Death of a one-year-old boy, Nolan, in 2015 as a result of serious head injuries with the explanation inconsistent with the injuries sustained. Mother had a troubled childhood including exposure to domestic violence and neglectful care and was on the Special Educational Needs register at school. She lived with her mother and partner. Her first child was born when she was 16 and Nolan was born when she was 17. Both infants were born prematurely and had medical problems. Nolan's father had mental health issues, a permanent movement disorder and lived in supported housing. Reluctance by mother to engage with services, including late booking for pregnancies and missed medical appointments for the children. Five referrals were made to Children's Social Care, the last eight days before Nolan's injuries. Identifies learning including: lack of curiosity about late booked pregnancy; no recognition of the impact of prematurity, unexpected home birth and illness on the parents' ability to cope and implications of any rejection of help; challenges to parenting capacity should be communicated; the need to follow up referrals with checks and a visit. Follows a systems based methodology which maximised staff involvement and kept the depth of the inquiry proportionate to the complexity of the case. Recommendations include: make the reporting of bruising to non-mobile babies mandatory; ask member agencies to report on how they ensure the role of fathers and wider family members in the household are properly assessed; ask the Police to review its internal handover processes; and the LSCB should demonstrate the essential value of professional curiosity.
      
 Title:  Serious case review into services provided to Nolan and Family. LSCB: Central Bedfordshire Safeguarding Children Board Author: Alan Bedford and Jane Held Date of publication: 2017  This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC.  This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above.                                                                                                                                                                                                         SERIOUS CASE REVEW INTO SERVICES PROVIDED TO  Nolan and FAMILY                                                April 9th  2017  Final Report                                     Independent Reviewer - Alan Bedford       Independent Second Reviewer - Jane Held           Section  Page 1 Introduction 1    2  Nolan’s story 1 4    3 The family’s views 13    4 Summary and system learning 35    5 Recommendations 36    App 1 Collated learning points 37 App 2 The initial recommendations made during the review 41 App 3 Agency updates on progress 42 App 3  Acronyms 47                                             1 Please note Nolan and Jack are pseudonyms   1 INTRODUCTION  1.1 In 2015 Nolan (age 1) died as the result of serious head injuries. The forensic pathology report said that the explanation given ‘cannot possibly’ account for the head injuries he sustained.   1.2 His parents, who did not live together, had two children: Nolan, and a first child, Jack who was nearly 2 at the time of Nolan’s death. Nolan’s mother was still a child herself (i.e. under 18) when she had both children. Their father is also young, and now in his early twenties.  1.3 In autumn 2015, the Chair of the Central Bedfordshire Local Safeguarding Children Board (CBSCB) concluded that the circumstances of this case met the statutory requirements for a Serious Case Review (SCR) as set out in statutory guidance.2.   1.4 Alan Bedford was commissioned by the LSCB to undertake this Review. A senior leader in the health and social care field he worked independently as Alan Bedford Consulting and from 2009-13 was chair of the Brighton and Hove Safeguarding Children Board. He conducted many SCRs, was accredited as a SCIE Systems Reviewer, and completed the 2010 and 2013 national training for SCR authors/chairs. Following his unexpected short illness and subsequent death, the Review was completed by Jane Held, an experienced Chair of a number of Safeguarding Children Boards and SCR Lead Reviewer.  1.5 Final SCR reports are expected to provide a sound analysis of what happened in the case and why, and what needs to happen in order to reduce the risk of recurrence. This Review followed a systems based methodology which maximised staff involvement and kept the depth of inquiry proportionate to the complexity of the case.  1.6 All the agencies in contact with Nolan, his sibling and his family were involved in the SCR. These included:   Central Bedfordshire Council  Relevant Schools  Luton and Dunstable University Hospital NHS FT (The hospital)  Great Ormond Street Hospital for Children NHS FT  (GOSH)  South Essex Partnership NHS FT ( SEPT)  Bedfordshire Clinical Commissioning Group (CCG)  General Practice  East of England Ambulance Service NHS Trust (The ambulance service)  NSPCC  Bedfordshire Police                                             2 Working Together to Safeguard Children (DfE, March 2015).    1.7 The Review has avoided, as far as possible, including family details in order to protect the identity of the surviving sibling. Some facts have been altered slightly to enhance anonymity.   1.8   It asked the fundamental question, “What can be learned from Nolan’s death that  could prevent similar situations resulting in harm to other vulnerable children in the future”?  In doing this, the Review:   Involved front line staff and family members   Appraised the quality of work in this case  Established what lessons can be learned about the quality and effectiveness of      agency and multiagency working  Identified the key themes that characterised work with this family, and;  Makes proposals for improvement where any shortfalls are identified  1.9   A well-attended frontline professionals meeting was held, chaired by the Independent     Reviewer, with staff and managers involved in the case. The group contributed     significantly to the accuracy of the facts and the analysis and learning gained and    also identified key themes for the Reviewer to explore. This was helpful in engaging    staff in thinking about the possible learning.    1.10 To support the process there was a small Reference Group of senior staff from key   agencies which the Reviewer could use as a sounding board, and if necessary to resolve any stumbling blocks in the process. The group reconvened to consider the draft SCR, to advise on whether it addressed the facts and issues, and to consider what recommendations would be most helpful for their work. The Reviewers would like to thank staff for their openness and commitment to the learning process.   1.11 Whilst the review was originally scheduled to be completed within the statutory six month timescale it was delayed due to a range of factors including the parallel proceedings, and the need to find a second reviewer.  1.12 Jane Held met with Nolan’s father, accompanied by his own mother, and, separately with Nolan’s mother to seek their views as to what happened and why, as part of the review process.  1.13 The report sets out key events in Nolan’s “story” in Section 2. This includes the views of his parents about Nolan’s life. In Section 3 the report identifies the key themes arising from professional practice and analyses what happened and why. During the process of the review many key learning points were identified on a single and multi-agency basis and action was taken to address these. The detailed key learning points are attached as Appendix 1.     1.14 The ‘Conclusion’ in Section 4 summarises the learning gained from the analysis, in order to identify what can improved to prevent similar situations resulting in harm to other vulnerable children.   1.15 Section 5 sets out the key learning for the LSCB to consider given the Boards’ responsibility for assuring the quality of child protection systems in Central Bedfordshire.  1.16 Towards the end of the Review process the Family Court hearing the care proceedings ordered that the ‘local authority has permission to disclose the court’s Judgment to the Local Safeguarding Children Board and to the author preparing the report and the Panel considering the Serious Case Review concerning this matter’. A small number of adjustments were made to this report to reflect the findings, the basis of proof being the in the balance of probability.  The court concluded that the injury was from inflicted trauma, but was unable to definitively conclude who was responsible for the injury.     2. NOLAN’S STORY 2.1   Nolan’s mother’s own childhood was troubled and included exposure to domestic   violence, leading to police action, violence towards her siblings from her own mother    (Nolan’s Maternal Grandmother, MGM) and some neglectful care, including injuries    inflicted on Nolan’s mother by a dog). When his mother was 16, and pregnant with    Nolan’s older sibling, Jack, MGM and MGM’s partner were arrested for growing    cannabis in the home the three lived in. The partner was given a community order.   2.2   In the early months of her first pregnancy Nolan’s mother was seen several times by    the GP with urine infections. Three months before Jack was born the GP advised a    sexual health screening (it is not known if this took place) and prescribed a    contraceptive pill, although she was denying she had any sexual partners. There is    no evidence that the GP considered at that time that she might be pregnant.   2.3   The mother’s pregnancy was not diagnosed until 5 weeks before she gave birth after    she attended the GP Practice with abdominal pain.  She was 15 years old.  She was    thought to be 26-28 weeks pregnant and was referred to the Community Midwife. No    one discussed with her the paternity of the baby or asked questions to make sure she    was not in a risky relationship or indeed subject to a criminal offence.   2.4   Nolan’s mother was on the Special Educational Needs register at school but did not    need a formal ‘assessment’. In the months leading up to her pregnancy becoming    known, the school noted incidences of her being unwell. One member of staff did    notice Mother’s weight gain. Mother put this down to a urine infection which her own    mother (MGM) confirmed. The school also noted she was becoming more difficult    and, just over three month before the birth, her attendance was poor enough to    warrant a warning letter about a fixed penalty notice for non-school attendance. She    left school about six weeks before giving birth.  2.5   Nolan’s father was a premature baby and suffered a brain haemorrhage as a new-   born, being diagnosed at 2 with a permanent movement disorder3 that can also    impact on thinking and reasoning. He had limb and speech therapy as a child, and    was seen by a psychologist at 10 with behaviour problems. He attended a special    needs school. He was from a large extended traveller family.  2.6   Normally, expectant mothers are booked in with the hospital at 8-12 weeks gestation.   Because of the very late identification of her pregnancy with Jack, Nolan’s mother    was not booked in until she was 31 weeks gestation. On booking in she was allocated    to the ‘Teenage Caseload’ Midwives Service. This service aims to provide more    intense and varied services to vulnerable younger mothers. Nolan’s mother attended    antenatal care appointments for the remaining period of pregnancy, but this service    was unable to deliver the full range of pre-natal support that would normally be    provided because of the very late booking, and the fact that Jack was born                                                3 Not specified to retain anonymity     prematurely at 36 weeks.   2.7   The Teenage Caseload Service knew that mother lived with MGM and MGM’s    partner, who were noted as being ‘supportive’. Jack’s father was recorded as living in   a hostel in a neighbouring town, and as having a disability. No safeguarding concerns    were noted by Midwifery, and a pro-forma question about parental capacity to provide    basic care was answered with ‘no reason to think they can’t’. A Midwife on a home    visit saw evidence of preparation for the birth.  2.8   The Health Visiting Service was informed promptly of the pregnancy (but not that the    father had a disability4) and they graded the case as ‘targeted’ (i.e. that an antenatal    visit should take place). They would normally visit before birth but did not due to the    limited time and resources. By the time of Jack’s birth, no assessment of any risks to    the baby by either service had been completed, despite mother’s age and father’s    disability.   2.9   Mother declined a telephone offer of help from the Teenage Parent Support Advisor    from the Council’s Early Intervention Service (who had been informed about Mother’s    pregnancy by the Teenage Service Midwife). The worker ‘reluctantly’ agreed to make   further contact in 3 months (when support was again declined). Jack was born five    days after this offer of support.  2.10 Three months before the birth of his first child, Jack, Nolan’s father (19 at the time)     was seen by his GP5 with low mood, feeling depressed. He said he had been    accused of punching a fellow resident at the hostel where he lived, and had fleeting     thoughts of self-harm by cutting. He was under threat of eviction. Prescribed    antidepressants, the father told the GP three weeks later he was feeling more level     headed and eating better, but still sleeping poorly. None of this seems to have been    known by or shared with other agencies until this Review.  2.11 On the day Jack was born, it was noted that father was rude and aggressive to     midwifery staff when asked to go after visiting time.   2.12 The day after the birth, Jack was transferred to Great Ormond Street Hospital     (GOSH) with intestinal problems which required surgery. Jack was discharged home     over two weeks later. He was seen at home by a Community Neonatal Nurse four     days after discharge, but when the Health Visitor did a New Birth Visit several days     later they were unaware of Jack’s medical problems until told about them by mother.     SEPT’s records show that no handover from the hospital based Neonatal Service to     the Health Visitor took place.  2.13 At this New Birth Visit, a New Birth Assessment was started and advice was given     about cot death and smoking risks. The Assessment was not fully completed and no                                              4 The midwife understood there was no concern about birthfather being able to function normally 5 Father had a different GP from mother, and there is no indication that this GP knew the patient  was about to become a father     one was in when the Health Visitor attended ten days later to finish the assessment.     This was on the same day that a Midwife visited and discharged the case to the      Health Visiting Service.   2.14 The replacement health visiting date was cancelled by father, and yet another     appointment 2 weeks later also failed. A replacement two days later was cancelled     by mother, and eventually the New Birth Assessment (which an audiologist also     attended) was completed when Jack was nearly two months old.  The baby was said     to be ‘alert, thriving’. Jack’s weight at that time, whilst low, was in the 10th centile,     which was appropriate for a low birth weight premature baby recovering from       surgery.   2.15 Just before this visit, GOSH called the Health Visitor concerned that Jack’s parents     did not grasp the importance of regular weighing. There was a suggestion made that     father may have a learning disability.  2.16 When Jack was just under three months old, their parents were involved in a ‘heated    verbal altercation’ at the father’s residence in Hertfordshire. Father had kicked a     cupboard and mother, ‘emotionally upset’, called Hertfordshire Police. They informed     Bedfordshire Police who told Children’s Social Care (CSC) but in no more detail than     that there was a ‘young child’ involved, with police taking mother and baby to the     train station6. There was no mention of MGM with whom mother lived7.  (Referral     One)  2.17 Father was described as Jack’s father in the Bedfordshire Police referral to CSC, but     it is unclear where this came from as the Hertfordshire Police notification only     described him as ‘boyfriend’. No prior domestic incidents or criminal record were     noted. Police recorded it as a ‘non-crime domestic’ and assessed it as low risk.   2.18 CSC decided to take no further action other than writing to mother (copy to father) to     advise her that it can be harmful for a child to witness domestic disputes. No further     checks were made and the fact that the family was known to the Council’s own Early     Help Service was not identified. The letter added that no further action would be     taken, and mother was given the CSC duty number should she wish to ‘explore     support services that may be beneficial to you and Jack’.    2.19 When Jack was just over 5 months old (and their mother was in the early stages of     pregnancy with Nolan) CSC received a referral via the Hertfordshire Adult Social      Care Department responsible for commissioning father’s supported living unit. The    referral expressed concern that mother was staying there with Jack. Another resident    had reported that Jack’s parents knocked on their door in the middle of the night    wanting help as they could not stop Jack crying. The referral said the residence    manager would also call CSC, but apparently this did not happen. A call back to the                                              6 This protective action was not in the referral form sent by Police to CSC 7 Although MGM’s name was on the CSC Contact record, no information had been supplied by the Police about her. Her existence or name then does not appear on subsequent contact records.     manager did not reach them. (Referral Two)  2.20 Mother (who was 17 a few days earlier) was phoned by CSC. She denied that she     had asked the resident for help, and said she needed no support as her family and     friends were helpful. (The record does not say who her ‘family’ were but mentions     her own mother without saying she lived with her). She also said there had been no     more domestic incidents, but added, according to the case note, that ‘if they have     arguments one of them will leave the property for a while’.   2.21 She was told that information on Early Help services would be sent to her, and put in     a letter that followed. This time the letter was not copied to father. No other agency     was consulted before CSC decided to take no further action despite mother’s youth.     The Health Visitor was copied into the letter to mother. Using the Early Help service     was left as a choice for mother to consider and the case was not followed up.  2.22 A week later the father was arrested at his residence after another female, resident    had been seriously threatened. The informant, his Case Worker, who was a     Hertfordshire council employee, said that ‘he shows violent behaviour towards other     people who live there and members of staff’. Apparently, the father thought the     resident had reported him to Social Services.  Hertfordshire Police recorded this as a     Public Order Offence, but no further action was taken. The incident did not involve     mother or Jack, and CSC was therefore unaware of it.   2.23 Two weeks after this incident the father called the GP feeling in a low mood again,     and wanting to resume antidepressants. He said he was not going out much and had     demonstrated ‘threatening behaviour at times’.  A new prescription was given. Two     months later, in the month before Nolan’s birth, he said his mood was better, but he     was still stressed over his possible eviction. The GP, unaware of other events, did     not communicate this to anyone.  2.24 Nolan was born prematurely and unexpectedly at home at 33 weeks and    immediately admitted to hospital. This was 8 days after a clinic visit with Jack but the     Health Visiting Service was apparently unaware of the pregnancy until after Nolan’s     birth.   2.25 Nolan’s mother (who was 17 years old by now) had booked late, directly with the    hospital maternity service, (at 23 weeks) not with the GP, and the hospital had     informed the Community Midwife. The booking was done at home by the Teenage     Case Midwife and mother saw a Consultant two days later. The GP was sent a letter     about this. No concerns were noted when Midwifery saw mother six weeks after     booking. This was a second late booking (when even one is rare) and such late     bookings are often identified as risk factors when considering parenting capacity.  2.26 Both parents apparently appeared well supported by other family members.  At day     10 after Nolan’s birth the Teenage Case Midwife, who knew the family from the first     child, recorded that there were no concerns with this family ‘…happy that mother is       well supported by her mother’. Nolan was discharged home (to his     mother/grandmother’s) at 17 days. The Health Visitor was faxed accordingly. The     day before, the Health Visitor invited Jack for a one year check, but the letter was     sent to the paternal grandparents’ address by mistake.   2.27 A Midwife visited three days after Nolan arrived home. The Health Visitor phoned six     days after discharge to arrange to make a New Birth visit in two days’ time. This was    done and thoroughly noted, with no obvious concerns. The day after the Health     Visitor’s New Birth visit, the mother consulted the GP about what sounded like a     nappy rash. Medication was prescribed unseen and mother did not bring the baby in    as suggested. She did attend a few days later for long-acting contraception.  2.28 The Health Visitor went to the home for a New Baby Review visit when Nolan was 5      weeks old. Mother said she was supported by father and her family, and was not      feeling low or depressed. Interaction between mother and Nolan seemed good. At      the next visit (to assess maternal mood) when Nolan was about seven weeks old      the assessment was good enough to move the baby to ‘universal services’. Nolan      had a swollen eye and a visit to the GP was recommended by the Health Visitor.      The mother did not take up this advice.  2.29 At a follow up visit at 4 months an appropriate discussion took place with her about     feeding. Mother had expressed concern to the Health Visitor about Nolan’s vomiting,     screaming, and the fact she felt he was behaving differently from Jack when he was     6 months old. She was advised to seek medical advice if she was still concerned     there was no improvement in his behaviour. A GP appointment was made but not     kept.   2.30 Mother missed Nolan’s Paediatric Review, and a further appointment three months     later was made. This appointment was not kept either. Three paediatric     appointments in all were not kept. In between those missed appointments Nolan was     seen at hospital with a swollen groin. A hernia was later diagnosed and repaired     surgically when Nolan was 19 weeks old.   2.31 A nurse at the hospital at the time of the repair saw and asked about a bruise on     Nolan’s eyebrow. Father said he did not know the cause. This was not referred to     doctors or CSC, and one call made but not responded to by the nurse to try to     discuss this with the Health Visitor was not repeated.  Nolan’s father was also     observed as being unable to undertake much of Nolan’s physical care due to his    disability, and the phone call to the Health Visitor would have been as much about     discussing that issue as the bruise.  2.32 Following the repair, Nolan was seen by the GP with minor illnesses, but was not     seen by a Health Visitor in the 8 months prior to the injuries that led to his death.     Invitations to attend a 9 month Health Visitor Review (sent when Nolan was nearly     11 months old) were not responded to.     2.33 Three and a half weeks before Nolan was injured, an anonymous on-line referral to     the NSPCC asked that Central Bedfordshire CSC investigate the family. The     information was received overnight and sent to Central Bedfordshire CSC in the late     morning. It was dealt with during office hours. The caller gave no surname, only the     address. The referrer expressed concern for the two children at the address due to     their poor cleanliness as well as the alleged use of cannabis. The referrer is also     logged as saying “Her mother and step boyfriend are always arguing and shouting in     front of the children and smoking cannabis which would scare the children”. (Referral     Three)  2.34 It is clear, looking now at the use of the phrase ‘her mother’ that the referrer is talking    about MGM and her partner. There is no reference to Jack and Nolan’s parents    arguing, although a superficial read might make one think so.  It appears that CSC    thought it was Jack and Nolan’s parents who were arguing as that is what it says on    CSC’s own note of the referral that day.    2.35 This confusion about who was alleged to be arguing is important as it affected what     and who needed to be assessed. In fact, the transcript of the online referral does not     mention father at all. The confusion may have stemmed in part from the NSPCC and     CSC interpreting the referral as saying the children lived with their mother and     partner- which the referral did not actually say. There was also no clarity about family     membership. The CSC record gives neither age nor name for Nolan and merely says    ‘Child baby (Please note: no further details known)’   2.36 The following day, the Health Visitor was spoken to as part of the referral follow-up     process ‘with regards to Jack’. CSC recorded the Health Visitor as saying “Jack was     a poorly baby and was struggling to put on weight when he was born and was under    Great Ormond Street Hospital, but do not have an update on this, all Jack’s jabs were    up to date although he was not seen at the 1 year check, no safeguarding concerns    raised and no mention of any drug abuse in their notes”.  There was no mention of    Nolan.   2.37 CSC thought that what the Health Visitor told them was an up to date report, but     neither Jack nor Nolan had in fact been seen by their Health Visitor for seven     months prior to the conversation. A CSC ‘no further action’ letter was then sent to     mother (without any further checks) advising her of the referral, that the Health     Visitor had been spoken to, and informing mother of the Early Help Service. There     was no liaison with Early Help to suggest they be proactive. The letter made no     reference to the content of the referral or a child other than Jack.  2.38 A week later, there was another referral, from an anonymous ‘neighbour’ via the     NSPCC. This referrer said the mother and both toddlers all live in one bedroom,     mother smokes cannabis in front of the children, cannabis can be smelled outside     the house, children can be heard crying and screaming, mother shouts at and slaps     the children and puts them to bed late, and the children are dirty and unclean. It     mentioned that the child had contact with MGM. The neighbour wrote “I would urge       social services to investigate the situation’. Nothing was done that day, despite this     being the second referral in a week. (Referral Four)  2.39 The next morning another anonymous referral was made directly to CSC by email     stating concerns about ‘a young mum who is 18”. The referrer gave a lot of detail     similar to the previous referrals in relation to the conditions the children were living in,    the arguments and rows in the house, the use of cannabis, and the emotional     neglect of the children. (Referral Five).   2.40 The referral of the previous day was ‘closed’ as this fifth referral was allocated to a     Social Worker to do a Child and Family Assessment. An urgent home visit in order to    assess the immediate safety of the children was not felt to be warranted on the     strength of the referral information, despite the number of referrals that had been     received in a short space of time.   2.41 Five calendar days after the fifth referral CSC unsuccessfully tried to phone Nolan’s     mother. The next day an unannounced visit was also unsuccessful. A note was left     asking mother to contact CSC. The following day, at another unannounced visit, the     social worker saw the parents and both children. This was eight days before the     injuries to Nolan.   2.42 CSC did not seek information from other agencies when beginning this assessment.     This means that the Social Worker made the visit without any recent assessment of     the children, or information about the children from the Health Visitor. As a     consequence the Social Worker did not ask relevant questions at the home visit     about Nolan’s care, needs or poor attendance at medical appointments.   2.43 Information requests and agency checks were initiated on the evening of the home     visit. The assessing Social Worker requested that an administrator initiate checks     with the GP, nursery and Health Visitor to test out their findings with professional     colleagues, but by the time of Nolan’s admission to hospital eight days later only one    check letter had been written. The record shows the check letter went 12 days later     to the GP (three days after Nolan’s admission to hospital), with no reference to that     admission. The nursery was not written to until 25 days after Nolan’s death, and the     letter made no reference to this. CSC has described these delays in getting checks     as unacceptable8 and has since changed procedures.  2.44 At the home visit, MGM (whose home it was) and her partner were not in There is no     mention in the case note of the relationship between MGM and her partner with Jack    and Nolan and their parents, nor about the MGM/partner’s arguing or drug use as     that had not been identified as an issue from the referrals.   2.45 At the visit the children’s parents said they ‘see each other’ once a week. Mother told     the Police a few days after Nolan’s admission to hospital that he ‘stays at weekends                                              8 CSC say that now checks are overseen by a team manager and processed within three days      and sometimes during the week’.  2.46 Nolan’s nappy was changed during the visit so there was an opportunity for the     social worker to examine him even though they noted that there was no expectation     that the parents should be asked to show the children unclothed to check for marks     at this type of visit.   2.47 Mother’s explanation about “slapping” her children i.e that she only ‘tapped’ the older     child’s hand was accepted and Father disclosed his disability. As no injuries were     seen, parent child interaction was evaluated as good, the parents denied (much or     any) alcohol or cannabis misuse, and home conditions were acceptable, the     preliminary conclusion of the assessment was that, subject to checks, the case could     be closed. There was no consideration of whether Early Help support services to a     vulnerable family would be an option to pursue.  2.48 Three days later in the early evening, following the injuries to Nolan, the ambulance     service was called by Nolan’s father (with mother taking over the call later).They     attended promptly, with a paramedic on the scene in five minutes, and another     paramedic and an ambulance crew arriving shortly afterwards.  The hospital was     pre-alerted so a paediatric team was ready. The crew made a safeguarding referral     after delivering the child, not because they had any evidence of wrongdoing, but     because they had a sense that something was not right. This was faxed to the CSC     Emergency Duty Team that evening.   2.49 A&E did a brain scan which showed a subdural haematoma (bleed), and called the     Police mid-evening because of the presentation.  CID made extensive studies of the    home that evening. As, at that point it was not clear that Nolan’s injuries were fatal,     the case was transferred to the specialist Police Child Abuse Investigation Unit     (CAIU) the next day. Nolan was sent to GOSH the same day for specialist     neurosurgical care.   2.50 With it being clear early after Nolan’s arrival at A&E that a non-accidental injury (NAI)     was suspected, the protection of Jack became a priority for CSC. The CSC     Emergency Duty Team (EDT) made a late night attempt via the Police and hospital     to ascertain the whereabouts of Jack and both said he was ‘with relatives’. Jack was     understood to be with MGM and her partner, No action was taken by any agency to     ensure the safety of Jack being with his grandmother despite the referral information    on file.   2.51 CSC and GOSH wanted to hold a strategy meeting9 for Jack on the day after Nolan’s     admission but the Police declined while the cause of injury was unknown. GOSH     was clear with CSC that the parental account was not consistent with the injury and     that NAI was a distinct possibility.                                              9 The purpose of the Strategy Discussion/Meeting is to decide if a Section 47 Enquiry is required and, if so, to develop a plan of action for the enquiry.     2.52 The Police called CSC to say the plan was for the parents to stay at GOSH and for    Jack to be cared for by MGM and her partner.  2.53 The records held by CSC and by GOSH are at this point different. CSC’s records      indicate that they agreed to assess MGM but on phoning they were told that the      hospital and police had agreed Jack could stay with his parents at GOSH. GOSH      records indicate that the arrangement with CSC EDT was that Jack should be in the      care of his paternal grandmother and her friend in separate accommodation to other      members of the family overnight. This difference in records indicate very different      perceptions of what was actually agreed, which is a serious matter.  2.54 On the second day after admission, before the first strategy meeting held at GOSH     the father and social worker spoke on the phone. He gave a very different account as     to who was with Nolan when the injury happened than the family had given to date.     This was reported to the strategy meeting which was well attended with CB CSC, a     wide range of GOSH staff, and the Bedford Police CAIU.   2.55 On the evening of the third day after admission when it was clear Nolan’s injuries     were likely to be fatal, the Major Crime Unit took over the investigation from the       CAIU. Five days after admission Nolan passed away.     3. THE FAMILY’S VIEWS 3.1 As part of the review process the second reviewer, Jane Held met both Nolan’s mother and father separately. These meetings took place after the care proceedings in respect of Jack were concluded and police investigations completed but prior to an inquest. Both houses were immaculate, and both parents well cared for physically, giving a superficial impression of stable, ordinary and competent family lives.  3.2  Nolan’s father was supported by his mother, PGM and the family social worker. He  was of the view that lots of things happened that were not right, and he and his mother both felt that the way Nolan’s mother cared for the children was not good enough. He accepted that he did not always get things right either. He informed the review that mother had been the aggressor in some of their fights, and that he had had to defend himself.  3.3  It is clear that the relationships between the two families are very poor and both Father and PGM expressed considerable antagonism towards Mother and her family. 3.4  His mother appears to have played a more significant role in supporting the family than the SCR review records suggest. She said that she saw the children and their mother regularly at first, and she tried hard to support mother with the care of the children, especially in terms of feeding and personal care.  3.5  Both father and PGM gave a lot of information about their view of mother’s failure to maintain regular appointments and PGM was very clear she had tried to get mother to attend appointments. How far that had extended to providing practical help such as lifts to the clinic was not addressed and the degree to which hindsight affected her views of her role was not clear. 3.6  When asked why, if the father and PGM had had concerns that mother was neglecting the children, as well as hitting them, they had not reported those concerns to either the Health Visitor or Social Care, they were both clear that in their community (they were from a traveller background and culture) that was not how things were dealt with.  3.7  They were both very clear Social Care should have done something. When asked how Social Care would have known things were not right they were unable to respond fully. They rightly indicated that mother’s erratic attendance at medical appointments should have been a trigger. 3.8  Mother was unaccompanied when she met with the Reviewer although her mother’s partner was in the house. She had not remembered the appointment, so was unprepared, but willing to go ahead. She was clearly still very distressed by events, and referred regularly to Jack and her “desire to get him back”.  3.9  She presented as very young and vulnerable, could not understand her own agency in what had happened and felt it was all Father’s fault. She said she provided good physical care, and fed the children properly. She said they were both poorly children when they were born.    3.10  As far as the referrals were concerned she felt they were malicious and that she had                       done nothing wrong.  3.11 Clearly both parents were distressed by what had happened and by the fact that Nolan’s brother, Jack, was now looked after. However in terms of whether anything could be learnt from what happened they merely wanted Social Care to be blamed and for there to be nothing critical published about the family. This was understandable from both their perspectives but demonstrated a significant absence of any sense of responsibility for what had happened. 3.12 Neither parent could suggest any learning for the LSCB and the agencies involved.            4. ANALYSIS AND PRACTICE LEARNING   4.1   This chapter sets out the key issues arising from a detailed examination of Nolan’s     life and explores why they occurred. The views of the front line staff at the     professionals meetings were very helpful in preparing this section. His parent’s views     were also taken into account.   4.2    In summary, Nolan was injured whilst in his parent’s care and died. He was born to a    family where his very young mother had two pregnancies in quick succession (both     booked into midwifery late, both born prematurely and one an unplanned home     delivery) and his father was a disabled young man living in supported housing. His     mother was offered Early Help support but declined the offer. Two referrals to CSC     when Nolan’s older sibling was a few months old were not investigated, despite    mother’s youth and the events occurring some way from home with an older    boyfriend.   4.3    Both Nolan and his older sibling were not always well cared for physically, and not     always taken to medical appointments, they both needed significant medical     intervention very early in their lives, and there were difficulties between family     members. Universal services were provided to them in the same way as they are to    any young children and babies, and, despite a range of issues, the family were not     targeted or identified as vulnerable despite their youth, their home conditions, the     concealed/late bookings of pregnancy, the prematurity of both babies, the hospital    interventions on two very young babies and their own challenges as adults.  4.4    The medical care of both Jack and Nolan was characterised by missed     appointments, and long gaps without Community Nursing oversight. A third referral     made to CSC when Nolan was one was also not investigated, despite the age of his     mother and her children and the concern expressed about neglect. A check with the     Health Visitor led to CSC wrongly feeling reassured as only one child was discussed     and the information given was from some time ago. The referral was misinterpreted     and allegations against other adults in the home were not followed up.    4.5    It was only after two further anonymous referrals on consecutive days, this time with     the additional information that the children were slapped, that an assessment visit     was undertaken. No inquiries or checks were made with other agencies before the     assessment, or before Nolan was injured. This assessment, limited by     misunderstandings about who was implicated in the referrals and the historical     nature of the health visiting information, concluded that the allegations were     unsubstantiated based on a single snapshot in time without triangulation of the     evidence.  4.6    Information gathered after the injuries shows a considerable amount of key     information about Nolan and his family could have been obtained. This does not     necessarily mean that injuries would have been prevented. Even in hindsight, the     facts would have probably only triggered a child protection investigation and       consequent action. However the fact remains that Nolan’s life could have been better     had multi-agency practice been more effective, information properly shared and key     risks recognised and responded to. The Review provides some important learning     about what needs to change and be improved in Central Bedfordshire to better     protect vulnerable children and, importantly, promote their welfare.   4.7    There are a number of key points at which, had multi-agency practice been handled     differently, services could have responded better to what they saw, heard or were     responding to, improving the life experiences of both Nolan and his older sibling as     well as that of his parents, both of whom were young themselves. These points are     set out and analysed below.  The pregnancies:     4.8    Nolan’s mother was 15 when her first pregnancy was identified, and her pregnancy     was well advanced. In the early months of her first pregnancy she was seen several     times by the GP with urine infections. Three months before she gave birth the GP     advised a sexual health screening (it is not known if this took place) and prescribed a     contraceptive pill, although she was denying she had any sexual partners. There is     no evidence that the GP considered that she might be pregnant nor, when     pregnancy was established, was any inquiry made about paternity or to establish that     she was not in an inappropriate relationship. For example the partner’s age was not     ascertained. The named GP for Safeguarding has now discussed the learning with     the Practice and changed how they handle similar circumstances.  4.9    The late booking of the first pregnancy and the premature birth of Jack left little time      for an antenatal visit from a Health Visitor, or for in depth engagement with the      Teenage Pregnancy Midwives service the Health Visiting Team was significantly      short of resources at that time and was (and still is) in an area that already has high      levels of need and vulnerability’.10 SEPT told the Review that they would have      expected that a more comprehensive pre-birth assessment would have been done      by midwifery that could have been handed over in writing to the Health Visitor,      leading to more than routine postnatal health visiting. This did not happen.  4.10  Nolan’s mother was still at school when pregnant with Jack but there is no indication           that anyone made inquiries of the school or School Nurse to help with the           assessment of this young mother’s needs, strengths and vulnerabilities. The school            did not discuss with the Teenage Pregnancy service or vice versa how best to           support Mother, or share any concerns about her vulnerability, despite knowing she           was assessed as having additional educational needs and had significant absences           from school. The school did work hard to keep Mother engaged.  4.11  With both pregnancies, there were issues with the way in which information was                                              10 There is now a Family Nurse Partnership Programme in place for families like this with targeted health visiting and midwifery support.            shared between the GP practice, the Hospital, Community Midwifery, and Health          Visiting Services   4.12  By the second pregnancy, Nolan’s mother was 17 years old, but this was the     second late-booked pregnancy in less than a year. This should have been a greater     concern to those professionals in contact with her given that she was still technically     a child, especially with both births being premature. In addition, when Jack went     straight to GOSH after birth, and Nolan to the NICU this would have been     challenging for a parent of any age, but agencies accepted the fact that their mother     was refusing extra help at face value. The professionals involved saw the fact that     MGM was supportive of her daughter and grandchildren as evidence she had     enough support within her family.   4.13   There was no reason for health staff to know of MGM and her partner’s old history            in relation to (albeit brief) child protection concerns or recent involvement with the            police about cannabis growing in the home during the pregnancy with Jack. It is            also not possible to argue that earlier identification of the pregnancies, more            insistence on providing support, or greater discussion between agencies would            have led to action that would have prevented the injuries (although it might have            done) but there are nevertheless a number of learning points about this period            which could have affected the children’s lives for the better including:    The need for professional curiosity about repeated symptoms and signs that might indicate pregnancy  The need, when teenage pregnancy is identified, to make inquiries about paternity and the nature of the relationship   The need to be curious about late booked pregnancy, and obtain information from others who know the parent/s  The need for thorough antenatal health visiting assessments for young mothers/late bookings  Maternity to health visiting handover needs to be formal and clear.  A recognition of the impact of prematurity, unexpected home birth and illness in very young babies on their parents’ ability to cope appropriately  Professional rigour in relation to the context and environment within which teenage parents are living and caring for their children  4.14  The learning from this has been used to address practice and the review has seen           evidence that improvements to the management of teenage pregnancy and            concealed or late booking of pregnancies are being put in place.  4.15  In addition there are lessons to be learned about the need for a more assertive           approach where, for example, a young and potentially vulnerable mother declines           offers of support. This was not saying that a service can be forced on someone, but           that there was a need to be more inquiring about the impact of being told “no thank            you”, not to take apparent support from extended family for granted and at times the          need to be more assertive with vulnerable families about their need for support in the          interests of their children.  4.16 Research into the needs and vulnerabilities of teenage mothers is extensive and          helpful. Similarly NICE research into late booking and or concealment of pregnancy      11 provides clear professional guidance. There were clear indicators of possible risk          arising from Mother’s situation which showed that assertive professional curiosity and          a multi-agency conversation were needed despite the assumed presence of          protective and supportive grandparents.  4.17 Learning Point:     The younger the parent, the more professionals need to consider the implications of any rejection of help, and the need to take a more assertive approach   Missed appointments   4.18 In relation to Nolan and his older sibling there were a large number (15) of missed or     cancelled appointments at two hospitals, at community clinics, Health Visiting home    visits, and at the GP surgery. The Hospital identified in the course of the Review that    from early in Jack’s life, there appears to be an emerging pattern of non-attendance    at clinic, cancelled visits, “no access” home visits, and non-attendance at routine    developmental reviews. This is followed by a similar pattern for Nolan i.e. repeated    non-attendance at clinic, paediatric appointments and developmental reviews’. This    conclusion was reached from records available during Nolan’s life, so there was an    observable pattern that could have been taken into account if it had ever been    studied.   4.19  Despite requests from the hospital to follow up Nolan’s missed appointments, and           both the GP and Health Visitor being aware of them, there is no record of anyone               having discussions about this with his mother. However had the Health Visitor, when           asked about Jack on the 3rd referral to CSC reported all this, or had the Social           Worker consulted the GP before visiting, a more concerning context would have           contradicted the positive parental self-report.   4.20  Many professionals knew about the missed appointments, but their cause or           significance was not established, which may suggest insufficient priority is given to            this locally.   4.21  Regular missed appointments are a widely recognised risk factor, and features in          learning from a very significant number of SCR’s across the country. Greater clarity           about the ownership of action to understand missed appointments is needed in           Central Bedfordshire. Many LSCB areas have health economy wide “Was not                                              11 EG. Pregnancy and complex social factors NICE Clinical Guidelines 110 2010           brought” guidance for practitioners, with common expectations and standards for how          non-attendance is dealt with, and evaluated, and clear pathways for sharing that          information in the best interests of the child involved  4.22      Learning Points:  Children cannot choose whether to attend an appointment or not, and are brought by their parents or carers.   Missed appointments can be signs of vulnerability, struggling parents, evasion, or neglect. They need to be recorded, collated and understood by the agencies involved  Hospitals should be clearer about the significance of missed appointments   GPs and health visitors need to be clear who will follow up notified hospital non attendance   CBSCB needs to consider the need for a health economy policy for “was not brought” situations  Marks on non-mobile babies:    4.23 In this case there were two incidents which could have elicited a better response.          When Nolan was seven weeks old a Health Visitor saw a swollen eye when mother          drew her attention to it. She advised Nolan’s mother to take him to see the GP. The          next time Nolan was taken to the GP was five weeks later so the advice was not          followed.12. As with any baby this may or may not have been an issue but the fact          that Nolan’s mother did not take him to the GP was a potential indicator of less than          fully committed parenting. Given the Health Visitor was not visiting regularly and          mother was not at that point receiving a highly targeted service it is unlikely it would          have been noticed but with hindsight it is important.  4.24 The second incident is much more straightforward. When Nolan was in hospital for          surgery at 19 weeks, a nurse saw a bruise on his eyebrow. The father had no          explanation for how this had happened. With a non-explained bruise to a non-mobile          baby, hospital policy required there to be a discussion with a paediatrician and a          referral to the Trust Safeguarding Team but neither happened. (It was merely written          in the medical notes). The nurse felt that was insufficient concern to inform          safeguarding due to the bruise’s size and position. This demonstrates a          misunderstanding about bruising in non-mobile babies.   4.25 It cannot be assumed that dealing with the bruise properly would have prevented the          later injuries, but had it been referred on to the Hospital Safeguarding Team and/or          to CSC and the Health Visitor at least the information would have been available to          and would have informed later professional assessments.  4.26 Most LSCBs have a specific policy advising on injuries to non-mobile babies. Many                                               12 B also missed a paediatric outpatients appointment three weeks after the swollen eye was seen          require mandatory reporting to CSC, some require reporting to be strongly         considered. CBSCB had no such policy, and indeed almost no guidance on bruising         at all in its procedures but Luton LSCB (which the hospital was also a member of),        did. The Hospital should have had its own policy in line with Luton despite the CBSCB         gap.  4.27 The Trust says that as a result of another SCR, a bruising flowchart has now been           introduced, which is available in clinical areas and included in all levels of           safeguarding training  4.28  Learning Points:  The LSCB needs a robust well implemented policy on bruising to non-mobile babies, ideally including mandatory referral to CSC.  No professional should make a decision about marks to a non-mobile baby on their own.  Understanding, involving and working with fathers:   4.29 Nolan’s father’s role in relation to his children’s lives was not explored, considered,          evaluated or understood by any of the partners to this Review. When the pregnancy          with Jack was booked with maternity his disability was noted but it was not              mentioned in the referral on to Health Visiting nor evaluated in terms of its impact on          his parenting capacity. Neither Midwifery nor Health Visiting recorded any information          about how large a part he played in the baby’s life.    4.30 When CSC received the first referral (when mother was 16 and Jack three months          old) about the domestic incident, they knew Father was 20, but not that the address          where the incident happened was a hostel for young people with additional support          needs. The police did not mention this and CSC made no inquiries about the          circumstances of where the 16 year old mother had been with a very young baby, or          father’s role in family life.  4.31 CSC did know where he lived when the second referral came in as it was from a          neighbouring council, but no inquiry was made about him to help assess risk. He was          not copied into a post referral letter to Nolan’s mother. As we know now, reference to          mother’s partner in the referral was related to MGM’s partner, and not the children’s          father. But CSC thought it referred to the children’s father and the referral was closed          without any inquiry as to who mother’s partner was and what his involvement was. If          there was an assumption it was the same man as before there was no evidence of          this in the referral. Again the “no further action letter” was not copied to anyone.  4.32 The fourth referral makes no reference to a father being involved. The final referral          (which led to the assessment) also makes no reference to a father being involved.          When checks were eventually commissioned after CSC’s home visit there is no          evidence that any check requested was in relation to Nolan’s father. The father told            the Social Worker at the visit he had a disability, and that seems to be the first time          CSC were aware he was disabled. The impact this had on his parenting was            unexplored.   4.33 It seems that there was no real understanding of his background, family context, role,          strengths and weaknesses in relation to Jack and Nolan and no one attempted to find          out. His GP knew about his depression and an assault on another resident, but no          one ever consulted his GP about him. For a time, the nature of where he lived was          unknown to CSC and when it was known no further enquiries were made about him,          why he lived there and what his own background was. There was also little          knowledge or professional curiosity about how extensive and hands-on his role was         with the children   4.34 Midwives experienced an aggressive reaction from him in hospital, but no one else          knew that and they did not share it with anyone. The hospital nurse was concerned          about his inability to care for Nolan, but stopped trying to report it after one failed          phone call. Finally, the father was asked to answer allegations that were not made          about him, but about the MGM’s partner.  4.35 At the staff session it also emerged that different professionals had a range of          different understandings about how permanent a fixture MGM’s partner was at the          family home. His role too was not explored, and his contribution to supporting Nolan’s          mother or the children not considered. The referrals relating to his relationship with          MGM and the various issues within the household that he was part of were not          identified or evaluated. Whether he was a protective factor or a risk factor in Nolan’s          life was never considered.  4.36 Learning Points:   Numerous SCRs have highlighted the risks from not assessing fathers properly. This is the case here too.  When assessing the vulnerability of a young mother and baby the role of father must always be assessed as far as is possible  Knowledge of possible challenges to parenting capacity, (e.g. specific types of disability)  should be communicated by clinical and other professionals   When assessing a referral about a domestic dispute involving children there has to be exploration of the circumstances of the man involved and the context within which it occurred   The Midwifery Booking Form could be looked at with a view to making it easier to write about the father specifically, and not just a ‘family’ heading   The role of all men within the family context needs to be properly identified by professionals in contact with the primary carers  Understanding of Nolan’s wider family:   4.37 If practitioners working to support vulnerable children are to be effective, they need to            fully understand the family context within which the child is living, and to assess,          evaluate and respond to the impact those wider family members have on the child’s          lived experiences. Many SCR’s have identified the importance of understanding the          whole family context.  4.38 Midwifery and Health Visiting knew mother lived with her own mother and with          someone the booking called ‘stepdad’. There was no obvious reason to ‘assess’ the          older couple or challenge the mother’s self-report of having a supportive extended          family with whom she lived although professional curiosity should have led to more          assertive questioning of the context. Only one home visit by a Health Visitor mentions          MGM being there, and none refer to her partner, so Community Nursing’s          understanding of their role in the children’s lives was limited. No one questioned          whether the paternal grandmother or family had any role. As there was no action          following the first three referrals to CSC, the older adults’ roles in Nolan’s life were          also not established by CSC.   4.39 Although the first referral records the MGM’s name, this was not known at the time as          it was not mentioned in the Police referral to CSC, which provided the only           information CSC had13. For all CSC knew mother lived alone.   4.40 The next referral (about the incident in the hostel) established that Nolan had a MGM          who Nolan’s mother said was supportive as were other wider family members. Her          name or what the family constituted was not recorded, and the record of the          conversation the Social Worker dealing with the referral had with Mother does not          indicate mother actually lived with MGM. The degree to which mother’s assertion was          tested by the Social Worker is not clear.  4.41 The third referral (which was made anonymously via the NSPCC) did refer to MGM          and partner (‘her parents and step boyfriend are….’) but CSC thought this meant the          children’s parents. A call to the Health Visitor would presumably have clarified this          but no calls were made. The note of the fourth referral, (also via NSPCC), says the          children ‘also have contact with MGM but does not state the nature of the ‘contact’.          The final referral (made by email to CSC) refers to concerns about the family who live          at Nolan’s address.   4.42 Even if CSC misunderstood the content of the two referrals, given the nature of the          referral information it was important to understand the relationships in the household          the children lived in. This becomes more troubling when taking into account that had          checks been made it could have been established that both the older adults (MGM          and her partner) were subject to earlier safeguarding concerns, both had been          arrested for drugs offences, and the partner convicted of growing cannabis in the          house where the anonymous allegations suggested cannabis was a risk to the          children. CSC procedures require an assessor to identify which family members need                                              13 If the name had come from the address when inputted, then this would have given the opportunity to identify the historic concerns about the MGM.            to be assessed ‘including wider and absent family members’.  4.43 This lack of knowledge or indeed professional curiosity about significant adults,          suggests a lack of rigour both of process and thought associated with the          interrogation and management of referrals that goes beyond individuals. This is          especially so given the situation involved such a young mother with two children          under two, and the nature of the allegations being made.  4.44 This is compounded by the fact that as part of the considerations there was an          automatic assumption that the presence of a grandmother was a benign or          supportive force. This type of assumption is unhelpful, and professionally naïve. It          can lead to potentially risks being missed or not properly explored, and over-          optimistic conclusions about the specific situation being reached.   4.45 Learning Points:  The whole family context must be properly identified, understood, evaluated and well recorded, in assessing the safety of a young family   Assessments must include all members of the household, and other significant adults involved in the children’s lives   Information which refers to more than one ‘mother’  or ‘the family’ must be recorded with no ambiguity about to whom it refers  There are risks in assuming young mothers living at home with their parent(s) are automatically in a supportive environment because of grandparental presence  The approach to referrals:   4.46 One of the important issues in this review is the way in which referrals were both          made and responded to. Each referral is analysed against what would constitute          acceptable practice in the light of both Ofsted standards and the Central Bedfordshire          LSCB Multi-agency guidance for assessment and thresholds of needs, risk and          intervention for children and young people. The effective use of the “threshold          guidance” is a central tenet of safeguarding practice. It is not possible to say that          better practice would have prevented the injuries, but even so there is significant         learning to be achieved from how information was provided, shared, evaluated and          responded to.  4.47 The first referral:  CSC receives significant numbers of Police reports on their          attendances at domestic incidents where children are present. As a result those          which are described as low risk get very limited attention. The information provided in          this referral did not trigger any agency checks, home visits or other responses. It was          immediately closed as a referral and a letter advising of the risks to children of          domestic disputes and a phone number if mother wished to explore unspecified          ‘support services’ was sent.    4.48 At the staff event, there were different views expressed about this. Whilst managers            indicated this response was not adequate, the impression given by front line CSC          staff was that this was not an unusual response at the time.  To have been effective          CSC needed to assess whether the child involved needed support at one level or          another (within the threshold guidance), and this could not be done for the following          reasons.   There was no demonstrable understanding of the impact of the incident on a very young baby or their 16 year old mum.   No multi-agency checks were undertaken following the referral to establish who knew what about the family, so nothing was known beyond the Police contact information (which indicated the parents were not known).  CSC did not identify from their records the link to the earlier maternity referral for Early Help in relation to Jack.  Nothing was asked by CSC about the place where a 16 year old mum with a baby under three months had been involved in a domestic incident, despite it being some distance from her own home.  Nothing was asked by CSC about the mother or children’s home circumstances or with whom they lived.   There was no questioning about the relationship between the children’s mother and father or indeed anything about the father.   The police assessment of “low risk” gave rise to an assumption that the situation did not need significant attention paid to it so it was treated as a routine process, rather than as a matter for professional curiosity,   Management oversight or challenge was not demonstrated.  4.49 Unfortunately all the onus to keep safe and get help was left with a 16 year old mum.          It seems that the fact that mother was so young was not really taken into account.          Looked at from a basic practice point of view, (without taking into account the          pressure arising from high numbers of such referrals) a home visit to assure the          safety of the two children involved (mother and baby) and to explore the issues          above would be a justifiable option to consider. At the very least, a check with the          Health Visitor or GP (or even the school she must recently have left) was needed and          the facts needed to be clarified with the police. It would also have been better if the          father was written to in his own right   4.50 As part of the learning from this review, CSC have subsequently changed the          procedure for responding to Domestic Incident Notifications involving 16-18 year olds   4.51 The second referral: This referral which came via Hertfordshire Adult Social Care           was made after Nolan’s parents were seeking help to care for him in the early hours           of the morning, at the hostel where Nolan and his mum were staying with father.           Again the referral was not properly considered given mother’s age, and the           circumstances father was living in  In addition to the same points of concern as in           paragraph 4.48, there are additional points here:     CSC did not discuss with the neighbouring social care colleagues why and what they were concerned about.  There was no exploration of why the father needed supported accommodation.  No significant weight was given to the fact that this was a second referral within in two months of a very young mother (17 only five days earlier) of two very young children, who was clearly staying with her children at a hostel some distance from her home away from home.   4.52 Mother was telephoned by the Social Worker involved with the referral. Nolan’s          mother said she knew how to get help if she needed it from family (unspecified          except ‘Mum’) and friends. She was given information about the existence of Early          Help services and how to access them.   4.53 In some respects the fact that Nolan’s parents were seeking help could be seen as          positive. On the other hand the notion of a teenage mum with a disabled partner14          struggling with a baby’s crying in the small hours having to go out for help is          worrying.  Either way, Nolan’s mother’s denial of any issues was accepted, his father          was not spoken to and the case was closed. Given the facts this was an inadequate          response. Consideration should have been given to undertaking multi-agency checks          and establishing whether this was a vulnerable family with children who might be in          need of help and support.  4.54 The third referral: This was forwarded by the NSPCC a month before Nolan’s death.           Many of the same issues from referrals 1-2 apply again. The Health Visitor was           spoken to, but despite the growing picture of sporadic concerns in relation to this           family and the existence of a significant number of potential risk factors there was no           further action except another letter to Nolan’s mother.   4.55  Even considering the limited information about and decisions not to pursue the first           two referrals, this referral was at a different level of concern with suggestions of           cannabis being used around the children, neglectful care and the presence of adults           arguing and shouting in front of the children which could ‘scare’ them. The response           did not recognise the risk factors present or give weight to the information provided           given that there was now a record of previous concerns and referrals.  4.56  Attention was not given to the referral details, which were misunderstood and           wrongly recorded as it being the parents who argued/shouted/smoked in front of the           children. This was the first time it was established that Jack had a sibling, but the           case was closed without knowing Nolan’s name, age or sex. The family composition           was not discussed with the Health Visitor and CSC could have found out details from           the child health database) MGM’s details were still not established and although an           agency check was made with the Health Visitor, but as CSC knew almost nothing of           the family it could not ask informed questions about Mum, Dad, or Nolan’s sibling           and no questions were asked about the baby.                                             14 CSC did not know he was disabled, but the hostel would have done    4.57  Undue weight was also given to the information provided by the Health Visitor, which           was not properly understood or interrogated. Just because a Health Visitor may be           unaware of any safeguarding issues does not mean there were none but a lack of           rigour meant that the information provided was taken as evidence there were no           concerns, rather than evidence that that specific professional knew of no concerns            last time there had been contact.   4.58  There can be no justification in not considering at this stage whether a home visit to     assess the case was needed. At the very least, there was a suggestion that there     were children in need. At worst, they were at immediate risk. If it was thought the     referral did not quite meet the threshold for a Section 47 investigation, then a     speedy Section 17 assessment should have been initiated. The LSCB procedures     say “It is also crucial to understand the timescale for the child’s welfare and the     serious impact neglect and harm can have on babies and young children” and it     quotes Working Together 2015 as saying ‘For children who need additional help     every day matters’ That guidance goes on to say ‘The actions taken by     professionals to meet the needs of these children as early as possible can be    critical to their future’.   4.59 Instead, the only action taken was a third letter to the mother. The letter says ‘as I   was unable to contact you I made contact with the Health Visitor’. ‘Unable’ is an odd    word to use given that there is no recorded attempt to see or find mother. This time    the letter talked about the option of an ‘Early Help assessment’15 (a lighter touch     than Child in Need assessment) which it said could be done by ‘any professional    that works with you’ but initiating one was left entirely up to Nolan’s mother.  This    was poor practice and was neither child focussed nor likely to guarantee an    improvement in Nolan’s lived experiences of his care and protection.  4.60 The fourth and fifth referrals: These two referrals were received on consecutive    days. Both were anonymous. The first was about mother smoking cannabis with her   children present, adults shouting, and the children being neglected. The second, an    email sent via NSPCC to CSC, was additionally about ‘the family that live at her (i.e.    mother’s) address’ and their cannabis and alcohol use. They may not have been    from the same referrer as the address the referrer gave in the email was vaguer. It    said the children were ‘neglected’ and ‘bullied by mother’. It added new information    that mother was depressed, and that she slapped both children.   4.61 The decision about how to respond to the fourth referral was taken the following day    as the record says ‘outcome will be determined on the next referral as we have    received another referral with the same concerns. Therefore this referral will be    closed’. Quite why both referrals were not treated as one is not clear. The decision    taken in the light of the information in both referrals was however that was to do a    Child and Family Assessment, not the more urgent Section 47 Investigation when a                                              15 Which used to be known as a CAF- the common assessment framework     child might be at risk of serious harm.  The Review heard that as there was no     indication the children were injured it did not have that degree of urgency. This is too    narrow an understanding of risk and harm. Whilst the presence of physical injuries    make it easier to assess urgency, a combination of worrying risk factors can be    equally concerning and strong indicators of the risk of serious harm.   4.62 The threshold documents used by the LSCB and Council talk of a child needing to    be ‘at risk of serious harm’ for there to be immediate involvement. ‘If there are    indications that a child is suffering or is likely to suffer significant harm  an    assessment must be authorised with a view to holding a strategy discussion prior to   a Section 47 inquiry’. In this case the assessment visit which took place eight days    after the fourth referral did not lead to that conclusion.  4.63 One of the ways of establishing whether a strategy meeting was needed in order to consider the needs for a Section 47 inquiry would have been to do rapid agency checks by phone and/or a home visit.    4.64 Neither of these steps were taken. The case was allocated for a single agency assessment and the Social Worker followed the normal maximum timescale of starting within five working days. Although the Review was told that there are very many referrals of this magnitude, the information available at this point if viewed in totality was cumulatively of some note. It was:   The fifth referral, with ‘no further action’ on the first three.  A teenage mother with a child of nearly 2 and one at least 9 months younger.  Various allegations of neglect against the mother had been received.  There were allegations of smoking cannabis and drinking in front of the children by the parents and MGM and partner.  There were allegations of arguing and shouting in front of the children by MGM/partner (although this was misread as being the parents arguing and shouting – which should not have made any difference).  There were allegations of mother slapping the children.   Between one and three people were concerned enough to make referrals of a similar nature to two different organisations within 10 days.   4.65 If information had been sought through agency checks by phone and CSC records examined there was evidence mum was very young and vulnerable, her pregnancies had been booked later, the babies were both born prematurely, both had spent time in hospital soon after birth, she had had her own troubled childhood, she was living separately from the children’s father, there were convictions in the wider family, and a history of some domestic violence, and father had challenges in acting as a supportive parent due to his disability and circumstances  4.66 The Review heard that given the allocated Social Worker’s workload it would have been impractical to visit earlier, but that had there been a concern that pace was   important another worker would have been allocated. What is not clear is exactly why this case did not warrant a degree of “pace”.. It is clear that, based on partial and untested information the case was not deemed to indicate the existence of significant risk. This suggests a lack of consideration of the range of alleged risks that had accumulated at that point. This case should in the circumstances have warranted a degree of urgency.   4.67 Agency checks: When asked about agency checks at the staff event the Reviewer was told that it was not practice to do this before the first visit, and in any case consent was needed from parents first. This was clearly not the case as the Health Visitor was phoned after referral three. National guidance16 is also quite clear that the need to get consent is not absolute, and that the needs of child trump consent requirements. There is nothing in the guidance to prevent an agency which is assessing referral information from seeking information from other agencies before visiting, especially when there are allegations of abuse. The guidance also says ‘But even without consent, or explicit consent, it is still possible to share personal information if it is necessary in order to carry out your role’.   4.68 The risk in not making some inquiries before the visit is that key information which might aid the assessment is missed and it then becomes possible, as in this case, to conclude quickly and on parental self-report that all is well. The checks initiated after the visit in Nolan’s case were narrow in range and not done quickly so had there been anything crucial it would have arrived rather late. In addition the Reviewer heard the Police would not be consulted in a case like this, it is unlikely that the residence where father lived would have been spoken to, and there was no evidence that father’s GP would be approached 4.69 The reviewer heard that improvements have now been made to how checks are undertaken.  4.70 The worker involved at that time could only go on what she saw and heard, and the checks to follow (for which consent was given) would have provided further information. In this case the checks, if made, could have revealed the following information which was unknown to CSC at the point of the assessment visit.                                              16 Information sharing - Advice for practitioners providing safeguarding services to children, young people, parents and carers  March 2015  HMG  Police Cannabis growing in the house and the conviction of MGM’s partner, also his history of drugs offences, and his assault of his own son The threatening behaviour and possible violence of father at his residence  Child protection concerns about MGM Health Visitor  Nolan’s medical history, and the missed appointments The late bookings of both pregnancies, premature births of both children, and significant medical interventions with both babies when    4.71 Many different workers, both qualified and unqualified were involved in processing the five referrals. In addition the quality of information in the referrals was limited. Referral practice is always a matter of information gathering, triangulation of information, and the application of professional evaluation of the facts on a multi-agency systemic basis. In this case this process was not properly followed, and no in- depth or rigorous effort was made to see beyond the facts presented to the wider context or to consider what life might be like for Nolan and his sibling.   4.72 In effect the referral was dealt with in terms of whether particular thresholds were met, or not, rather than asking “what is going on here, what is the child’s life like, what may be underlying this, how vulnerable are the family, what are their strengths, what are their vulnerabilities, what do they need, what is our role and what is the role of partners?” It is these interrogative and analytical questions which are the hallmark of a good referral process, not deciding whether a case “fits a certain category or not”.  The single assessment process  4.73 Despite the number of referrals only one CSC home visit was made, in order to begin a single assessment. The assessment was never completed, so only the preliminary conclusion can be considered by this Review and that preliminary conclusion had not been subject to appropriate managerial evaluation.  4.74 There were however a number of reasons why the Social Worker thought the allegations unsubstantiated including the facts that:  No injuries were seen.  The parental child interaction seemed warm and appropriate, with observations of a ‘positive attachment with Mum’.  Both parents denied alcohol use.  Father said he did not use cannabis.  Mother said that she did, but not during the day or when alone with the children.  The children’s clothing was appropriate and clean.  The family bedroom facilities although cramped were adequate and clean. very young Father’s GP Father’s treatment for depression concerns about his anger, and thoughts of cutting Mother/Children’s GP Further information of child and maternal health, late bookings. Missed appointments Father’s residence Concerns about his threatening behaviour and violence to other residents Historic CSC records The child protection issues with MGM and partner That fact that Jack had been referred for Early Help School Mother’s recent educational history and some indication of her learning capacity Father’s educational and additional needs and some indication of his learning capacity    Both parents said both children were in bed by 8pm, both children were in good health, and that they were supportive of one another.  Both parents gave consent to further checks.  4.75 The initial conclusion drawn on the basis of this visit, without the benefit of any triangulation of evidence following receipt of multi-agency information about the family must be seen in the context of the assessing Social Worker:  Not realising there were allegations against MGM and partner.  Not knowing about MGM’s partner’s conviction for cannabis growing in the house.  Having no Health Visitor view on Nolan’s care, health and wellbeing and that  the Health Visitor’s information about Jack was seven months out of date.  Not seeking to have the children medically examined.   The visit representing a single snapshot when  the allegations were mainly of ongoing neglect or emotional harm  4.76 A number of the ways in which assurance was gained to inform the assessment, were not robust. This is not saying the assurances were misplaced, but that information could not be proven or supported by the evidence. The couple do not seem to have been asked about the concerns about them arguing and shouting in front of the children. The relationship with the older adults in the house was not explored, in part because historic allegations about them had not been spotted.   4.77 There are a number of system dynamics that apply to this case. The application of threshold tools and frameworks requires an evaluation of the strengths and risks of a situation as far as can be ascertained and this is always challenging.  How best to respond if the risks are seen as not requiring an immediate response is a matter of judgement. It is essential judgements are not made until all available information has been accessed. This is necessary regardless of the initial impressions gained from the referral. The better the information available is identified and used to inform that judgement, the better the decision. That good clear information is provided is incumbent on both the referrer and the receiving agency.   4.78 The case as presented did not on the face of it indicate that serious significant risk to Jack or Nolan existed. However it is clear with hindsight that there was insufficient rigour in referring, gathering and evaluating the available information which restricted the judgement made. The response was accordingly less robust than it would have been if the risk had been assessed more accurately particularly by the point of the 5th referral. The response was, in addition limited, because consideration was not given to what the family needed regardless of whether serious risk existed or not. A good assessment never concludes with “no further action”. It should always contain an analysis not just of the concerns, and the evidence to support their existence or not, but of the family context, the children’s needs, whether the parents can actually meet their children’s needs well enough, and what could be done to improve that.     4.79 The Review has identified there are some significant Learning Points to be drawn in relation to the process of making and receiving referrals, evaluating them and responding. In particular the Review identified:    The importance of not allowing the volume of Police domestic dispute referrals to overcome the need for proper child focussed consideration of such notices.  That young teenage mothers who are still legally children are and need to be seen as especially vulnerable and their involvement in domestic incidents requires exploration.  Cultural awareness and sensitivities to a family’s own cultural context was missing. The absence of any recognition or understanding of the role of or cultural values and behaviours of both mother and father’s families is an issue of poor practice across the board. In fact father came from a very specific cultural family context.  All such referrals need at least some agency checks to be undertaken.  CSC should consider the impact of using “no further action letters” (especially successive letters) with young parents (indeed any parent) when there has been no contact or investigation. This could let the child or indeed their parent(s) feel abandoned or fail to create the best response from the child’s parent or carer.  The process of leaving the decision whether to access Early Help entirely to teenage parental choice- without any assessment or meeting is an inadequate response. Signposting should be properly nuanced depending on the circumstances.  Making no checks or visits on a second and certainly a third referral on young parents or vulnerable children is poor practice.  Referrals must be scrutinised in a careful way to ensure there is clarity about who is involved in a household, who might act as a protective factor, and who might present a risk to children.  Professional curiosity should be exercised far more robustly on a multi-agency basis and shared responsibility for evaluating the presenting issues and evaluating the degree of risk developed rather than practice which is based on “passing on” information to others.  CSC needs to ensure, unless immediate and extensive agency checks show the referral to be untrue, that allegations of neglect and illegal drug use near children and other similar risk factors are always assessed.  Agency checks should be made in advance of visits where there are allegations of potential abuse, and the assessment would otherwise run the risk of being not being sufficiently robust or targeted.  If agency checks are made after the initial visit, they must be prompt and give the agency some idea of context to guide their own inquiries.  The Police should be included in checks where illegal activity is seen (e.g. drug use in this case).  There need to be robust case audit processes in place to ensure that staff under pressure do not assume informal thresholds which clash with sound, well-judged responses to potential child need.    Referral practice should be regularly reviewed, audited and scrutinised on a multi-agency basis, and the degree to which referrals are well presented, well evaluated and rigorously evaluated against the threshold framework monitored.  All referrals should be reviewed, evaluated and signed off by managers who exercise proper scrutiny of decision making by frontline staff.  Strategy Meetings:  4.80  Following Nolan’s admission to hospital with head injuries, given that there was considerable concern about the cause of the injuries it would have been professionally appropriate to consider the quality and safety of care of Nolan’s sibling, Jack.    4.81 There should have been a multi-agency meeting or at least a formal strategy discussion the day after Nolan was admitted. That next day was a Sunday which might have made it hard to get all the right people involved, but not having at least a strategy discussion that day left Jack unprotected in concerning circumstances. The delay appears to have stemmed from the Police who were hesitant about whether the circumstances warranted such a meeting. In the circumstances this was unnecessarily cautious and not in line with statutory guidance or standards.      4.82 The second strategy meeting doubled as the information sharing meeting of the CDOP Sudden Untoward Death process. Although there was only one group of staff there, the meetings were minuted separately and with different attendees which made it look like two meetings. Although the strategy minutes said the CDOP minutes would be ‘sent or detailed information sharing’ the CDOP minutes were only circulated to those with secure email addresses, e.g. Police, so some agencies who should have been informed fully missed receipt of key information about the injury and explanations.   4.83 Learning Points:   Strategy discussions/meetings are vital to child focussed coordination in the immediate post harm period.  Up to date information from the local NHS is vital to good strategy meetings.  Strategy minutes should list everyone in attendance.  CSC should check the minute circulation process for strategy meetings.  CDOP minutes must, one way or another, be circulated to all attendees.  Professional curiosity and reflective practice:   4.84 Throughout Nolan’s life the professionals who came into contacted with him showed very little professional curiosity about what life was like for him and the ability of his parents to care safely for him and his sibling. The family context was not considered, and key information about the way he was being looked after was not solicited, was ignored or not shared. As a consequence his mother’s extreme youth was not seen   as an issue, the context within which he was being looked after was not explored, challenged or considered, incidents were minimised and information that was relevant not sought. When information and concerns were passed on the response was to try to minimise it and close it down rather than expand and explore what was happening.  4.85 The General Practice, Maternity Services and Health Visiting all did not enquire about the nature of the relationship which led mother becoming pregnant before she was 16 or about what was behind the double late booking. There is no evidence of the GP or Health Visiting exploring the regular missed appointments. No one was clear about the extent of father’s role. The hospital nurse’s concern about the bruised eye ended with one failed phone call to the Health Visitor. The referrals were dealt with without questioning what information was available.  4.86 It is clear that across the multi-agency system there was a culture of narrow issue based practice, where the specific issue or purpose of a contact or intervention was all that was considered. This naturally limits the extent of professional curiosity. Because there was some evidence of support to Nolan’s mum, and the contacts with her and the children did not raise significant concerns, the small, sometimes seemingly insignificant facts were missed and a picture of what life was like for Nolan and his sibling was never built up.   4.87 It is also clear that when action was taken information that was exchanged was limited, inaccurate, was not questioned, interrogated or considered against research and evidence about similar circumstances, and efforts were made not to expand and explore what was happening but to deal with it as quickly and briefly as possible. So, for example, when referrals were made practitioners sought to establish the positives rather than challenge the evidence.   4.88 Why this happened is hard to establish with any certainty. Pressure of work, the knowledge, skills and competence of front line practitioners, the high levels of tolerance of less than good enough parenting due to the high levels of vulnerability in an area, and managerial expectations and pressures may all have contributed.   4.89 Certainly there was never any “gross evidence” of significant risk. Nolan’s family were much the same, in the way they presented to professionals as many other young slightly vulnerable complex families. The children were reasonably well cared for when seen, and there was no single incident until Nolan’s injuries, that would have triggered immediate action.   4.90 However the most recent national review of SCR’s17 demonstrates that the greatest risks of harm exist in families that, like this one are “flying below the radar” where there is a gradual accumulation of small pieces of evidence, who are not in regular                                             17 Pathways to harm, pathways to protection: a triennial analysis of SCRs 2011-2014 P Sidebotham et al DfE 2016   contact with services, and who are not receiving purposeful, directed and child focussed support of any kind, be it through universal services or Early Help provision.  4.91 One key piece of learning for the LSCB is that the practice in this case, and potentially therefore in others is geared towards crossing a specific child protection threshold, and that Early Help as a purposeful and constructive protective intervention is under developed. Assertive, purposeful, proactive early help could have made a considerable difference to both Nolan and his sibling’s lives.   4.92 Supervisors and managers need to demonstrate and model this curiosity through respectful questioning about cases during supervision and when confirming decisions, for example, on how to respond to referrals.  The purpose of such curiosity is to be sure the case is understood, the context, the dynamics within the case and the evidence to support a specific informed course of action and above all to try and make sure the child really is safe.   4.93 The LSCB can also model this in the way there is peer review around the LSCB table. If the Board and members believe the lack of curiosity in this case is more widely present, they need to work together to create a more questioning culture.  4.94 In addition there appears in this case to be a significant absence of management oversight, supervision and no obvious culture of reflective insightful practice across the multi-agency system. Where this is the case, research tells us that this leaves front line practitioners feeling unsupported, overwhelmed and/or feeling they need to resort to limited system and process interactions rather than professional engagement, challenge, and evaluation of the needs, lives, and circumstances of the children they see.  4.95 Learning Points:  Curiosity and questioning is an essential part of professional life, and its value should be modelled in agencies by supervisors, and top leadership  It would be worth exploring with staff whether, for example, they feel inhibited from making more inquiries for reasons of work load pressures, a high level of vulnerability in the area, or a lack of knowledge, confidence and support.  The LSCB needs to model expectations of a more questioning culture and develop the application by partner agencies of reflective, insightful, professional curiosity, challenge and the use of informed research led and evidence based practice  Specific learning for each agency  4.96 Each agency in undertaking their own management review for this case has identified a range of issues that are relevant for them in terms of learning and improvement. The learning points are summarised in appendix 1. This review has   seen evidence that each agency has addressed the learning points, and has its own action plan. As the Review has taken some time to complete the Review has also seen good evidence of the progress and impact of implementing the learning on improved practice and better outcomes for children. Much of the learning is about not only setting but maintaining and managing basic practice standards, compliance with statutory and local procedures and requirement, and professional skills, knowledge and ability. How each agency does this, and how it assures itself of the quality of practice is essential.      5 SUMMARY AND SYSTEM LEARNING  5.1 In this Review it is clear even if practice was outstanding, and everything that was known was utilised to inform professional decision making before the injury, there would not have been sufficient cause for partners to trigger or to move into formal child protection processes. There were certainly issues however, and other forms of intervention could have been put in place and the children’s lives improved as a consequence. It is possible that CSC becoming involved at an earlier point may have identified risks and ameliorative action may have made a difference to the chance of a child being hurt.  5.2 There is much to learn from this case and it demonstrates that:   There could have been more thorough and coordinated assessment of potential risks by the NHS, before both births. This includes inquiring into the relationship that led the 16 year old to be pregnant and, potentially convening a multi-agency assessment of her needs.  Referrals to CSC led to responses which were minimal and which did not sufficiently reflect the vulnerability of a 16 year old mother and baby/ies.   There was almost no discussion with any other agency which might have held important information and the first three responses to referrals made single agency decisions which were based on assumptions and guesswork about risk.  The response to the last two referrals needed to be much quicker and informed by prompt agency checks given references to neglect, drugs, slapping, and a potentially emotionally harmful environment of conflict.  Cases which do not appear to meet the need for a Section 47 investigation may still require urgent attention and the absence of injuries does not equate to an absence of risk of serious harm.  Staff need to recognise that Early Help is not preventative in nature but protective. It is designed to improve and enhance a child’s welfare and well-being, and reduce the risks of harm.  The preliminary assessment put undue weight on self-reporting by the parents.  Immediate planning around the investigation, and protection of the sibling after Nolan’s death was uncoordinated, and there needs to be tighter coordination of information from strategy meetings, and police investigation processes  The handling of the case across agencies was characterised by a lack of professional curiosity about the lived experiences of Jack and Nolan  5.3 As well as this detailed learning the second stage of the Review identified some core overarching system wide themes which need to be considered and addressed by LSCB partners working together: These are, in short:  5.3.1 The need to develop a positive and strengths based culture in front line practice where staff, (regardless of professional role, or presenting issue) base every   intervention on the question “what is life like for this child?” as well as on. “Why am I here and what is expected of me”.  5.3.2 The need to support a multi-agency frontline workforce to develop better skills in terms of the identification, assessment, and response to need, vulnerability and risk based on a good understanding of the research and evidence base, especially in relation to compromised parenting.  5.3.3 A need to develop positive, coordinated multi-agency and assertive Early Help services, which are pro-active, well led and evidence based, and are seen as a central plank in the professional’s toolkit of protective interventions with vulnerable children and their families.  5.3.4 The need to decide how best to co-ordinate an NHS-system wide understanding of families who regularly fail to bring their children to medical appointments (i.e. “was not brought” or “did not attends”), and the relevant guidance, pathways and practice standards to support the way responses should be managed.  5.3.5 The need to address practice in terms of making and receiving referrals.  5.3.6 The need to address practice in terms of the assessment of the issues that have been referred and to significantly increase and improve multi-agency information sharing and decision making at the point of responding to a referral.  5.3.7 The need to make a significant investment in developing multi-agency frontline staff skills in terms of professional curiosity, professional assertiveness, and reflective. practice.  5.3.8 The need for stronger management oversight and support of frontline staff practice.  5.4   The LSCB and member agencies need to consider the findings, learning points and     recommendations of this SCR and determine what needs to be done to apply the     learning. It will also require ongoing processes of assurance so the LSCB can be     satisfied necessary standards of practice are in place.  6 RECOMMENDATIONS   6.1 The SCR recommendations after the first stage of this Review which are informed by the Reference and Professionals Groups cover a number of key areas of learning.  They are in addition to the more detailed ‘learning points’ (collated in App 1) which also need consideration by agencies and the LSCB. They are set out in App 2, and the impact of acting on them has also been set out in App 3.   6.2 The LSCB now needs to consider the system wide overarching learning themes in section 5 above) and decide how best to communicate them, act on them and seek to apply the learning effectively to improve practice.                                           Appendix 1 Collated Learning Points From: The two pregnancies:  The need for professional curiosity about repeated symptoms and signs that might indicate pregnancy.  The need, when teenage pregnancy is identified, to make inquiries about paternity and the nature of the relationship.   The need to be curious about late booked pregnancy and obtain information from others who know the parent/s.  The need for antenatal health visiting assessments for young mothers/late bookings.  Handover from Maternity to Health Visiting needs to be formal and clear.  In light of apparent communication issues over the mother’s pregnancy, the pathways and processes between midwifery and health visiting processes need checking.  From: Missed appointments.  Missed appointments can be signs of struggling, evasion, or neglect. They need to be monitored, collated and understood.  Hospitals might be clearer about how important is any missed appointment.   GPs and Health Visitors need to be clear who is to follow up notified hospital non-attendance.   From: Injuries to non-mobile babies.  The LSCB needs a robust well implemented policy on bruising to non-mobile babies, ideally including mandatory referral to CSC.  No professional should make a decision about marks to a non-mobile baby on their own.  Swelling and bruising on non-mobile babies should be medically assessed.   From: Understanding fathers.  Numerous SCRs have highlighted the risks from not assessing fathers properly. This is the case here too.  When assessing the vulnerability of a young mother and baby the role of father must be assessed as far as is possible.  Knowledge of possible challenges to parenting capacity, (e.g. specific types of disability) should be communicated by clinical and other professionals.   When assessing a referral about a domestic dispute, there has to be exploration of the circumstances of the man involved.  The Midwifery Booking Form should be redesigned with a view to making it easier to write about the father specifically, and not just a ‘family’ heading.  From: Understanding the wider family.  The whole family context must be understood, and well recorded, in assessing the safety of a young family.    Assessments must include all members of the household, and other significant adults involved in the children’s lives.   Information which refers to more than one ‘mother’ or ‘the family’ must be recorded with no ambiguity about to whom it refers. There are risks in assuming young mothers living at home are automatically in a supportive environment because of grandparental presence.  From: Assertiveness  The younger the parent the more professionals need to consider the implications of rejection of help, and the need to take a more assertive approach.  From: Strategy meetings (see also Police below)   Strategy discussions/meetings are vital to child focussed coordination in the immediate post harm period.  Up to date information from the local NHS is vital to good strategy meetings.  Strategy minutes should list everyone in attendance.  CSC should check the minute circulation process for strategy meetings.  CDOP minutes must, one way or another, be circulated to all attendees.  From: The responses by CSC  The importance of not allowing the volume of Police domestic dispute referrals to overcome the need for proper child focussed consideration of such notices.  Young teenage mothers who are still legally children are especially vulnerable and their involvement in domestic incidents requires exploration.  All such notices need at least some agency checks.  CSC should consider the impact of using “no further action letters” (especially successive letters) with young parents (indeed any parent) when there has been no contact or investigation. (This could let the victim feel abandoned).  The process of leaving the decision whether to access Early Help entirely to teenage parent choice- without any assessment or meeting is an inadequate response. Signposting should be properly nuanced depending on the circumstances.  Making no checks or visits on a second and certainly a third referral on young parents or vulnerable children is poor practice.  Referrals must be scrutinised in a careful way to ensure there is clarity about who is involved in a household, who might act as a protective factor, and who might present a risk to children.  Professional curiosity should be exercised far more robustly on a multi-agency basis and shared responsibility for evaluating the presenting issues and evaluating the degree of risk developed rather than practice which is based on “passing on” information to others.  CSC needs to ensure, unless immediate and extensive agency checks show the referral to be untrue, that allegations of neglect and illegal drug use near children .are always assessed.    Agency checks should be made in advance of visits where there are allegations of potential abuse, and the assessment would otherwise run the risk of being not being sufficiently robust or targeted  If agency checks are made after the initial visit, they must be prompt and give the agency some idea of context to guide their own inquiries.  The Police should be included in checks where illegal activity is seen ( e.g. drug use in this case  There need to be robust case audit processes in place to ensure that staff under pressure do not assume informal thresholds which clash with sound, well-judged  responses to potential child need  Referral practice should be regularly reviewed, audited and scrutinised on a multi-agency basis, and the degree to which referrals are well presented, well evaluated and rigorously evaluated against the threshold framework monitored.  From: Luton and Dunstable University Hospital NHS FT Partnership  Maternity antenatal assessments should attempt to include information about the fathers particularly in relation to underage conception/ or very young mothers.  Maternity/Community Midwifery handover information needs to give full information to subsequent colleagues.  Community neonatal nurse responsibilities must be fully understood by Health Visitors  The implementation of new requirements around non mobile baby injuries needs to be audited.  Staff need to be supported to use good professional curiosity about the children they are in contact with and ask rigorous questions about their circumstances when concerned.  From: South Essex Partnership NHS FT  SEPT can use this case as background for considering the criteria for when antenatal Health Visitor assessments are a requirement.  SEPT could use this case to stimulate a discussion about what would be an appropriate pattern of visiting for families like this, and how any long gaps are identified.  Visiting frequencies for ‘targeted’ families should be clear and monitored.  With children with early health problems coordinated collation of weights should be kept.  From: The NSPCC  The greatest care needs to be taken when converting the referral to the pro-forma so that this is done accurately and that important nuance is not lost.  From: The Police  There needs to be clarity about who is informing health agencies about a domestic incident with young children present.    Notification forms must give as much information as possible to aid the receiving agency.  When there is subsequent violent behaviour of someone referred (especially recently) to CSC regarding domestic abuse involving a child, consideration should be given to alerting CSC. (CSC might for example have been working with the parents on domestic abuse, or the mother and baby might return to a volatile setting).  Great care needs to be taken to ensure key information is transferred to a new investigative team, and that it is not assumed the new team will start from scratch and find out anyway  Where there is a police investigation a member of the investigation team should attend strategy meetings,  Accounts of how injuries are sustained given to professionals should be recorded at an early stage.  From: Professional Curiosity  Curiosity and questioning is an essential part of professional life, and its value should be modelled by supervisors, and top leadership.  It would be worth exploring with staff whether, for example, they feel inhibited from making more inquiry for reasons of work load.                     Appendix 2 The initial recommendations made during the review  The LSCB should:  i. Ensure that its procedures include appropriate guidance on the management of bruising. In particular, it should consider making the reporting of bruising to non-mobile babies to CSC mandatory.  ii. Seek assurance that there is a requirement for adequate assessment of potential risks with young teenage pregnancy, and that interagency notifications of such pregnancies are effectively completed. iii. Seek assurance that in Health Visiting there is appropriate pre-birth involvement with young parents, and that there is a process in place to identify inappropriate gaps in visiting vulnerable families. iv. Review the way strategy meeting timeliness, attendance, and the relationship with CDOP process in managed. v. Ensure it is clear to professionals making and responding to referrals and that, when assessing potential child protection concerns, that early efforts to seek background information from partners is a vital part of informing a child focussed assessment, and that ‘even without consent, or explicit consent, it is still possible to share personal information if it is necessary in order to carry out your role’.  vi. Should review threshold guidance to ensure that cases that may not meet Section 47 level but nevertheless require a prompt assessment are dealt with at an appropriate pace for the identified degree of risk. vii. Ask member agencies to report on how they ensure the role of fathers, and wider family members in the household, are appropriately assessed. viii. Following the lessons from this case, ask Children’s Social Care to review its emergency assessment process and provide the Board with assurance that there are processes in place to ensure:  Good access to historical family information.  Speedy agency checks inform impending assessments.   Children are visited to assess possible harm not just known harm.  There is a sufficiently inquisitive approach to allegations.  Child focus is not blunted by the volume of referrals.  Young parents in possible abusive relationships are not checked just by letter. ix. Ask the Police to review its internal handover processes and report on lessons learned. x. Through its own example, through training, and through audit programmes (and those of members); demonstrate the essential value of professional curiosity.     Appendix 3   Agency Updates on Progress             The submissions below are in the agencies’ own words and represent their summary of what is different at the conclusion of the first stage of the SCR from the time of the case..  Bedfordshire Police: As a result of this SCR there have been learning events held with Major Crime Investigation and Public Protection Teams to consider how the identification of potential non-accidental injury should be assessed, identified and responded to so that the investigation sets the right tone for how agencies subsequently engage with the family, including the safeguarding arrangements required for siblings. The conclusion is that in those cases where medical opinion suggests that non-accidental injury was present, the subsequent police investigative action should reflect this unless it is prudent to wait for further medical tests. In the early stages of an NAI investigation it is not uncommon for the Police to be presented with changing medical opinion on causation as new information or sample results are analysed. However if further medical tests are expected to take some time, investigators should work on the balance of probabilities as they are presented at the time otherwise investigative momentum can be lost and a confusing message is presented to other agencies. This principle has since been used in subsequent cases to provide a more assertive investigative response.  This SCR also contributed to triggering a review of the operating model and resources in the Police referral team so that the team is more investigative, professional curious and is encouraged to provide a richer picture in terms of inter-agency referrals. A business case for change is awaiting a decision South Essex Partnership University NHS Foundation Trust (SEPT) - health visiting: Since April 2015 SEPT have been commissioned to provide Family Nurse Partnership Programme. The Family Nurse Partnership offers a structured and intensive programme to teenagers under the age of 20 years, having their first baby and less than 28 weeks pregnant.  The service is structured to cover all aspects of pregnancy, health and parenting over the course of the pregnancy and up until the child is aged 2 years.  There is intensive work offered based on theories of attachment, self-efficacy and human ecology. The work is directed at the needs of individual clients and includes the delivery of all elements of the healthy child programme until the child is aged 2 years.  SEPT staff are aware of the Central Bedford Council pre-birth protocol which would now facilitate a request for a multi-agency pre-birth assessment; triggers include late presentation of pregnancy and teenage parents. A comprehensive multi-agency pre-birth assessment would identify need and support required to assist safe and effective parenting, along a continuum of need.    0-19 Team structural changes have increased Health Visiting capacity to facilitate full delivery of the Healthy Child Programme. Health Visitors have been up skilled to conduct guided conversations underpinned by South London & Maudsley NHS Foundation Trust Promotional Guide, including a family strength and need summary.   The structured conversation is designed to include both parents and supports professionals to explore a number of fundamental elements to support their assessment of parenting capacity.      0-19 Team local guidance implemented to support professionals to assess a continuum of need and develop tailored support packages for universal plus and universal partnership plus provision of the Healthy Child Programme. Live chronology for Universal Plus and Partnership Plus provision of the Healthy Child Programme is standard practice for professionals to use proactively, to assist identification of emerging patterns and the need for early intervention.      NHS Bedfordshire Clinical Commissioning Group (concerning general practice):  On ‘professional curiosity’ we can confirm that all GPs in Bedfordshire have access to a one day level 3 training, face to face training. This training is provided by both the Designated Doctor and Nurse with input by senior professionals from partner agencies. The need for Professional Curiosity and Challenge is emphasised and true life examples are given to illustrate this.  On the CDOP minutes circulation, we now ensure that all attendees receive the Minutes of meetings. If on the odd occasion, an attendee does not have an individual secure email account, this matter, is addressed by the Designated Nurse, on a case by case basis with the individual organisation. SystmOne is a software solution which provides clinicians and health professionals with a single shared Electronic Health Record (EHR), which includes a safeguarding template. This enables patient data to be shared securely across services—promoting efficiency and standardisation. Most importantly it enables services improve the patient experience and deliver safer patient care.  All GPs in Bedfordshire have been on SystmOne since 2013. Information share is good across Bedfordshire but you are correct that nationally not all GPs are on the same IT system. National guidance on the need for a unified medical records would address the concerns raised.  Central Bedfordshire Council- Children’s Services: As a result of the learning from the Serious Case Review (SCR) for Nolan, a number of changes have been made to the way that Early Help and Social Work staff and managers evaluate and intervene to address risk of harm to children. The key areas of change are around the identification of risk issues in particular in respect of the potential vulnerability of pregnant teenagers and young teenage parents; understanding the role of fathers, wider family members, members of the household or those who have day to day contact with the child, to ascertain the details of their circumstances and capacity; the potential meaning and response requirements of multiple lower level concerns, such as repeated missed health appointments and multiple referrals and a considered and child safety focused decision making about consent to information from other agencies   Staff and managers have been briefed on the findings and learning from the SCR for Child B. Particular attention has been paid to awareness raising in respect of:  The potential inherent high vulnerability of young pregnant teenagers and parents, who are in law children and who are developmentally managing the challenges of adolescence as well as being parents.  That young teenage parents and pregnant teenagers in possible abusive relationships need to be assessed in a proactive and child safety focused way; this includes evaluating potential risk if offers of assessment and help are declined.  That all Contact/Referrals include clarity about the role and circumstances of fathers and any others who are part of the child’s household – Engaging Fathers Workshops have been provided to Hub and Assessment staff.  That all assessments must include analysis of the role and circumstances of fathers and others who are part of the child’s household or day to day lived experience – Good Quality Assessment Workshops have been provided to all Assessment Team Social Workers, and on 7 July 2016 all Assessment Team staff will be attending Good Quality Assessments training from Research in Practice.  That referrals expressing possible concerns for the safety and welfare of children should in most cases warrant agency checks.   Unless extensive agency checks show a referral to be untrue, allegations of potential harm to children, including neglect and concerns that adult drug misuse is impacting on the safety and welfare of children, should be assessed by a Social Worker.  All reasonable efforts should be made to secure parental consent for multi-agency information sharing but should this not be possible, and the concerns are such that it is believed that the child is at risk of harm, management advice is sought by staff about obtaining information without parental consent where this is felt to be in the best interests of the child.  That agency checks can be made in advance of a Child in Need visit where there are allegations of potential abuse and assessment visits would otherwise not be sufficiently robust or targeted.  That the Police should be considered for inclusion in agency checks where illegal activities such as drug use, domestic violence, weapons or any other violent behaviour is reported, and clear management guidance provided in these cases.  Day to day adherence to awareness of the learning from the SCR for Nolan, as laid out above, is routinely checked and challenged by managers through supervision of staff and audit activity.  Overall, internal reviews of the quality of the service indicate that the service is good in terms of the learning issues laid out above and more generally.   This view was confirmed by the Joint Area Inspection in March 2016.  This provided a detailed independent regulatory review of decision making in the   Access and Referral Service for Children’s Services Operations and concluded that the service provided to families was of a good quality. ‘The single point of access safeguarding hub and social care assessment teams effectively provide a timely response to the range of problems that children and young people experience. In particular, children and young people generally receive high quality services at the first point of contact with children’s social care.’18  In addition to awareness raising, training and the management team providing a clear steer on expectations, a number of practical processes have been implemented, refined and reinforced.  These are that:  All received interagency notifications of young teenage pregnancies are now recorded by the Early Help service on Mosaic (the Children Service’s Operations electronic data base), increasing opportunities for early identification of vulnerable families.  Assessment Team social workers and managers are clear that assessment Child in Need (S.17) visits to children must be completed within 24, 48 hours or within five working days; the nature of the risk issues reported or indicated inform the decision making about how quickly the child will be visited by the allocated social worker, with clear evidenced management oversight of this decision making.  The Head of Service maintains oversight of timescales from referral to first visit, and challenges any apparent delays in visits to children, in particular those that go over the 10 days.  The referral form has been amended and work has begun to support other agencies in providing comprehensive referral information to assist the Early Help team and Hub practitioners to make well informed and prompt decisions on next steps.  The Parental Consent aspect of the multi-agency referral form to Children’s Services has been given more prominence in order to clarify and resolve this complex and important issue early in Children’s Services involvement.     Further development work is in hand to raise awareness of the potential risk issues when families decline or do not engage with Early Help assessment or services for young teenage parents or pregnant teenagers.  This includes understanding the need for consideration of possible risk issues, including historical information on the parents, and emerging patterns of multiple lower level risk issues and repeated concerns. The Emergency Duty Social Work Team has made it routine practice to complete a family genogram/tree, to help staff and colleagues are clear about who they are referring to in multi-agency communications.  This practice will be rolled out to all the Social Work Teams.                                             18 Ofsted, the Care Quality Commission (CQC), HMI Constabulary (HMIC) and HMI Probation (HMI Probation) May 2016   East of England Ambulance Service: We have included a section on non-mobile babies and bruising on our Professional Update (PU) programme for 2016-7. This will be delivered to all emergency and non-emergency staff within the Service. Academy: If there were concerns that a student may be pregnant now, they would be seen by one of the safeguarding staff and spoken to about the concern.  Should they disclose that they are, or might be pregnant, they will be advised and supported to tell their parent or another responsible adult, and we would also refer them to our school nurse or the Brook service, both of which hold weekly clinics in the Academy.  A referral to Children’s Social Services would also be made and the Local Authority guidance on teenage pregnancy followed.  Should they not admit this, the situation would be monitored closely for more evidence and / or family informed of concerns. The above system can be evidence by the fact that we have had two student pregnancies in the last two years, both of which were dealt with as above and resulted in significant support from Social Care and other agencies which led to improved outcomes for the children concerned. At the conclusion of the second stage of the review, the LSCB action plan was all being delivered and returns from agencies gave assurance that further action was being taken based on the learning and new action on the additional learning during the second stage of discussions.                       Appendix 3   Acronyms  A The first child B The second child CAIU Police Child Abuse Investigation Unit (CB) CSC (Central Bedfordshire) Children’s Social Care CBLSCB Central Bedfordshire Local Safeguarding Children Board CCG Clinical Commissioning Group CDOP Child Death Overview Panel DI Detective Inspector EDT Emergency Duty Team FT Foundation Trust GOSH Great Ormond Street Hospital L&D Luton and Dunstable University Hospital NHS FT LSCB Local Safeguarding Children Board MGM Maternal grandmother MCU Major Crime Unit NHS FT NHS Foundation Trust NSPCC National Society for the Prevention of Cruelty to Children PGM Paternal grandmother SCR  Serious Case Review SEPT South East Partnership NHS FT SIO Senior Investigating Officer                                      