Serious injuries to a 3-month-old infant in December 2018. Baby L was taken to hospital by ambulance. Subsequent medical assessments concluded that some of the injuries had happened prior to the hospital admission. Parents were arrested and bailed pending further criminal enquiries. At the time of the reported injuries, Baby L and their older half-sibling had been subject to Child Protection Plans and to a Public Law Outline (PLO) process. Baby L's parents had lived separately in several other areas of England prior to meeting in 2017. Father had two children from a previous relationship where there had been concerns about neglect and historic injuries. Mother had a child from a previous relationship; contacts made to Children's Services in relation to Baby L's half-sibling. Paternal history of mental health problems and domestic abuse. Ethnicity or nationality not stated. Learning centres around: the effectiveness of pre-birth and post-birth multi-agency assessment, multi-agency case management, inter-agency communication and information sharing; how well practitioners considered the inherent vulnerability of babies to abuse and non-accidental injury, particularly in the context of the trilogy of risk; barriers to recognising and addressing over optimism in parents. Uses the Welsh Model. Recommendations include: ensure that pre-birth assessments are completed on time by social workers and include all relevant information, and parents' accounts and views are appropriately tested and triangulated by evidence from other sources; ensure that guidance on injuries to non-mobile babies has been widely disseminated to all front-line practitioners and embedded in practice.
      
    Serious Case Review No:  2020/C8466  Published by the NSPCC On behalf of an unnamed local safeguarding children board      This report was written by an independent author and is owned by the commissioning LSCB.  This report is published by the NSPCC with the agreement of the National Panel of Independent Experts.  Publication of this report by the NSPCC does not constitute endorsement of the contents. Copyright of this report remains with the commissioning LSCB.   Appendix i – combined chronology of key events        Learning  Summary in relation to Baby L  August  2020    2 | P a g e     Table of Contents   1. Introduction          3 2. Scope and methodology of the review       3 3. Brief family background and synopsis of baby’s circumstances    4 4. Key findings           6 5. Recommendations         8 6. Key learning points                         10  3 | P a g e   1. Introduction This summary provides learning emerging from an independently led review commissioned by the LSCB in relation to a three-month-old, Baby  L who upon being taken to hospital by ambulance in December 2018, was found to have suffered serious injury (a fractured femur, swelling to both legs and five rib fractures). The subsequent medical assessments concluded that some of the injuries had occurred some ten or fourteen days prior to the hospital admission. During that time, Baby L was in the care of their parents, although there had been other wider family members present in the immediate days before.   At the time of the reported injuries, the baby and their older half-sibling had been subject to Child Protection Plans and to a Public Law Outline (PLO) process.   It is important to note that Baby L has made a full recovery from the injuries and is reported to be developing well while in the care of the paternal grandparents.    2. Scope and methodology of the review  The Serious Case Review scope covered information regarding professional involvement with the children for a period of twelve months (late 2017 to early December 2018).  A multi-agency review panel chaired by the lead reviewer was established at the outset. The Panel, which met on three occasions, comprised of senior leads from the following agencies and organisations:   • Local Authority1 • CCG  • NHS Trust1  • Hospitals • Police • CAFCASS • Local Authority2 • LSCB Board Office   A ‘Welsh Model’ review was used and included most (not all) of the practitioners involved with the child. The parents did not respond to the Independent Reviewer’s invitation to participate in this process.        4 | P a g e   3. Brief family background and synopsis of Baby L’s circumstances Baby L’s parents are from the Local Authority1 area but, prior to meeting in late 2017, they had lived separately in several other areas of England.  The Baby’s father had two children from a previous relationship where there had been concerns about his part in their care (neglect and historic injuries in 2013 and 2017), in addition to domestic abuse and parental mental health issues. He and the mother had separated in 2017 and, for various reasons, the two children were taken into local authority care (Local Authority2) and eventually became subject to care orders and were placed in long-term foster care. A court order was made against father having contact with the two children. During this set of care proceedings, Baby L’s parents commenced their relationship.  Baby L’s mother already had a child from a previous relationship prior to meeting Baby L’s father. There had been several contacts made to Local Authority1 Children’s Services and other local authority agencies in relation to Baby L’s half-sibling, albeit not resulting in statutory interventions.  In April 2018, a referral was made by Local Authority2 to Local Authority1 in relation to unborn Baby L and their half-sibling. The concerns included amongst other things, that father was a high-risk individual of domestic abuse, he had no contact with his older children (who were subject to Court proceedings) and was now in a relationship with mother and living at the family address.  A social worker was allocated, and a single / pre-birth assessment was commenced.  Following a period of assessment, in May 2018, at an Initial Child Protection Conference (ICPC), Baby L became subject to a pre-birth Child Protection Plan (CPP) while their sibling was initially subject to a Child in Need Plan (Section 17, CA 1989). Sufficient concerns were identified around potential neglect and possible physical abuse risks to Baby L (unborn) to warrant the implementation of the CPP. At the time of the ICPC, mother advised that she was no longer in a romantic relationship with father and that he had moved out of the family home. Mother confirmed ongoing contact with father (as good friends) and committed to supervise all contact between her now ex-partner and her child (Baby L’s sibling) Following a review of the ICPC’s decisions by the Child Protection Service Manager, in June 2018 a reconvened ICPC for Baby L’s sibling reached the decision that the sibling should also be become subject to CPP. The view was that the same levels of risks applied to Baby L as well as their sibling.  In the summer of 2018 Baby L’s father was subject to assessment and intervention by his GP and mental health services, due to a deterioration in his mental health presentation. father was admitted to hospital in June 2018 and by the end of July 2018, he underwent a core mental health assessment at a Local Mental Health Unit (LMHU)  5 | P a g e   conducted by a psychiatrist and a community psychiatric nurse. Father mentioned that he did not have the care of his two children who were in the care system; that he had a girlfriend who was giving birth to his child in five weeks’ time and that he was not allowed to have unsupervised contact with his girlfriend’s  child. He was diagnosed with depression and prescribed suitable medication. This information was not shared in a timely manner with the Social Worker or any other member of the core group and therefore not included in any risk assessment. In August 2018, the Public Law Outline (PLO) process was also initiated in relation to the children with a 12-week pre-proceeding period being commenced. This course of action was triggered by the parents’ confirmation of being in a relationship and living together alongside information from Local Authority2 that the court proceedings in relation to father’s two older children were finalised. Final orders were made for the children not to return to the care of either parents, in addition, a Contact Order was made preventing father from seeing his two older children.  Baby L was born in September 2018 and discharged into the care of their parents. During October and November 2018, parents and Baby L are seen by various practitioners (Social Worker, Health visitor, GPs) and Baby L is reported to develop very well. Both mother and father describe Baby L as unsettled, crying excessively and suffering from reflux and vomiting. Mother was reported as being depressed and the lack of sleep was impacting on father’s mental health.  In late November 2018, the Health Visitor noticed marks on Baby L’s body (three-month old baby). Information is shared with the Social Worker, who arranges a visit to the family home the following day. Baby L is seen and some ‘marks are observed’ however no child protection procedures (to include medical assessments) were instigated as per agreed current legislation and procedures.  In early December 2018, during the core group meeting, the marks on Baby L were acknowledged and deemed ‘not worrying’. Parents were provided advice regarding the supervision of the children and how to ‘handle’ the baby.  Four days later, Baby L, at three months old, was taken by ambulance to hospital. A full skeletal scan showed that Baby L had suffered serious injuries, namely, a fractured femur, swelling to both legs and five rib fractures. Given Baby L was a non-mobile baby, medical opinion suspected the injuries to be non-accidental, with some healing fractures having occurred some ten to fourteen days previously. During this time Baby L’s parents had responsibility for Baby L’s care, albeit Baby L had also been with other wider family members in the immediate days before the injuries.  Baby L’s parents gave an implausible and inconsistent explanation to the Police and Children’s Social Care (CSC) as to how Baby L sustained such serious injuries. They were arrested and bailed pending further criminal enquiries; and a Section 47 enquiry was  6 | P a g e   initiated. Baby L and their sibling were removed from their parents’ care by the local authority who commenced care proceedings on both children.  4. Key findings   The review analysis was considered against six main issues and these, along with the key findings, are presented below.  1. The effectiveness of pre-birth and post birth multi-agency assessment, including the use of historic information, regarding family and parental functioning, in decision making.   1.1 The pre-birth assessment presented at the Initial Child Protection Conference held in May 2018 (unborn) was missing key information around the parents’ parenting histories (including relevant assessments from another local authority in relation to father’s care of his two older children), the parents’ mental health and the children’s lived experiences. This led to an underestimation of risk with father being allowed to remain in the family home while having supervised contact with Baby L’s sibling. It was expected that mother would supervise all the contact.  1.2 An over-reliance by professionals on parental self-reporting and a lack of triangulation and lateral checks with other agencies. 1.3 The Local Mental Health Unit’s (LMHU) risk assessment and management plan was focused on father only without consideration of any potential risk implications to the other adult and children in the family. An assumption was made by the Psychiatrist that because the children were already involved with Children’s Social Care there was no need to share the assessment of the father with them or escalate any concerns. This would only happen in the event of newly identified safeguarding concerns (which these were) rather than to update the childcare professionals on the psychiatric assessment as a crucial part of the wider risk assessment. The same beliefs were reportedly held by other adult mental health workers.  2. The effectiveness of multi-agency case management, planning, implementation and reviewing of the Child Protection Plans:   2.1 The review identified practice deficits in the front-line case management in relation to oversight and compliance with statutory processes. This affected the functioning of the core group, with limited multiagency communication and co-ordination of actions leading to delays in the progress on the Child Protection Plan. There was lack of effective challenge from all the core group members.  2.2 Impact and management of risk within the Child Protection Process is impaired by poor assessments and lack of information sharing and core group activity.   7 | P a g e   2.3 Despite the Independent Child Protection Chair’s recognition of shortfalls in practice across the multiagency group, the formal escalation raised had minimal impact on the progress of the plans.  3. The effectiveness of inter-agency communication and information sharing, including any barriers preventing information sharing in an appropriate and timely manner.  Inter-agency communication and information sharing fell short of the required standards for the effective safeguarding of the children. There were: 3.1 Significant lapses in information sharing within the child protection process from the majority of professionals involved;  3.2 Absence of sharing some key information by Adult Mental Health Services and LMHU with Children Social Care and the core group on the father’s mental health and its implications for potential risk to the children and mother.  3.3 There was a lack of information sharing, contribution and attendance to the Child Protection Conferences by a GP practice despite being aware that the children were subject to child protection plans.  3.4 A lack of a robust systems ensuring the entering of safeguarding alerts within the GP practices.  3.5 Lack of appropriate and timely information sharing between local authorities (parenting assessment completed with father by the other local authority was only received in August 2018, almost 4 months since the receipt of the referral, and was not properly considered till December 2018). 3.6 Inappropriate information sharing and transfer arrangements within Children’s Services (use of duty workers).  4. How well did practitioners understand, identify and respond to risks regarding Baby L, in the context of the inherent vulnerability of babies? There was minimal evidence to show that the practitioners involved with the children in November 2018 had considered the inherent vulnerability of babies to abuse and non-accidental injury, particularly in the context of the trilogy of risk. This view is based on the inadequate multiagency response to the reports of bruising/ marks on the baby noticed by the Health Visitor in November 2018. It was identified that: 4.1 The social workers did not arrange a child protection medical for Baby L, consequent to Health Visitors noting some marks on the child on the previous day. This breached existing Local Safeguarding Children Board procedures and there was a missed opportunity to intervene to protect Baby L and sibling.  4.2 There was lack of challenge by the health visitor and the core group to Children Social Care’s decision not to take any further action in relation to the marks on Baby L.    8 | P a g e   5. What are the barriers to practitioners recognising and addressing over optimism in parents?  The review identified that: 5.1 Professionals were over-optimistic in their perception of the risk posed by the parents. The parents mostly complied with the limited and uninformed expectations of the professional network. They did not avoid contact with professionals, they attended health and medical appointments, sought medical attention for the children, attended the Initial Child Protection Conference and the reviews. 5.2 Father completed a domestic abuse programme which was seen by that agency in a positive light, albeit not providing a risk assessment. Father also gave himself a score of 7 (Signs of Safety rating) at the Review Child Protection Conference, whereas the professionals gave a score of 9.   6.  Were there any organisational and/or agency/multi-agency, systemic factors that accounted for Child 2 suffering serious harm?   6.1 The lead reviewer found no evidence of any systemic or institutional factors accounting for the lack of robust action following the marks noticed on Baby L’s body in November 2018.  6.2 However, as outlined at point 1.3, a training need has been identified across Adult Mental Health Service in relation to their responsibility in sharing information in a timely and systematic way.  6.3 During October and November 2018, both parents were reported to experience fluctuating mental health, struggling with the lack of sleep and challenges brought by a new baby. The review identified a lack of practical support plans being developed with the parents to identify alternative routines to assist and ease the pressures. No arrangements were made to explore the available family and social network able to support the parents    More detailed individual agency’s learning points are available in Appendix A  5. Recommendations  Recommendation 1 The Local Authority’s Children’s Services should assure the Safeguarding Children Partnership that pre-birth assessments:  • are completed on time,  • include relevant historical and recent case information (especially any previous parenting assessments) • information is shared between all professionals involved with the children and relevant adults (including adult mental health and GP Services)  • contain evidence of the child’s lived experiences   9 | P a g e   • parents’ accounts and views are appropriately tested and triangulated by evidence from other sources  • are overseen by a front-line manager to the requisite practice standard. • social workers and their managers have liaised and made the relevant lateral checks with all involved agencies, including adult mental health and GP services. Recommendation 2  The Local Authority’s Children’s Services should assure the Safeguarding Children Partnership that child protection plans are: • informed by good quality assessments of risks • ‘tracked’ and subject to robust scrutiny and challenge from the child protection reviewing service, and • overseen by competent front-line managers who can provide effective guidance, support and challenge to their social workers • include the support and provisions available within the children’s family, social and community networks  Recommendation 3 The Local Authority’s Children Services should ensure that its performance management data is used to identify, at an early stage, where statutory interventions (visits, core group, social workers supervision) are not being complied with and take timely and appropriate remedial/supportive action that results in the safeguarding of children not being compromised. Recommendation 4 The Safeguarding Children Partnership should be assured by the relevant agencies that their staff are knowledgeable, competent and confident to use the SCP escalation/professional dispute procedures when challenge is necessary with regard to an agency’s decisions and (in)actions.  Recommendation 5 The Safeguarding Children Partnership should receive assurance from partner agencies’ safeguarding/internal governance that its guidance on injuries to non-mobile babies has been widely disseminated to all front-line practitioners and embedded in practice Recommendation 6 The NHS Trust1 and the CCG should assure the Safeguarding Children Partnership that the ‘Whole Family’ policy is understood, well embedded and implemented by all its services, especially Adult Mental Health and GP practices, so that any salient safeguarding information on adults is shared with Children’s Social Care social workers, midwives and health visitors.   Recommendation 7: NHS England should include GP practices in the second phase of the Child Protection Information Sharing Project (CPIS). However, the CCG reported that this is already being considered by NHS England.     10 | P a g e   Appendix A 6. Key Learning Points  • All relevant professionals are invited to Initial Child Protection Conferences, especially those who have extensive knowledge of previous case background. • That all single/pre-birth assessments are completed on time by social workers and include all relevant information, especially parenting and trilogy of risk; and do not over rely on parental self-reporting. • That professionals have the requisite experience, knowledge, capacity and managerial support to effectively carry out their safeguarding responsibilities and roles.  • That the Child Protection Review system uses effective case tracking to inform Case Conference Chairs of progress with child protection plans and empowers them to mount robust, timely and effective challenge to professionals when appropriate. • That core groups are effective in challenging agency decisions and (in) actions when required, through the use of the Safeguarding Children Partnership escalation/ professional dispute procedures. • All professionals in contact with non-mobile babies to be familiar with the local Safeguarding Children Partnership’s guidance.    For the NHS Trust1:  • The need to ensure that its ‘Whole Family’ policy and safeguarding procedures (as per the Safeguarding Children Partnership) are well embedded and operational across the NHS Trust; specifically within its Adult Mental Health Services.   For Children’s Services:  • That front-line Children’s Social Care managers provide effective case management oversight and challenge to their social workers.  • The need for Children’s Social Care and the Child Protection Reviewing Service to ensure that the contact details of the GPs of all family members are captured and recorded at the beginning of the single assessment process; and/or at the Initial Child Protection Conference (it is understood that all GP details are now recorded by the child protection reviewing section).  For GP Practices:  • The need for the GP Practice to ensure that it has the necessary systems/process pathways in place for the correct read codes to be entered in a timely and accurate way onto SystmOne/the appropriate electronic patient record system.  • That all GPs, as part of the CCG commissioning and contracting processes, are signed up to and cognisant of their statutory responsibilities and obligations regarding the protection of children, in accordance with Royal College of GP safeguarding policies and procedures.  • The need for GP practices to understand and implement the ‘Whole Family’ approach.   11 | P a g e   • The need for the GP practices to understand their obligations to share information that is relevant, proportional and compliant with data protection and patient confidentiality, with other Local Authority Children’s Social Care, midwifery and the health visiting services, regarding the safeguarding of children.  • The need for the GP practice to remind its clinicians to refer directly to Child and Adolescent Mental Health Service (CAMHS) when appropriate, in respect to children’s emotional and behavioural difficulties, including symptoms of soiling/faeces smearing.   