midwifery services in Barnsley use the national paperwork because it is evidence based, regularly reviewed and perceived to be ‘gold standard’.  However as a result of the Child X SCR, the BHNFT representative on the national Perinatal Institute made a suggestion to the institute in December 2010 that when the antenatal records were next updated they should be modified to include the need to take a full social history of all members of the household.  This suggestion was well received and the author of the BHNFT IMR has informed the IORA that the paperwork was reissued in December 2011 having been revised in line with the suggestions made by the Barnsley representative.   It now contains a specific field to ask about the father’s mental health and the boxes for information about issues such as alcohol and smoking now refer to anyone in the home.   The IORA considers this to be a good example of when the findings of an SCR are used, not just to improve practice locally, but to improve things nationally.   4.3.49 Recommendation 3 (to SWYPFT) The caring experiences and responsibilities of all known responsible adults must be clearly recorded by the health visitor.  4.3.50 The action plan from the Child X Serious Case Review shows that March 2011 was the timescale for implementation of this recommendation.  This was after the death of Child L and therefore health visitors were not required to record this information at the time they were working with Child L and her family.  The action plan also shows that an audit of compliance will be undertaken in March 2012.  The author of the SWYPFT IMR states that this recommendation has not been embedded in practice.    4.3.51 In response to term of reference 13 the author of the SWYPFT IMR has written that:  “(The) recommendation of identification of people present in the household in the SCR of child X was outside the remit of this case as the timescales would not have been enacted until after the death of child L.”    4.3.52 The author of the IMR has not explained the current position but following a request from the IORA the assistant director of nursing within SWYPFT has provided information that SystmOne now includes a mandatory field on which health visitors must record who is present at a contact.  Previously it was possible to move to the next screen on the records without completing the box which asks who was present but the system has been amended to prevent this.  There is also a text box for health visitors to record details of the contact and this can be used to include information about the caring experiences and responsibilities of known adults.  4.3.53 Whilst this action is welcome, it does not represent implementation of the original recommendation which required health visitors to record “the caring experiences and responsibilities of all known responsible adults”, not just who is present at a contact.  The issue concerning gathering information about adults will be explored in greater detail further into this section of the analysis.  Page 31 of 46  4.3.54 As well as looking at the Child X Action Plan the IORA has also looked at the recommendations contained within the Overview Report and Executive Summary for Child X and has found that there are four recommendations, two each to SWYPFT and BHNFT, that are in the Overview Report and Executive Summary but not in the Action Plan.  These are as follows: 4.3.55 For SWYPFT  1. Clear lines of accountability for Nursery Nurses and Health Visitors need to be established and communicated.  2. Deviations from the timings of child health assessments that are communicated from Nursery Nurses to Health Visitors need to be countersigned by the Health Visitor.  4.3.56 For BHNFT 1. The Midwifery Service should consider the feasibility and appropriateness of recording if someone else is present at a professional contact. 2. The guidance relating to post natal depression should be revisited to ensure it addresses the need to follow up appropriately concerns relating to maternal health.   4.3.57 Issues relating to nursery nurses were not particularly evident in the work with Child L as the only nursery nurse involvement was at the baby clinic when a health visitor was also in attendance.  Nevertheless, the Designated Nurse, Safeguarding Children has informed the IORA that action has been taken with regard to lines of accountability and health visitors and now required to sign off nursery nurses’ work.  There are some difficulties with achieving this on SystmOne but these are being addressed.  4.3.58 Although BHNFT have undertaken important work regarding taking a history of significant adults it appears that the recommendation that the midwifery service consider the feasibility and appropriateness of recording if someone else is present at a professional contact has been overlooked.  It has, however, been included as a recommendation in the BHNFT IMR for Child L.  4.3.59 It is unclear whether action has been taken in relation to the recommendation that guidance relating to post natal depression should be revisited to ensure it addresses the need to follow up appropriately, concerns relating to maternal health.  However in the case of L it appears that the appropriate mental health pathway was followed by the midwife.  4.4 Consideration of significant adults  4.4.1 In both this Serious Case Review and the one relating to Child X it was found that professionals had paid insufficient attention to significant adults other than the child’s mother.  As has already been stated, this omission has been found in other SCRs and is discussed at length by Brandon et al 2009.    4.4.2 Recommendations relating to this issue were made in the Child X Serious Case Review and further recommendations have been made in this review.  Whilst these recommendations are welcome, it is the view of the IORA that greater clarity is required as to what the problems are and what changes need to be made.   Page 32 of 46 4.4.3 Across the two reviews the following recommendations have been made which relate to significant adults: 1. A full family history (including social history) should be obtained relating to mother, partner and any members of the household.  This should include previous and present alcohol misuse, substance misuse, mental illness and learning disabilities / difficulties, previous child protection concerns.  Child X aimed at BHNFT  2. The Midwifery Service should consider the feasibility and appropriateness of recording if someone else is present at a professional contact.  Child X aimed at BHNFT  3. The Midwifery service at BHNFT should ensure that it becomes routine practice for midwives to routinely document who is present at a contact.  Child L aimed at BHNFT   4. The caring responsibilities of all known adults within a family to be clearly recorded by the Health Visitor.  Child X aimed at SWYPFT  5. The Business Manager to expand SystmOne (electronic records system) to include “others in the household” at home visits and also “others attending with the child” at clinic attendances. This should be a prerequisite before being able to fill in the context and content of each home visit or baby clinic attendance. This should be an addendum to Child X Recommendation as identified in Term of Reference 13.  Child L aimed at SWYPFT   4.4.4 Recording who is present during visits and appointments will help agencies to build up a picture of who is significant in the family’s life whilst recording the caring responsibilities of known adults will further extend this picture.  Recording histories for people who are significant in the child’s life will maximise the chance of establishing whether information is known about an individual that would suggest that they may pose a threat to the child.  It is the view of the IORA that both SWYPFT and BHNFT need to be developing their staff so that midwifes and health visitors routinely undertake these tasks.  4.4.5 The action detailed above, that has been taken since the Child X SCR is to be welcomed but, the IORA believes that it needs to go further to ensure that midwives and health visitors act upon the information they gather.  This will involve a degree of assessment of the information they gather and, where there are concerns, will also involve communication with other professionals, such as GP’s, Social Care and the Police, who may have information about individuals.  4.4.6 It is also important to stress that these recommendations should not be directed solely at fathers or even at men.  Families are structured in many different ways and practitioners need to know how to respond in different situations.  Addressing this complicated area requires a change of mindset within organisations so that professionals understand that a key part of their role is to safeguard children and, in order to do so, they need to take a pro-active role in gathering information about the individuals involved in a child’s life and to take action if they have any concerns about the way any of those people are caring for the child.     Page 33 of 46 4.4.7 Finally it should be stressed that this is not solely an issue for midwives and health visitors but applies to all services who have contact with families.  The emphasis in this review is on midwives and health visitors as they were the professionals who had the most involvement with the family.  4.5 Analysis of IMRs  4.5.1 All the IMRs produced for this review follow a set format specified by the Barnsley Safeguarding Children Board.  As a result they are all well structured with a shared introduction explaining the background to the review and the reason it is being undertaken.  They also contain a clear statement as to the time period for the review and the key issues to be addressed as set out in Terms of Reference produced by the Serious Case Review Panel.  The IMRs include brief family details, a genogram and consideration of any ethnic, cultural, linguistic and religious issues relating to the family. They also include sections to summarise the agency’s involvement with the family and to analyse that involvement.  Individual chronologies were written on a standard template to enable continuity and to facilitate the compilation of the integrated chronology.  The IMRs have all been signed off at an appropriate level within the organisations.  4.5.2 The Serious Case Review panel and IORA provided substantial challenge to the performance and practice of agencies throughout the Serious Case Review with the result that IMRs were revised on a number of occasions.  This challenge was provided in Serious Case Review Panel meetings and in individual discussions that the IORA had with IMR authors.    4.5.3 The IMR from BHNFT addresses the maternity services provided to the family from the point at which Mother had her booking in appointment until the final postnatal midwifery visit.  It also considers the actions of BDGH staff from the time of Child L’s arrival in the Emergency Department following the incident that led to her death until she was transferred to the care of Embrace for the journey to SCH.  4.5.4 The IMR addresses all the terms of reference in detail and identifies the key learning points.  It demonstrates that action had already been undertaken to address the issue relating to there not having been a CT scan of Child L whilst she was at BDGH and the issues relating to midwives taking a family history of all members of the household.  Four SMART recommendations are made that address the other learning points from the IMR and an action plan is included that shows that implementation has taken place with regard to these actions and there are plans to audit compliance in the months ahead.  4.5.5 Whilst the IORA considers the BHNFT IMR to be of a high standard he has some concerns regarding the robustness of recommendation 3.  This requires Midwifery leads to meet with Health Visiting leads to discuss the optimum time to discuss ‘Shaken Baby’ syndrome with parents and who should do this.  However, whilst the action plan provides a date of December 2011 for the meeting request to be made there is no target date for when practice will have been changed to ensure that relevant information about ‘Shaken Baby’ syndrome is being routinely provided to all parents of new born babies.  Given that resolution of this issue involves the co-operation and agreement of two health providers the IORA has made a recommendation to the chair of BSCB to ensure that this issue to seen through to a conclusion.  Page 34 of 46  4.5.6 There was only one significant GP contact for the Barnsley Primary Care IMR to consider and consequently it is a fairly brief report.  Nevertheless the IMR author has addressed all the terms of reference and has appropriately given detailed consideration to whether the GP could have identified fractured ribs at the consultation with Child L.  Although it was not particularly pertinent to Child L the IMR author has identified a potential shortfall in the information contained in medical records and has made a recommendation to address this.   4.5.7 The IMR from SCNFT provides a detailed consideration of the services provided by the trust to Child L.  All terms of reference are addressed and the IMR author concludes that, even with hindsight, it is difficult to see anything that could or should have been done differently.  The IORA concurs with this conclusion.  The issue of greatest concern for SCNFT concerned the refusal of the radiologist to carry out a CT scan of Child L whilst she was at BDGH and whilst the SCNFT IMR author does not believe the Trust could have done anything differently at the time, she does make one SMART recommendation which has the potential to lead to improvements for the future.    4.5.8 The IMR from SWYPFT addresses the involvement of the Health Visiting Service with the family following the birth of Child L.  This amounted to two home visits from a health visitor and one clinic attendance when Child L was seen by a nursery nurse and a health visitor.  The IMR provides a good summary of these contacts and addresses all the terms of reference.   The section headed “what do we learn from this case” is incomplete; for example it does not make reference to the failure to record who was present at visits even though this is identified in the analysis and carried through to a recommendation.  Four SMART recommendations are made and an action plan is included which identifies how and when these recommendations will be implemented. Three of the recommendations are focused on developing the electronic records system.  The IORA believes that there is also a need for the service to develop the awareness and skills of front line staff and managers in respect of safeguarding children.  It is much harder to write SMART recommendations to address these issues but it is only by raising awareness and skill that safeguarding practice will become routinely embedded in the work practitioners.  4.5.9 The Health Overview Report highlights the key issues that have been identified within the IMRs and looks at the links between the various health organisations involved with Child L and her family during the period covered by the review.  The authors of the Health Overview Report have included significant amounts of research and a number of references in order to support their findings.  The authors of the Health Overview Report state their support for the recommendations within the individual IMRs and add one further recommendation which relates to the implementation of the recommendations made within the IMRs.   5. Conclusions  5.1 The death of Child L at only five weeks of age was a tragic event and it was appropriate for Barnsley Safeguarding Children Board to commission a Serious Case Review.  Child L’s death occurred as the direct result of a serious injury which is believed to have been sustained as a non-accidental injury and her father has been charged with her murder.  However, this review has found that there was  Page 35 of 46 no information available to any practitioners that could or should have led them to have concerns that Child L was at risk of non-accidental injury or even that she was a child in need.  There is no suggestion that Child in Need or Child Protection procedures should have been instigated at any stage in agencies’ work with the family or even that a Common Assessment Framework (CAF)2 was indicated.  Consequently it is view of the IORA and the Serious Case Review Panel that Child L’s death could not have been predicted or prevented.  5.2 The review has been conducted with a view to identifying any specific factors that impacted on the injury to Child L and also on learning broader lessons.  Whilst it has found that the injury to Child L could not have been predicted or prevented it has identified a number of issues where agencies could improve their practice in order to better safeguard children.   5.3 The review has identified failings in the record keeping by both the midwife and the health visitor.  There was no written record of a conversation they both state they had when the midwife handed over care of Child L to the health visitor.  This problem was exacerbated because the documentation from the hospital did not include a discharge form as would have been the case if Child L had been born in Barnsley.  However, given that it is not uncommon for women living in Barnsley to give birth in other areas this problem should not have arisen. In addition the health visitor’s record of her first visit to the family was incomplete.  5.4 The absence of a written handover means that there is no record of the midwife making the health visitor aware that Mother had been tearful at the midwives final visit.  Apart from the absence of a written record of Mother being tearful, it does appear that sufficient consideration was given to Mother’s mental health in accordance with both the antenatal and postnatal mental health pathways.    5.5 Neither the health visitor nor the midwife documented who was present at appointments and visits, although it should be noted that this was not a requirement at that time.  There is, however, a need for professionals to pay greater consideration to the wider community around a child; not just the child and his or her mother.  This needs to involve being aware of who is present at appointments and making a record of this, identifying who is significant in the life of the family and gathering information about their history.  BHNFT were right to identify, in the SCR for Child X, that this is a national issue that requires a national response and the IORA fully supports the action taken and welcomes the fact the suggested changes have now been made.    5.6 The review has found out that no-one discussed the dangers of shaking a baby with either Mother or Father and it appears that, whilst at one stage this was done routinely, that is no longer the case.  A recommendation has been made that midwifery and health visiting leads discuss who will take responsibility for this task.  The IORA stresses the need for this action to be completed as a matter of priority.  5.7 Detailed post mortem examinations revealed that Child L had suffered rib fractures seven to ten days prior to her death and therefore may have had fractured ribs when she was taken to the GP and certainly had them prior to attendance at the                                             2 a shared assessment and planning framework for use across all children's services and all local areas in England. It aims to help the early identification of children's additional needs and promote co-ordinated service provision to meet them.  (Children’s Workforce Development Council website, 2011)  Page 36 of 46 baby clinic.  The Serious Case Review Panel and IORA have carefully considered whether the GP, health visitor and/or nursery nurse should have identified this injury during their contact with Child L.  The Panel and IORA are satisfied that it would be unreasonable to expect them to have done so.  5.8 Following the 999 call in February 2011, emergency care for Child L appears to have been carried out professionally and appropriately by staff from YAS, BHNFT and SCNFT.  The exception to this was the refusal by the Teleradiology Consultant to undertake a CT scan whilst Child L was at BHGH.  This appears to have been a potentially serious error of judgement but one that, in this instance, made no difference to the outcome for the child.   BHNFT took decisive action to investigate the incident and have now changed the provider of out of hours radiology and added additional safeguards.  Whilst this is of benefit to BHNFT it will not necessarily improve the service provided by the previous provider or the individual consultant.  Whilst it is understood that this issue will be addressed by the coroner this Overview Report includes a recommendation which will ensure that the Radiology Provider and the consultant are made aware of the pertinent findings of this review.    5.9 The IORA acknowledges that Mother and Father feel that a doctor at SCH spoke to them inappropriately and also that the timing of the Police and Social Care, in talking to them whilst their daughter was dying, was also inappropriate.  It is understandable that Mother and Father feel this way but, having considered the matter the Serious Case Review Panel and IORA believe that the Police and Social Care acted correctly.  The doctor was faced with the difficult task of effectively raising suspicions against Father and/or Mother in connection with their daughter’s injuries and in such circumstances it is not surprising to the IORA that Father and Mother took a dislike to the him.  Nevertheless this information will be fed back to the doctor so it can be reflected upon and used as a learning opportunity.  5.10 Issues raised by Father and Mother about services they have received since Child L died are outside the scope of this review but have been addressed by the SCR Panel as described in the body of the report.  5.11 It is a matter of concern to the IORA that four recommendations from the Child X review are not included in the action plan although there is no evidence that the omission of these from the action plan had a detrimental impact on the work undertaken with Child L and her family.  It is important that the LSCB check whether these recommendations have been fully implemented and, if they have not, they should be added to the Child X or Child L action plan to ensure that work is undertaken to implement them.  5.12 In response to an issue raised by Father and Mother about bereavement support the Designated Nurse explained to the SCR Panel that, if a child dies in BDGH, a pack is given to bereaved parents with lots of helpful contacts for agencies in Barnsley.  Similarly SCH does this for bereaved families in Sheffield.  Given that it is not uncommon for seriously ill children from Barnsley to be transferred to SCH the IORA believes that it should be in a position to provide a pack of appropriate contacts to families from Barnsley.   Page 37 of 46 5.13 As well as identifying areas for improvement, this SCR has also identified a number of examples of good practice.  The midwifery and health visiting services had an appropriate level of contact with Mother and there was good continuity with the one midwife carrying out the majority of visits and one health visitor carrying out both visits.  All professionals largely complied with required policies and procedures.   5.14 Of particular note were the comments of Mother and Father who commented on how helpful they found it when professionals explained things to them and kept them informed as to what was happening.  They were even able to appreciate that this had been useful during the last few hours of Child L’s life.  By contrast they have felt unclear about Social Care’s role in recent months and what to expect from the social worker.  This is a useful reminder for all agencies of the importance of communicating with their service users and providing clear and unambiguous explanations.     6. Recommendations  6.1 Eleven recommendations are made within the Individual Management Reviews and the Health Overview Report and these have all been accepted and signed off by the individual agencies.  The Panel and author are in agreement with all the recommendations, which are listed below.  An action plan has been written for the implementation of each of these recommendations and these action plans will be monitored by the Barnsley Safeguarding Children Board Quality Assurance Sub-Group to ensure that they are fully implemented.  It is evident from the action plans that many of the individual agency recommendations have already been fully or partially implemented.  Recommendations in the Health Overview Report 1. The Executive Director for Safeguarding Children will ensure that all recommendations identified within the health IMRs are completed within the timescales identified.  Recommendations in the BHNFT IMR 2. The midwifery service at BHNFT should ensure itself that midwives have readily available to them and use all the required paperwork needed to be completed antenatally and postnatally to meet local record keeping standards.  3. The Midwifery service at BHNFT should ensure that it becomes routine practice for midwives to routinely document who is present at a contact.    4. Midwifery leads should meet with Health Visiting leads to discuss the    optimum time to provide / discuss ‘Shaken Baby Syndrome’ and who should do this.    5. The Named Doctor should amend the current child death checklist to ensure it contains a prompt for the consultant leading the rapid response, to assure themselves that hospital notes folder has been created and contains all relevant information and is available for inclusion of any subsequent relevant clinical information.    Recommendations in the Barnsley Primary Care IMR  Page 38 of 46 6. As part of an educational programme – review record keeping with Primary Care in Barnsley  Recommendations in the SWYPFT IMR 7. The Business Manager to expand SystmOne (electronic records system) to include “others in the household” at home visits and also “others attending with the child” at clinic attendances. This should be a prerequisite before being able to fill in the context and content of each home visit or baby clinic attendance. This should be an addendum to Child X Recommendation as identified in Terms of Reference 13.  8. The Business Manager to ensure completion of all data area/text boxes within SystmOne e.g. Marital Status, Religion and Ethnicity to improve diversity recording and maintaining accuracy of the status of the family unit.  9. The Business Manager should undertake an audit to ensure the recording of all conversations related to clients are recorded within records and dated and timed so they form part of the chronology of the work with the child and family.  10. The Lead Health Visitor to ensure that Health Visitors receive a discharge letter from Midwives at the end of their care, and if not received the identified Health Visitor should actively seek a written discharge letter to complete records.  Recommendations in the SCNFT IMR 11. Sheffield Children’s Hospital and Barnsley District General Hospital to discuss feasibility of setting up a radiology advisory service for complex cases.  6.2 In addition to the recommendations made in the IMRs the IORA and Serious Case Review Panel make the following recommendations:  Recommendations to Barnsley Safeguarding Children Board 12. The Independent Chair of BSCB, on behalf of the board, should ensure that the Chief Executive of BHNFT draws to the attention of previous Radiology Provider the findings of this SCR in respect of the CT scan and requests that they provide evidence that this issue has been considered by the organisation and that the individual consultant involved has been made aware of this.  13. The Independent chair of BSCB, on behalf of the board, should ensure that BHNFT and SWYPFT agree and implement a procedure that requires appropriate staff to discuss ‘Shaken Baby’ syndrome with the parents of all new babies either shortly before the baby is due or within days of birth taking place.  14. The Independent chair of BSCB, on behalf of the board, should arrange to be provided with information as to whether the recommendations that were made in the Child X Overview Report, but not included in the Action Plan, have been implemented.  If they have not, they should be added to the Child X or Child L action plan to ensure that work is undertaken to implement them.  15. The Independent Chair of BSCB, on behalf of the board, should ensure that child safeguarding training for all staff emphasises the need to be mindful of all adults who are significant in a child’s life so that staff understand the need to routinely gather information about these adults.  Page 39 of 46  Recommendation to all agencies 16. When providing feedback to staff about this SCR, all agencies should use Mother and Father’s comments to remind staff of the value communicating clearly with service users and providing clear and unambiguous explanations so that they know what is happening and what they can expect from services.     Recommendation to BHNFT 17. The Named Nurse for Safeguarding Children at BHNFT should ensure that staff at the mortuary at Sheffield Children’s Hospital are provided with bereavement support information which will be of relevance to families living in Barnsley.        Page 40 of 46 Appendix 1 – Genogram  Genogram of Child L                        Father   Child L2   Child L3   Child L4  Child L dob12.01.11 dod17.02.11  Mother   Adult 2  Adult 1   Page 41 of 46 Appendix 2 – Integrated Action Plan      No  RECOMMENDATION  ACTION    TIMESCALE STATUS RAG rated RESPONSIBLE AGENCY & PERSON(S) PERSON RESPONSIBLE FOR MONITORING   MEASUREMENT(S) OF  SUCCESS  1 On behalf of BSCB the Independent Chair will ensure that the Chief Executive of BHNFT draws to the attention of the previous Radiology provider the findings of the SCR in respect of the CT Scan. Independent Chair to provide Chief Executive of BHNFT with copy of SCR findings.  Report back to BSCB in March 2012. March 2012  Independent Chair, BSCB Head of Safeguarding and Welfare The Chief Executive of BHNFT provides written report to the Chair of the BSCB confirming that the  issue has been considered and the individual consultant has been made aware of the issue  Page 42 of 46 2 On behalf of BSCB, the Independent Chair will ensure that BHNFT and SWYPFT agree and implement a procedure that requires appropriate staff to discuss 'Shaken baby Syndrome' with the parents of all new babies shortly before the baby is due or within days of the child's birth. Independent Chair to write to the relevant managers requesting that the procedure is written and disseminated. April 2012  Independent Chair, BSCB Service Development Sub Group Through the Service Development Sub Group the procedure is agreed.  Page 43 of 46 3 On behalf of BSCB the Independent Chair will ensure that all the actions identified in the Child L overview report have been implemented. If they have not been implemented they should be added to Child L and implemented. Designated Nurse to confirm the position re implementation and add to the action plan if required. To confirm this with the Chair of BSCB. March 2012  Designated Nurse, NHS Barnsley Designated Nurse, NHS Barnsley Confirmation that actions have been completed or added to the Child L Action Plan.  Page 44 of 46 4 On behalf of the BSCB the Independent Chair will ensure that Safeguarding training for all the staff emphasises the need to be mindful of all adults who are significant in a child's life.  Staff need to understand the need to routinely gather information about these adults. All training courses to be reviewed to take account of this requirement. Joint Training Work Group to review amended courses. March 2012  Head of Safeguarding and Welfare The Joint Training Work Group  Joint Training Work Group completes review of revised courses.      Page 45 of 46 Appendix 3 – abbreviations  BDGH – Barnsley District General Hospital BHNFT - Barnsley Hospitals NHS Foundation Trust BSCB – Barnsley Safeguarding Children Board CAF – Common Assessment Framework CPR - Cardio Pulmonary Resuscitation CT scan – Computerised Tomography scan CYP&F – Children Young People & Families DRI – Doncaster Royal Infirmary IMR – Individual Management Review IORA – Independent Overview Report Author LADO – Local Authority Designated Officer LSCB – Local Safeguarding Children Board MRI scan – Magnetic Resonance Imaging scan NAI – Non accidental injury NHS – National Health Service NICE – National Institute of Clinical Excellence PCT – Primary Care Trust PICU – Paediatric Intensive Care Unit RCGP - Royal College of General Practitioners SCNFT - Sheffield Children’s NHS Foundation Trust SCH – Sheffield Children’s Hospital SCR – Serious Case Review SWYPFT - South West Yorkshire Partnership NHS Foundation Trust YAS – Yorkshire Ambulance Service   Page 46 of 46  Appendix 4 - References  Barnsley Hospital NHS Foundation Trust, Department of Medical Imaging (2011):  Departmental Policy for Out of Hours Radiology Requests at BHNFT  Barnsley Safeguarding Children Board (2011): Serious Case Review: Child L.  Barnsley Safeguarding Children Board  Brandon, M et al (2009): Understanding Serious Case Reviews and Their Impact. A Biennial Analysis of Serious Case Reviews 2005-07. Department for Children, Schools and Families  Cavanagh K, Dobash RE and Dobash RP (2007): The Murder of Children by Fathers in the Context of Child Abuse.  In Child Abuse and Neglect 31 (7) July 2007 p 731-746  Children’s Workforce Development Council (2011): Common Assessment Framework (CAF). Available from www.cwdcouncil.org.uk/caf  Department of Children, Schools and Families (DCSF); Working Together to Safeguard Children (2010). HMSO, London  Haringey Local Safeguarding Children Board (2009): Serious Case Review: Baby Peter. London: Haringey Local safeguarding Children Board. Available from: www.haringeylscb.org   Segre L (2007): Listening Visits, Supportive Listening/Problem Solving Intervention, Iowa Clinical Research Centre, University of Iowa.      