Serious injury of a nine-week-old girl resulting in permanent disability in November 2014. The injuries to Child B were caused by a single episode of shaking and impact to the head perpetrated by one of Child B's parents. Both parents were in their early twenties and had been known to a number of services in Camden, including mental health services and a young parents' support service following a domestic abuse incident. Child B's mother had briefly been looked after by a London local authority as a child. Findings include: Child B's parents received a number of services for short periods of time leading to a lack of continuity and fragmented service provision. Recommendations include: Camden LSCB should seek evidence as to how information on the dangers of shaking small babies is delivered in antenatal settings; Camden LSCB should seek evidence that providers of antenatal services in Camden are asking women about domestic violence; LSCBs and training providers should take account of the 'halo effect' of seemingly cooperative parents; the LSCB should work with commissioners to ensure perinatal services are consistent and accept post-natal as well as antenatal referrals; the LSCB should consider what steps can be taken to improve effectiveness of risk assessments for children affected by domestic violence.
      
 Title:  Serious case review: overview report and executive summary: services provided for Child B and her family. LSCB: Camden Safeguarding Children Board Author: Keith Ibbetson Date of publication: 2016  This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC.  This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above.                             1  Camden LSCB  Serious Case Review  Overview Report and Executive Summary  Services provided for Child B and her family        Independent Chair  Camden Safeguarding Children Board   Dominic Clout Independent Lead Reviewer  Keith Ibbetson    Review completed September 2015 Published September 2016   2 Foreword by the Independent Chair  Camden Safeguarding Children Board  Between January and September 2015 Camden Safeguarding Children Board conducted a Serious Case Review about a 9 week old infant, referred to in this report as Child B, who was very seriously injured while in the care of her young parents. Child B was born in Camden, as was her father. Her mother grew up in another area where she was briefly looked after by the local authority. There are no other children in the family. The functions of the Serious Case Review are to provide a rigorous analysis of the actions and decisions of professionals and to identify ways in which services for other children and their families can be improved. This report presents the full findings of the review. I am grateful for the cooperation of everyone who has supported the work of this review over the last year, enabling it to be concluded in a timely fashion. I am particularly grateful for the constructive way in which staff and managers in all of the services involved have participated in the review, recognising from the outset that there were potentially useful lessons for agencies in Camden. The delay in publishing this report was necessary in order not to prejudice the criminal investigation which has been complicated by the nature of the injuries to Child B.  In order to make the learning from the Serious Case Review as accessible as possible the findings of the overview report are presented in the following way:   Part 1 of the report is an Executive Summary which provides an overview of the key events and findings  Part 2 contains the recommendations made for individual agencies and the Camden Safeguarding Children Board. These sections of the document can be read independently of the full findings  Part 3 provides a full explanation of the most important findings of the review, together with additional factual information about the case history  The appendices to the report contain further information about the way in which the review was carried out and other background documents. I hope that by setting out the report in this way it will be possible for readers with different objectives to find the information that they need.  This Serious Case Review deals with the serious injury to a young baby which experts believe occurred as the result of a single incident of shaking. Although the review has found that that episode could not have been anticipated or prevented it has identified a number of areas in which local services for children need to be strengthened.    Dominic Clout Date 02/09/2016   3  Services provided for Child B and her family   Foreword by Independent Chair of Camden LSCB  1 Executive Summary Key events Summary of Serious Case Review findings 4 2 Recommendations 19 3 Serious Case Review Findings 28 3.1 Introduction 28 3.2 Would different professional actions or decisions have prevented the injuries to Child B? 28 3.3 A description of services, the way in which agencies worked together and how this reflected the wider provision for vulnerable children in Camden 31 3.4 Referral arrangements for ante-natal care and the sharing of information between GPs and antenatal services 35 3.5 Screening for domestic abuse during hospital antenatal care 37 3.6 The availability of perinatal mental health services in Camden 39 3.7 The assessment of risk to children following episodes of domestic abuse 41 3.8 Local authority provision of child and family assessment under Section 17 of Children Act 1989 and the associated function of the Multi-Agency Safeguarding Hub (MASH) 49 3.9 Local authority child and family assessment – multi-agency working 54 3.10 Whether the parents’ positive presentation may have distorted the assessment made by professionals 59 3.11 Arrangements in Camden for the provision of early help services and the allocation of a lead professional worker  60  Appendices 65 I Principles from statutory guidance informing the Serious Case Review,  methodology and terms of reference  II Membership of the review team and Serious Case Review panel  III North London antenatal for referral and self-referral   IV List of documents and material considered by the Serious Case Review panel and designations of staff involved  V References     4 1. EXECUTIVE SUMMARY 1.1. Between January and September 2015, Camden Safeguarding Children Board (the LSCB) conducted a Serious Case Review (SCR) in relation to the services provided for a nine week old baby, who is referred to in this report as Child B. The review was carried out under the guidance Working Together to Safeguard Children 2013. 1  Its purpose is to undertake a ‘rigorous, objective analysis…in order to improve services and reduce the risk of future harm to children’. The LSCB is required to ‘translate the findings from reviews into programmes of action which lead to sustainable improvements and the prevention of death, serious injury or harm to children’.  1.2. This document sets out the SCR findings which, in keeping with the statutory guidance, are published in full.  Injuries to Child B and family background 1.3. In November 2014 Child B was taken to hospital gravely ill. Abuse was immediately suspected and she received a high level of medical attention. Investigations established that she had subdural haemorrhages (bleeding into the space between the brain and the skull); damage to her brain; bilateral retinal haemorrhages (bleeding in the back wall of both eyes); a skull fracture and a fractured tibia (shin bone). She also had some bruising. Child B survived these injuries because they were rapidly diagnosed and treated, but she has been left with complex disabilities and her development has been severely impaired. 1.4. The consensus of medical opinion is that the injuries were caused by a single episode of shaking and an impact to the head in the hours before her collapse. There are no old injuries and there were no reports of previous mistreatment. Child B had no siblings or half siblings and was living with her young parents in Camden when the injuries were caused. 1.5. The family court found that one of the parents had caused the injuries but that it was not possible to exclude either as a potential perpetrator. Following police investigation both parents have been convicted of offences in relation to the injuries. 1.6. Child B’s parents had been known to a number of services in Camden. In particular the mother had received support for a brief mental health crisis during her pregnancy; the parents had been referred to and had attended a number of sessions at a project for young parents, part of                                             1 Working Together to Safeguard Children (2013),  4.1 and 4.6. This guidance was updated in April 2015. The changes largely affected the decision to conduct reviews and have not altered the purpose of review or the way in which this case was reviewed. The approach taken complies with both sets of guidance   5 the Child and Adolescent Mental Health Service (CAMHS) early intervention service, based in the borough’s children’s centres. When Child B was just under four weeks old the parents had a fight, while Child B was present. The father accepted a caution for assault. Subsequently Camden Council’s Family Support and Social Work Service carried out a child and family assessment. At the time when Child B was injured the family was awaiting a decision as to which family support and early help services would continue to work with the family and who would act as the ‘lead professional’ to coordinate work with the family.  1.7. Child B’s mother had briefly been looked after under Section 20 Children Act 1989 by another London local authority and was eligible to receive financial support and services as a care leaver. In practice, she had lived independently for a number of years, had full time employment, had strong links with her own family and was making important decisions about her life without involving professionals in that local authority. Reasons for conducting the Serious Case Review 1.8. The LSCB convened a meeting of its SCR panel on 12 December 2014 in order to consider whether the circumstances met the criteria for a SCR. The panel was independently chaired by a senior professional from a neighbouring local authority. The panel recommended that a SCR was required because a child has been seriously harmed and there was ‘concern as to the way in which the (local) authority, their Board partners or other relevant persons have worked together to safeguard the child’.2 1.9. Dominic Clout, Independent Chair of Camden LSCB, decided that a SCR should be undertaken. In making this decision he took account of the guidance in Section 4.13 of Working Together 2013 that in such circumstances the LSCB must commission a serious case review ‘unless it is clear that there are no concerns about inter-agency working’.  1.10. Agencies recognised at an early point that there were potentially important lessons about the practice in this individual case and about the way in which services were working to safeguard children in Camden, current pressures on those services and how services should develop in the future. The focus and scope of the Serious Case Review  1.11. The bulk of the work on the review was carried out by a small group which consisted of an independent reviewer and a number of senior local professionals, none of whom had direct involvement in the case or                                             2 Regulation 5 of the Local Safeguarding Children Boards Regulations 2006. Regulation 5 (1) (e) and 2 apply   6 management responsibility for services involved. Details of the review team and SCR panel membership are set out in Appendix II of this report.3  1.12. In its initial discussions the review team agreed comprehensive terms of reference and lines of enquiry as a starting point for discussions with staff who had worked with the family. These are set out in Appendix I of the report. The review has focused on the period between December 2013 (when it became apparent that the mother was pregnant) and the point in November 2014 when Child B presented at hospital. It has received information about, but not reviewed, the period when the mother was a looked after young person as this has no direct bearing on the injuries to Child B. 1.13. As it progressed the review team decided that this report should focus on the following:  An account of the services provided, the way in which agencies had worked together and how this reflected the wider provision for vulnerable children in Camden  Whether the injuries to Child B could have been prevented by different professional actions or decisions  Referral arrangements for ante-natal care and the sharing of information between GPs and antenatal services  Screening for domestic abuse during hospital antenatal care  The availability of perinatal mental health services in Camden  The assessment of risk to children following episodes of domestic abuse  Local authority provision of child and family assessment under Section 17 of Children Act 1989 (including the work of the Multi-Agency Safeguarding Hub (MASH) and the role of other agencies in the assessment  Whether the parents’ positive presentation may have distorted the assessment made by professionals  Arrangements in Camden for the provision of early help services and the allocation of a lead professional worker.                                             3 The independent reviewer has no connection with services in Camden. He had previously acted as author of a SCR in Camden in 2008-2009   7 Agencies involved 1.14. The SCR considered the work of the following agencies and contracted professionals:   Camden Council Family Services and Social Work service (referred to subsequently as children’s social care)   Camden Council’s children’s centres and family support service  Primary care health services (family GPs)  University College Hospital NHS Foundation Trust, including antenatal care services, Emergency Department and perinatal mental health provision (UCLH)  Camden and Islington NHS Foundation Trust (Emergency Department liaison psychiatric assessment and Crisis Intervention Team) (referred to as C&I)  Tavistock and Portman NHS Foundation Trust - the CAMHS Young Parents Service, which is part of the Integrated Early Years Service children’s centre multi-agency team (subsequently referred to as the YPS)  Royal Free Hospital NHS Foundation Trust – which provided the post-natal community midwifery service (RFH)  Central and North West London NHS Foundation Trust, which provides the health visiting service for Camden (CNWL) In addition the local authority leaving care service and three health trusts in the area where the mother grew up have been involved in the review.4                                              4 These agencies are not named. Naming this locality and the services involved in a published report increases the risk of identifying the individuals concerned without there being any likely additional benefit. The draft and final report have been submitted to the involved agencies and to the LSCB in the area concerned in order to ensure that they are able to act on learning from the review. The local authority concerned has agreed to change aspects of its practice in relation to care leavers and this is referred to further in Section 3.   8 How the review was undertaken 1.15. Details of the steps taken to carry out the review are set out in Appendix I.  1.16. At an early point, family members were notified in writing of the reasons for the review and how it would be conducted. Both were asked for and agreed that the review could access their health records. Later the parents were invited to participate by meeting members of the review team to discuss their view about the services that they had received. Copies of all letters were sent to the parents’ solicitors with a suggestion that they should take advice. There has been no response from the parents and it was always considered unlikely that the parents would wish or be advised to participate in the review at a point when there were both criminal and civil legal proceedings in progress.  Key events Family background 1.17. The parents are both in their early 20s. The father had grown up in Camden and had no significant history of involvement with services and no known history of violence. The mother grew up in another local authority area and briefly became looked after shortly before her 18th birthday, making her eligible for a range of support services as a care leaver. Information about her involvement with the local authority would have been readily accessible. She had some limited contact with CAMHS services in that area, information about which was summarised on her records and transferred to her Camden GP. GP records do not identify that she had been looked after. The mother moved to Camden in 2013. Early pregnancy 1.18. In January 2014 the mother made a self-referral to the ante-natal service at UCLH. This was mistakenly treated as a GP referral, because there was scope for confusion in the form that she used. The hospital did not then notify the GP of the pregnancy for some months because screens in the hospital health record triggering this action were bypassed.  1.19. The parents attended the ante-natal booking appointment on 26 January. During the appointment Child B’s mother related an episode of depression in 2012 which she said was related to her home life and family difficulties. She was offered a referral to the hospital’s perinatal mental health service, but refused saying that she currently felt well. 1.20. The midwife did not ask the mother questions about domestic abuse at the antenatal booking because the father was present and there was no opportunity to speak to the mother alone during the appointment.   9 The enquiry was not made later in the pregnancy as none of the midwives who saw the mother perceived there to be a need.  1.21. Other aspects of antenatal care were routine for the next few months. Records do not show how often the father attended, but no concerns were raised by or about him. The mother saw a number of midwives at her appointments. 1.22. On 30 January 2014 the mother called the police to report an argument with her partner, who was not present when police arrived. No physical violence or crime was alleged. The mother was not noticeably pregnant and denied being pregnant, so there were no grounds for the police to be concerned about children or report the episode to the local authority.  1.23. In May the mother attended a review meeting with her Personal Assistant (PA)5 and her mother about continuing financial support and education. She did not mention her pregnancy to the PA until the end of July. It is not known when she told other family members. 1.24. In mid-July (at the 34 week antenatal appointment) the mother reported feeling anxious and having ‘mood swings’. She agreed to a referral to the perinatal service. The referral was considered by the team, but it was decided that the level of need did not meet the team’s threshold for providing a service.  Brief mental health crisis 1.25. In late August (shortly before the expected delivery date) the mother presented at UCLH Emergency Department describing suicidal thoughts. She was seen by the duty liaison psychiatrist, working as part of the Camden and Islington mental health service. A full psychiatric and psycho-social assessment was undertaken which concluded that the mother was safe to go home, with support visits arranged over the next few days from the community-based crisis service. The psychiatrist also liaised with the Camden hospital social work team, the perinatal mental health team and the local authority where the mother had grown up. Information about the attendance was sent to the mother’s GP. The social work team alerted the emergency out of hours service as the mother was very late in her pregnancy. 1.26. The mental health crisis service made visits and calls over the next six days which found the mother to be calmer and focused positively on the imminent birth, about which she had very normal anxieties. The parents were well prepared for the baby’s arrival. The father was involved and found to be helpful and supportive.                                             5 An member of staff with no social work qualification working to coordinate services for care leavers.   10 1.27. As a result of further contacts and discussions involving the parents, the mental health crisis team, the perinatal service and the hospital social work service the parents were referred to the Young Parents Service based at the children’s centre in their locality.6 A member of staff in this service subsequently became the professional who had the most contact with the family. Birth and early care of Child B 1.28. The mother’s pregnancy went some time beyond term, but Child B was delivered without complications and well. The family was discharged to stay with the maternal grandmother, where post-natal midwifery visits were made. There was good liaison between the local health trust and the Royal Free Hospital in Camden which was responsible for the continuing post-natal care. During the post-natal visits the parents were noted to be focused on the infant and nothing remarkable was identified.  1.29. The health visitor’s new birth visit noted positive observations about the care of the infant. Recognising the mother’s history of antenatal mental health difficulties, the health visitor allocated Child B to the Universal Plus level of provision, which would allow an additional follow up visit to review the mother’s mental health. The health visitor did not ask screening questions about domestic abuse because the father was present. The health visitor encouraged the parents to take Child B to the baby clinic in the normal way, though they did not subsequently do so. The health visitor later liaised with the family GP and the YPS to share information about the family and discuss impressions of the family.  Assessment and subsequent involvement with the Young Parents Service 1.30. On 17 September both parents attended an initial assessment appointment with an experienced and qualified member of the multi-disciplinary team at the YPS. At the appointment the parents provided information about their family backgrounds, housing problems, the mother’s mental health, their jobs and their daughter. They showed interest in various support services and agreed that the YPS worker could contact other agencies to obtain further information. The worker agreed to arrange for a family support worker to attend the next                                             6 The Young Parent’s Service works with parents aged 24 and under who are pregnant or have a baby aged under 5. Work focuses on the perinatal period, parent child relationships, parental mental health and work on couple relationships. The service is based in Camden’s Children Centres where a range of services can be offered such as family support workers, health and developmental services for children, welfare rights and employment. Parents can be signposted or referred for other services, after an initial assessment.   11 appointment and complete children’s centre registration forms to enable to family to access a range of services. 1.31. Over the following six weeks the parents attended four further appointments, one of which the mother attended alone and one of which the father left after a few moments. One appointment was missed and rescheduled.  1.32. At the second appointment the duty family support worker from the children’s centre told the parents that there was a long waiting list for the allocation of a family support worker. Alternative sources of potential support were identified and the YPS worker referred the parents, though they did not attend them. Due to the timing of events neither the YPS worker nor the duty family support worker were aware of an episode of domestic violence that had taken place earlier that day (referred to further below). 1.33. During their further contacts the YPS worker became aware in more detail of the parents’ histories and a number of practical and family stresses. She sought to assist them, both in her own sessions and by making referrals to more specialist mental health services. Both parents engaged with these sessions and as they progressed the mother in particular reported feeling more positive and confident about being a parent. When seen alone she reported difficulties in the relationship with the father and felt that it might not last. However she was always positive about the role that he was playing in Child B’s life. Domestic abuse incident 1.34. On 29 September the mother reported an incident of domestic violence to the police. The police arrested the father, who accepted a caution for assault. The mother was offered transport to her own mother’s home, but preferred to stay at home and agreed that the father should return on the basis that he had accepted responsibility for what he had done and was remorseful. The police reported the incident to the Camden MASH7 in line with the established procedures. A referral was also made to Camden Safety Net, a voluntary organisation which supports victims of domestic abuse, though the mother refused any involvement. 1.35. The MASH rated the episode as ‘amber’ (pointing to the need for a child and family assessment under Section 17 Children Act 1989) and quickly passed it to the social care assessment team with a                                             7 Multi-Agency Safeguarding Hub The purpose of the MASH is to enable the local authority and partners to pool information quickly and make well informed decisions about the level and type of further assessment or support that is needed. Cases are the subject of checks among participating agencies. This is done with parental consent, unless there are reasons to believe that this would place the child at risk. The MASH process is deliberately swift. The target is to triage urgent contacts within four hours.   12 recommendation that there should be a quick home visit to confirm that the child was safe.  Social care child and family assessment 1.36. The case was quickly allocated to an experienced social worker and a manager gave detailed directions for the areas to be covered in the assessment. The allocated worker and a newly qualified colleague made a lengthy visit on 1 October, discussing with the parents what had happened and observing their care of Child B. In order to evaluate potential risks the visit established details of the parents’ history and the services that were currently working with them. The parents, who were both upset and genuinely concerned about what had happened, agreed ways in which they could modify their behaviour in order to avoid a repeat of the episode and make the best use of the services that were available in order to minimise further risks to Child B. 1.37. This visit formed the basis for the child and family assessment. The allocated social worker attempted a second visit five days later, which was unsuccessful because the family were visiting member of the mother’s family. The social worker had a phone contact with the YPS worker, who reported on the positive engagement of the parents. The social worker did not at that point contact the other professionals who had been working with the family, including the mother’s local authority PA, who could have provided a limited amount of family history, though she had had no recent contact with the mother and had not spoken to her since the birth of Child B. 1.38. The allocated worker made a second visit on 24 October, which was also viewed positively. The parents reported that they were finding the sessions at the YPS helpful. They said that communication between them had improved in the last 3-4 weeks. They told the social worker that they had attended a parents group and intended to return (though this was not checked and there is no evidence that they had). Details were taken of their contacts with health professionals. The mother was asked about her time in care and explained that there had not been any severe family problems, but that she had really been in care to gain access to housing and support with education. No check was made, but if it had this account would have been confirmed. 1.39. The social worker’s assessment was that there were no current or foreseeable safeguarding concerns for Child B and highlighted the services with which the family had been engaging. The assessment recommended that the case should be taken to the borough-wide panel which would identify a lead professional to coordinate early help services for the family.   13 1.40. This assessment was signed off by the assessment team manager and the case remained open awaiting the panel discussion and decision about the allocation of a lead professional. Final professional actions 1.41. The couple attended their final session at YPS on 29 October. Prior to this the YPS worker had made arrangements for the couple to be seen separately by adult mental health services and she explained that they should receive appointments shortly. 1.42. The couple talked about how difficult it had been for them to implement the changes that they were trying to make and spoke about a recent argument. The father became frustrated about 20 minutes into the session and left. The mother voiced her growing frustration with her partner, as he seemed less committed to the relationship, and she said that she also wondered whether she wanted it to continue. She continued to be committed to attending support services and starting a professional training course. She was aware of where help could be obtained if things deteriorated. A further appointment was made for 4 November. 1.43. On 31 October the health visitor, who was leaving his post, started to make arrangements to hand over the case. The health visitor was aware that, despite numerous attempted contacts, the service had not seen Child B since 19 September and asked the new health visitor to revive the plan of seeing Child B once a month. An email was sent to the allocated social worker and her manager asking the social worker to make contact. 1.44. These were the last professional actions before Child B presented with serious injuries on the morning of 3 November 2014. Summary of Serious Case Review findings 1.45. Section 3 of the report provides a detailed evaluation of the services provided and the reasons for recommendations made. They are summarised in the following paragraphs. Would different actions and decisions have prevented the injuries? 1.46. There has been detailed, reflective discussion throughout the review about whether the injuries to Child B could have been predicted or prevented. The review has concluded that they could not. These discussions have repeatedly highlighted the very unpredictable nature of the injuries to Child B, which are understood to have been caused in a single episode. There is no evidence that Child B had been injured previously and no professional had observed concerns about the way in which her parents were caring for her.    14 1.47. There were tensions between the couple and professionals were aware of one incident of domestic abuse, which took place in the vicinity of the child, five weeks before she was injured. The potential seriousness of this episode was recognised. The task for professionals was to assess the nature and extent of the risk to the child and to provide services that would assist her parents and make her safer. 1.48. The family was receiving services from a project that had been specifically designed and commissioned to meet the needs of young parents who had difficulties in their backgrounds and faced stresses in their lives. The parents were motivated to address their difficulties, attending appointments, discussing their difficulties in an open way and reporting some improvements. They were about to start receiving more specialist support for their moderate, individual mental health difficulties and there were plans to offer sessions which would have given the couple help to improve their behaviour towards one another. 1.49. The review believes that it is right that professionals should seek to work in this way with families on the understanding that risk is properly evaluated, but that it can never be predicted with complete accuracy or eliminated entirely. 1.50. Assessments of risk and need had been undertaken by the local authority which recommended that this pattern of provision should continue and that an allocated social worker was not required. The case review has recognised that there were gaps in this assessment; however there is no evidence that a fuller assessment would have significantly altered the understanding that professionals held of the family. The review recognises that in other circumstances a fuller assessment might make a difference, so it is important that the factors that caused the weaknesses in the assessment are understood and addressed. Section 3.8 considers this in detail. 1.51. Nobody considered seeking to remove this child from her parents and the evidence of risk that could have been presented to a court would have fallen far short of the prevailing legal threshold for removal given the current interpretation of the Children Act 1989 by the courts. The overall pattern of professional involvement 1.52. The review has highlighted considerable strengths in the provision made by a number of agencies, as well as gaps. Individuals and agencies largely worked in line with expected procedures and there are examples of good collaborative practice and information sharing. Detailed critical scrutiny has identified areas in which there could be improvements which will be of benefit to other children and their families.  1.53. Although the difficulties faced by Child B’s parents were not unusually complex and the review covers a period of only 11 months, it has   15 shown that there were a large number of services, with very specialist functions involved with the family often only for a very short period of time. The experience of the reviewers is that this pattern of service delivery is becoming more common as more specialist services are commissioned with very specific functions and fewer services offer long term support for parents. 1.54. The rapid transfer of cases between agencies that this pattern of provision requires increases the risk of information not being shared comprehensively, makes it harder to identify a stable group of professionals around a child and a single professional with an overview of the case. It also makes it more difficult for parents as they were required to build a series of relationships with a large number of professionals. This is inherently difficult for young adults, especially those living in stressful environments and those who have grown up in unstable circumstances. Arrangements for ante-natal care, the sharing of information between GPs and antenatal services and screening for domestic abuse during antenatal care 1.55. The mother’s GP records contained potentially important historical information about her history of mild, brief mental health problems. This information was highlighted on the opening summary screen of her GP record, but it was never known to the antenatal service or used to inform later assessments. 1.56. The review has highlighted vulnerabilities in the arrangements for transferring psycho-social background information from GP records to antenatal services as well as concerns that the GP was not notified about the mother’s pregnancy for some months.  1.57. Whilst there is no evidence that it made a difference in this case, the arrangements for antenatal screening in relation to domestic abuse at the hospital where the mother received her antenatal care were found to be limited. 1.58. The review has made recommendations to address these matters. Perinatal mental health services in Camden 1.59. The UCLH perinatal mental health service had a limited role because the mother’s mental health condition did not meet the threshold for the service. It played a very positive role in collaborating with other professionals to arrange for a referral to the Young Parents Service. 1.60. The review has highlighted concerns about the level of resources available to the UCLH perinatal mental health team in the face of a large number of referrals about women from Camden and other boroughs. Currently it is only resourced to respond to referrals made during pregnancy, not the post-natal period.    16 1.61. More widely, all participants in the review spoke very positively about the value of the service, both in relation to its work with patients and its role in linking with other services. However professionals who do not regularly work with the perinatal service find the differences in services, arrangements and referral routes in different parts of the borough confusing. 1.62. A review of this provision is already underway and the findings of the serious case review underline the need for this. Child and family assessment 1.63. There were gaps in the child and family assessment carried out by the local authority in relation to Child B resulting from a number of factors, including the workload of the social worker and the general level of pressure on the social work assessment team. The number of cases being referred from the borough’s multi-agency service hub (MASH) exceeded the capacity of the assessment team. Staff involved believe that as a result not all cases receive a good assessment and the local authority’s own auditing has identified areas in which there could be improvement. There were specific pressures on the individual social worker and on the managers in the assessment team at the time when the work with Child B and her parents was undertaken. 1.64. Since 2013 statutory guidance has required the local authority to undertake an assessment that is ‘proportionate’ to the perceived needs of the child; however it is not always easy for social workers and their managers to judge what that should mean in practice and the local authority had not set out clear guidance for staff. 1.65. There is scope to improve the involvement of other agencies in local authority assessments. At present the network checks undertaken by the local authority take too long to administer and return in some cases. The local authority and its partner agencies should agree specific standards for the return of information required by the local authority assessment team. 1.66. The review has recognised that improvements could be made if the child and family assessment included a multi-agency meeting of the professionals involved to share information, discuss and if necessary challenge ideas and formulate a plan for the child, rather than just sharing information by phone and email. It is recognised that this will not be possible in every case, so the local authority and its partners should agree which cases should be given priority. It will be of particular value when the outcome of the assessment may be to appoint a lead professional from the early help service in order to coordinate services for the child, rather than allocate the case to a social worker.   17 Assessment of risk following episodes of domestic abuse affecting children 1.67. The social care assessment was triggered by an incident of domestic abuse which the police believed might have a negative impact on Child B. This is one of several hundred referred by the Metropolitan Police Service to Camden’s MASH every year, a pattern which is repeated across London. The number of referrals about domestic abuse presents a significant challenge to all local authorities. 1.68. The assessments that followed this referral addressed the risk arising from domestic violence but did not include some elements that could have been in place. For example as part of the child and family assessment, parents should always be interviewed alone on at least one occasion in cases where there has been domestic abuse.  1.69. More professionals in the borough need to be able to understand and use the CAADA-DASH risk assessment and more staff need to be trained to understand and use the Barnardo’s risk assessment which is part of the London Child Protection guidance. However the review confirms that even when these tools are used they cannot be guaranteed to provide an accurate assessment of the risk to a child.  1.70. The parents of Child B chose to remain together after an episode of domestic violence that could have led their child to suffer harm. The LSCB and member agencies in Camden should develop a better understanding of the needs of couples who decide to remain together, despite the fact that there has been domestic abuse, and ways of safely working with them in these circumstances. Family support and early help 1.71. Limited capacity prevented the allocation of a family support worker for the parents. The children’s centre family support service had arrangements which could have allowed the case to receive priority above others in the waiting list, but the staff involved were not aware that this system existed.  1.72. The review has noted that Camden is currently undertaking a full review of the family support and early help services. There are plans to integrate a number of services. The pressures on the local authority assessment service described above inevitably also have a less direct impact on early help services, which already deal with families with complex needs. 1.73. The SCR has recommended that future planning for early services should take account of the findings of the case review, in particular recognising:   The value of skilled professional psychological help for young parents  18 •The value of family support workers and the need to maintain andbuild capacity•The need for work to overcome the barriers that face someprofessionals in becoming lead professions and the danger ofunderestimating the skill and knowledge needed•The need for a clear mechanism for allocation of a leadprofessional that takes account of actual pattern of agencyinvolvement with children and families.Recommendations and action to implement them 1.74. Section 2 of the report sets out the recommendations for the LSCB and its member agencies made by the serious case review. 1.75. At the request of NHS England the Designated Doctor and the Designated Nurse for Camden Clinical Commissioning Group (CCG) have prepared a health overview report. This makes specific recommendations for the health trusts and providers. These are set out in Section 2 below. 1.76. The LSCB should endorse these recommendations and seek evidence from the CCG that they have been implemented and are having the desired impact. 19 RECOMMENDATIONS FOR CAMDEN SAFEGUARDING CHILDREN BOARD AND ITS MEMBER AGENCIES 2.1 Recommendations from the serious case review overview report Section in the report Reason for making a recommendation as it relates to the case history Intended outcome Recommendation for member agency or LSCB 1. 3.2 Child B’s injuries were caused by a single episode of shaking. Predicting accurately who might shake a child is impossible so it is important that all parents receive unambiguous information about the danger of shaking small babies. All those who work with parents during antenatal care and children under the age of one year deliver information to parents about the danger of shaking small babies.  Professionals will be particularly aware of the need to provide information to parents who are vulnerable or under conspicuous stress Camden LSCB should seek evidence from member agencies as to the way in which all those who work with parents during antenatal care and children under the age of one year deliver information to parents about the danger of shaking small babies.  An initiative being piloted by the NSPCC, ‘Coping with Crying’ should be considered. Evidence should be provided in particular about how information is given to parents who are vulnerable or under conspicuous stress. The LSCB should monitor the effectiveness of what is done. 2. 3.3 Though their problems were not complex, the parents had contact with a significant number of different services over a brief period of time. This fragmented service provision creates difficulties for professionals and for service users.  Awareness of this pattern of service provision and its impact on service users should inform future service design and commissioning.  When new services are commissioned at the very least they should not make the pattern The LSCB should make commissioners of children’s services in Camden aware of the findings of this review and in particular the complex nature of some services so that this can be taken into account in future commissioning decisions   20  Section in the report Reason for making a recommendation as it relates to the case history Intended outcome  Recommendation for member agency or LSCB This is a significant lesson of the review, though it is not one that can be turned into a specific recommendation with a measureable outcome. of health and family support provision for vulnerable families in Camden more complex. 3.  3.4 UCLH wrongly believed that the mother’s maternity self-referral was a referral from her GP. The referral form used by UCLH leaves scope for confusion. The hospital did not notify the GP about the pregnancy for some months and this has been identified as a wider problem. As a result of these factors and others potentially important information in the GP records was never known to the hospital and the GP had no formal notification of the pregnancy There are reliable and effective arrangements for identifying psycho-social information in GP records that might inform antenatal care and risk assessment. UCLH will have safer arrangements for antenatal referral and self referral Camden LSCB should seek evidence from the health commissioners, GPs and providers of antenatal care in Camden that 1) GPs are consistently including relevant information about psycho-social risk in antenatal referrals 2) Camden’s hospitals and patients’ GPs use reliable systems for sharing information and ask for relevant information 3) The forms for maternity referral and self-referral are fit for purpose. 4.  3.5 The mother was not asked about domestic violence during antenatal booking as no opportunity presented itself. Hospital policy is not to repeat screening later in pregnancy which is not in line with national guidance. UCLH does not monitor compliance with its policies in this area Women receiving antenatal care at UCLH will be asked screening questions about domestic violence and abuse at their booking appointment. Staff will have the confidence to implement policies and will be supported by training and administrative arrangements. Screening will be repeated later in Camden LSCB should seek evidence from the commissioners and providers of antenatal care in Camden that 1) policy, procedures and training enable professionals in the ante-natal service to speak individually to women about possible domestic abuse at their antenatal booking appointment and later in pregnancy   21  Section in the report Reason for making a recommendation as it relates to the case history Intended outcome  Recommendation for member agency or LSCB the pregnancy 2) policy is implemented 3) this results services being provided and, in appropriate cases, in referrals being made to the local authority 5.  3.6 Child B’s mother was referred to the perinatal mental health service, though she was found not to meet the threshold for the service. Later the service played a key role in securing a referral to the Young Parents Project. The review has identified gaps in Camden’s provision, particularly that the service only takes antenatal referrals. Arrangements for service provision are not well understood by professionals who do not work in the hospital antenatal services. Camden will have access to a more comprehensive perinatal mental health service which maintains its strong positive connections to existing antenatal services and the borough’s early help services Camden LSCB should work with health commissioners and providers to seek to ensure that perinatal services in Camden  1) accepts post-natal as well as antenatal referrals  2) are consistent across the borough  3) maintain existing strong links with the borough’s social care and early help services. 6.  3.7 Camden Council had a policy that mothers who were previously looked after children should be offered a pre-birth assessment, but for a variety of practical reasons this was not implemented and some staff were not certain how it applied. Young people who have been looked after are given the earliest and best possible support when they become parents, without being stigmatised as a result of having been looked after. The Director of Children’s Services should clarify its policy in relation to the pre-birth assessment of parents who have been looked after.    22  Section in the report Reason for making a recommendation as it relates to the case history Intended outcome  Recommendation for member agency or LSCB 7.  3.7 Mother’s status as a young person who had been looked after was not known to health professionals until shortly before she gave birth The likelihood of identifying a parent who has been looked after  early in pregnancy is increased UCLH should include questions about whether a parent has been looked after by a local authority in its documentation for antenatal screening at the booking appointment  8.  3.7 The local authority has issued its staff only limited guidance to explain what it means by a proportionate child and family assessment. Partner agencies may now overestimate the level of work that is being undertaken in some cases by the local authority. Social workers and managers in the local authority will have clearer guidance on what constitutes a proportionate assessment in a range of cases.  This will be communicated to partner agencies so that they have a clearer idea so to what to expect of a local authority assessment The Director of Children’s Services should make expectations about ‘proportionate’ child and family assessment explicit to staff in the local authority and this should be reflected in policy documents and training.  The local authority should in turn make these expectations clear to partner agencies.  9.  3.7 Staff and managers recognise the pressure on the social care assessment service, some of which may result from assessments being undertaken which are unnecessary or could be carried out in other parts of the children’s services network Assessment activity will be allocated in the right place and there will be a good matchup between the amount of work going into an assessment and the service provision resulting from it. The number of assessments leading to no further action or service provision should be the minimised The local authority should review the current outcomes of work conducted by the assessment team to establish whether a proportion of the assessments were unnecessary or might have been better conducted in another part of the network of children’s services. This should be the subject of regular review. 10.  3.8 Pressure on the local authority assessment team is high, in part because the MASH processes cases swiftly, leaving There is a good balance in work between the MASH, the local authority assessment team and The local authority should consider how it can ensure that there is a good balance in work between the MASH, the local authority   23  Section in the report Reason for making a recommendation as it relates to the case history Intended outcome  Recommendation for member agency or LSCB further judgement about thresholds to be made during the children and family assessment. It is recognised that the MASH is a relatively new service which is learning and evolving, along with other similar services across London.  other parts of the network of children’s services which can assess children’s needs and cases are directed for assessment to the best place. assessment team and other parts of the network of children’s services which can assess children’s needs. 11.  3.8 The local authority acknowledges that there are often delays in obtaining information from other agencies during the course of the child and family assessment. The reasons for these delays are not fully understood and may not have been discussed fully with other agencies involved. There is likely to be some responsibility on both sides Information is gathered from other agencies rapidly during the course of the child and family assessment The local authority should review how the assessment team undertakes network checks and consider whether the burden of this work can be shared with the MASH, or undertaken with less substantial use of professional time.  12.  3.8 Same information Information is gathered from other agencies rapidly during the course of the child and family assessment Partner agencies should agree specific standards for the return of information required by the local authority assessment team, as they do with the MASH.  13.  3.8 It is recognised that in this case as in a proportion of others, the inter-agency aspect of child and family assessment is the weakest element and the most difficult element to improve. This affects Multi-agency working during the child and family assessment improves leading to better planning of services to meet children’s needs The local authority and partner agencies should consider how they can increase the role of face to face meetings during the child and family assessment to make the assessment a more shared process and to plan support   24  Section in the report Reason for making a recommendation as it relates to the case history Intended outcome  Recommendation for member agency or LSCB the quality of the assessment and the ability of agencies to create a multi-agency support package. following completion of the assessment, especially in cases that are going to be ‘stepped down’.  It will not be possible to hold such meetings in all cases, so agencies should agree on the type of cases that should be prioritised. 14.  3.9 There were gaps in the assessment of risk in relation to domestic violence.  There is an inconsistent level of understanding and use of frameworks to assist in the assessment of risk to children across agencies Professionals have an improved ability to contribute to or coordinate a risk assessment in relation to children where there has been domestic violence and abuse. The LSCB should consider what further steps can be taken to improve the effectiveness of risk assessment of children affected by domestic abuse and whether these should be included as standard elements in the work of agencies.  For example 1) whether in such cases as part of the child and family assessment parents should always be seen alone 2) whether to enable more staff to understand and use the CAADA DASH risk assessment 3) whether more staff should be trained to use the Barnardo’s risk assessment 4) asking the police to share the entire CAADA DASH assessment along with the MERLIN notification in some instances. 15.  3.9 Like other boroughs Camden experiences very significant numbers of referrals arising from incidents of domestic abuse which may have impacted on children.  Camden LSCB should consider a review of the current arrangements and thresholds for referring incidents of domestic abuse to the MASH and the local authority.   25  Section in the report Reason for making a recommendation as it relates to the case history Intended outcome  Recommendation for member agency or LSCB This results in a large workload of screening and assessment for the MASH and the local authority.    It may be that such a review is better undertaken as a cross London exercise, particularly as the majority of contacts and referrals are made by the MPS. 16.  3.10 A ‘halo effect’ applied in this case because the parents were genuinely positive and engaged with services, which is unusual. Along with other factors this may have limited the extent of the assessment undertaken. Professionals and supervisors are more aware of this commonly recognised human bias and incorporate this understanding into their practice LSCB and single agency safeguarding training programmes should in future take account of the potential impact of the ‘halo effect’ and other identified biases that may impact on assessment 17.  3.11 The case history revealed both strengths and vulnerabilities in the provision of early help services in Camden. The inability of the early help service to allocate a family support worker weakened the work with the family. The capacity of early help services is enhanced. A wider range of professionals will take on the role of the lead professional worker. It is noted that a full review of the family support and early help services is taking place and that there are plans to integrate a number of services. Future planning for services should take account of the findings of the SCR, in particular recognising: • The value of skilled professional psychological help for young parents • The value of family support workers and the need to maintain and build capacity • The need for work to overcome the barriers that face some professionals in becoming lead professions and the danger of underestimating the skill and   26  Section in the report Reason for making a recommendation as it relates to the case history Intended outcome  Recommendation for member agency or LSCB knowledge needed • The need for a clear mechanism for allocation of a lead professional that takes account of actual pattern of agency involvement with children and families There needs to be a recognition that if early help services are to take further responsibility for the assessment of families where there are higher levels of risk, training and supervision need to be further enhanced to match.   27 2.2 Recommendations of the Camden Clinical Commissioning Group health overview report  1. UCLH to review their process and procedures for GP ante natal liaison and ensure that when women self-book is there a robust communication pathway. 2. UCLH and Camden and Islington Foundation NHS Trust to review their information systems to ensure there is optimal information sharing when treating the same patient. 3. To raise awareness with all GPs in regards to the need to share information with maternity services in regards to pregnant patients with complex mental health problems and take a “Think Family Approach” 4. UCLH and Central and North West London NHS Trust to review their Domestic Abuse Policies and Procedures and ensure there are robust arrangements for screening women on their own. 5. Camden CCG and North Central London Maternity Commissioner to review the current provision Perinatal Mental Health Service in order to provide a consistent service 6. Tavistock and Portman Trust to review their engagement in the Camden MASH 7. CNWL to provide assurance that MASH alerts are being responded to in a timely manner. 8. Disseminate learning of case across all health agencies in Camden and the authority where the mother grew up.       28 3. SERIOUS CASE REVIEW FINDINGS 3.1. Aspects of service provision covered by the evaluation 3.1.1. This evaluation addresses the following:  Whether different professional actions or decisions would have prevented the injuries to Child B  An account of the services, the way in which agencies had worked together and how this reflected the wider provision for vulnerable children in Camden  Referral arrangements for ante-natal care and the sharing of information between GPs and antenatal services  Screening for domestic abuse during hospital antenatal care  The availability of perinatal mental health services in Camden  Local authority provision of child and family assessment under Section 17 of Children Act 1989 and the associated function of the Multi-Agency Safeguarding Hub (MASH)  The assessment of risk to children following episodes of domestic abuse  Aspects of the parents’ presentation that may have distorted the assessment made by professionals  Arrangements in Camden for the provision of early help services and the allocation of a lead professional worker.  3.2. Would different professional actions or decisions have prevented the injuries to Child B? The injuries inflicted on Child B and the quality of parental care for her 3.2.1. The extremely serious injuries inflicted on Child B were caused by shaking and an impact to the head sufficiently forceful to fracture her skull. They are likely to have been caused in a brief, single loss of control by one of her carers.  3.2.2. Shaking a small child, even momentarily can cause death or very severe, permanent harm. Such episodes are a well-recognised cause of death and serious harm in small children, particularly those under the age of 12 months. They are known to occur in families where there has been no previous concern about parenting or behaviour, as well as in families where there is an identified pattern of violence or other risk factors.  3.2.3. The vulnerability of the infant, and the danger of causing substantial harm the first time there is an episode, make this form of injury very difficult to predict, unless there have been previous less serious, but visible injuries such as bruising.  3.2.4. The unanimous opinion of the expert witnesses in the care proceedings was that Child B would have become gravely ill shortly   29 after she was assaulted. There is no evidence that Child B had previously been injured. If so it never came to the attention of a professional. There is no suggestion that professionals had failed to recognise or act on a previous injury. 3.2.5. The overall pattern of care and attention that Child B received from her parents was observed to be good. Professionals describe parents who were largely positive about their baby and caring. In the first few weeks of her life, the mother stated that she sometimes found it hard to show affection to the baby and that she was not confident about being with the baby around others, including her own family. Later she reported that this had improved. The father expressed some negative attitudes towards the baby, but no one feared he would harm her.  3.2.6. It is sometimes hard to observe and make judgements about the care of very young baby who may be asleep a lot of the time when parents see professionals. But when the care of the infant was observed the parents were attentive and handled her well. These observations were made by experienced midwives, a health visitor a social worker and a psychologist and there is nothing in the accounts to suggest that they were naïve or superficial.  3.2.7. The child’s consistent weight gain is a strong indicator of healthy development. Child B regained her birth weight after the expected dip after birth. She was noted by the social workers who saw her at four weeks to appear to have a healthy appearance and weight, though it was not their role to weigh her. However she was not taken to child health clinics to be weighed. 3.2.8. Five weeks before she was injured, when Child B was three weeks old, she was present during an incident of domestic violence between the parents. All of the professionals involved understood that if a similar incident occurred again, or if the incident was indicative of an underlying pattern of violence, it could pose a serious risk. Professionals recognised that there might have been other incidents that had not been reported, as this is an established feature of domestic abuse.  3.2.9. This left professionals seeking to understand what this single reported episode of domestic violence represented and what help would be most effective. Section 3.7 of this report addresses this difficulty, particularly in the light of the very large numbers of domestic incidents that take place in households where there are children that the police respond to and report to social care. Would different actions and decisions have prevented the injuries? 3.2.10. There has been detailed and reflective discussion throughout the review about whether the injuries to Child B could have been   30 predicted or prevented. These discussions have repeatedly highlighted the unpredictable nature of the event.  3.2.11. Professionals were aware of one previous episode of domestic abuse, which took place in the vicinity of the child. The parents did not want to separate. If a separation had been encouraged it would have been extremely difficult to monitor and would have created different, additional risks. The task then was to assess the nature and extent of the risk to the child and to provide services that would assist. 3.2.12. The family were receiving services from a project that had been specifically designed and commissioned to meet the needs of young parents, with difficulties in their backgrounds and current environmental stresses. The parents were engaging with their worker and reporting improvements. They were about to start receiving more specialist support for their moderate, individual mental health difficulties and there were plans to offer sessions which would have given the couple an opportunity to improve their behaviour towards one another.  3.2.13. Nobody considered seeking to remove this child from her parents and the evidence of risk that could have been presented to a court would have fallen far short of the prevailing legal threshold for removal given the current interpretation of the Children Act 1989 by the courts. 3.2.14. Assessments of risk and need had been undertaken by the local authority. It is recognised that there were gaps in this assessment, which are described in more detail in section 3.8. However there is no evidence that undertaking a wider assessment would have altered the professional understanding of the family or the services which were being offered. However in other cases it might. 3.2.15. Whilst the review has concluded that the injuries to Child B could not have been prevented it has highlighted gaps in the provision made by a number of agencies. It has also identified considerable strengths. The nature of the gaps and the reasons for them are described fully in the rest of this report. Detailed critical scrutiny has identified improvements which will be of benefit to other children and their families.  Camden LSCB should seek evidence from member agencies as to the way in which all those who work with parents during antenatal care and children under the age of one year deliver information to parents about the danger of shaking small babies.  Evidence should be provided in particular about how information is given to parents who are vulnerable and under conspicuous stress.   31 The LSCB should monitor the effectiveness of provision made.   3.3. An account of the services, the way in which agencies worked together and how this reflected the wider provision for vulnerable children in Camden 3.3.1. As well as learning from shortcomings, the review is required to identify aspects of service provision that were effective.8 3.3.2. In the main the review shows individual professionals working well and the arrangements for assessment of the needs of vulnerable children operating effectively. Individuals and agencies largely worked in line with expected procedures and there are examples of good collaborative practice and information sharing.  3.3.3. There are numerous points when services were effective:  Antenatal provision began early in the pregnancy  The antenatal care service responded effectively to the mother’s emotional needs and referred the mother to the perinatal service at a correct threshold. This allowed the service to assess her needs even though it did not lead to service provision at that point   There was a good psychiatric evaluation when the mother presented with suicidal thoughts late in her pregnancy, resulting in referrals to social care and the mental health crisis team   This was followed up by a good level of immediate support from the mental health crisis team   Services (the hospital social work team, the perinatal mental health service and the crisis team) combined to identify the need for a mental health service which could focus on the needs of the mother and her partner as young parents  Discharge and post-natal midwifery care arrangements meant that there was continuity of service, even though the family moved between Camden and the borough where the mother’s family lived  There was a good assessment by the YPS and regular appointments seeking to address a growing number of problems presented by the parents  The police responded in a timely way to reports of domestic abuse, managed the circumstances in the correct way and shared information with other agencies  Information gathering and triage by the multi-agency safeguarding hub (MASH) took place in a timely way and identified the likely level of need and arrangements for assessment correctly                                             8 Good practice should be shared so that there is a growing understanding of what works well’ Working Together to Safeguard Children 2015 ‘ (Section 4.1)   32  There was effective planning of the social care child and family assessment and a timely visit by two social workers soon after the domestic abuse incident  On several occasions professionals made careful observation of the child and the parents’ interactions with Child B and one another. It is hard to do this with a small baby, on short appointments, if the baby is asleep for some or all of the time  At the point when Child B was injured a number of services were being put in place which could have had a positive impact on the parents. The overall pattern of service provision 3.3.4. The parents were known to services in Camden for approximately 11 months, the mother’s pregnancy and the first two months of Child B’s life. The case was perceived to have some complications, but not a very high level of risk.  3.3.5. The narrative identifies a large number of services and individual professionals who were involved. (perinatal mental health, hospital social work, mental health crisis team, MASH, child and family assessment team, family support worker, YPS, Camden Safety Network). Two further referrals to mental health services had been made at the time when Child B was injured and the parents were waiting for appointments. This is illustrated by the table on page 34. 3.3.6. The difficulties faced by Child B’s parents were not unusually complex. However services have very specialist functions. All framed their involvement according to specific referral criteria. This means that cases can pass very rapidly from one professional to another, increasing the risk that information is not shared comprehensively. This pattern of provision is an outcome of the way in which many services have been planned and commissioned over the last 15 years, often drawing on different funding streams to meet specific needs.  3.3.7. The journey of Child B and her parents reflects the tendency in current arrangements to limit involvement to the specific purpose of the service, and to hand over cases once a particular task is completed. Services want to ‘step down’ cases to deal with a problem in the least intrusive way through the lowest level service which can meet needs. This increases the number of assessments that take place and puts the onus on everyone involved to make the right assessment the first time they have contact with the family. Many of the teams and organisations are small and have limited resources for supervision and oversight. It is widely recognised that risk increases the more complex and fragmented an operation is.9                                              9 David Woods et al (2010) Behind Human Error, second edition, especially Chapter 4   33 3.3.8. The current pattern of service provision also creates difficulties for service users. It requires them to build sequential relationships with a large number of professionals. This is inherently difficult for young adults, especially those living in stressful environments and those who have had a fragmented upbringing to do.    This is a significant lesson of the review, though it is not one that can be turned into a specific recommendation with a measureable outcome. Awareness of this pattern of service provision and its impact on service users should inform future service design and commissioning. When new services are commissioned at the very least they should not make the pattern of health and family support provision for vulnerable families more complex.          34 Involvement of agencies with Child B and her parents   June 2013  Jan 2014 Aug 2014 Sept 2014 Oct 2014 Nov  2014 Father GP      Mother GP      UCLH antenatal      Police      PA      UCLH perinatal service      Liaison psychiatry       C&I crisis team      UCLH social work      CAMHS YPS      UCLH perinatal service      Other  midwives      RFH midwives      Health visitor      Police       MASH      Children  Centre      FSSW assessment team      Camden Safety Network                        Beginning of  antenatal care  Birth of  child B Reported domestic  abuse incident Injury to  child B  Lines illustrate the period during which agencies were involved and (by the thickness of the line) the intensity of involvement. Solid lines indicate regular contact; dashed lines indicate sporadic involvement with the family, though there may have been contacts with other professionals.  35 3.4. Referral arrangements for ante-natal care and the sharing of information between GPs and antenatal services 3.4.1. The mother’s GP records contained potentially important historical information about her mental health, showing that she had experienced mild, brief episodes of anxiety and depression. The information is not detailed and it is largely based on self-report. As a teenager the mother had been seen briefly by the local CAMHS service which had begun to explore the idea that she might have an emerging personality disorder.  3.4.2. This information is visible on the opening summary screen of the GP record. It was never known to the antenatal service or used to inform assessment. Had this happened it may have positively influenced the mother’s early antenatal care and led to a better informed referral to the perinatal mental health service. The review has sought to understand why this happened and how reliable the system for sharing psycho-social background information between GP records and antenatal services is. 3.4.3. Child B’s mother made a self-referral for antenatal care very early in her pregnancy. She used the North Central London Maternity Services Referral Form, which is used for both GP and self-referrals across ante-natal services in North London and can be downloaded from the UCLH website. A copy of the form is reproduced in Appendix III.  3.4.4. The mother’s self-referral has the comment N/A (not applicable) against all of the standard questions about relevant social, medical and mental health history, whereas in fact her history included a number of potentially important psycho-social risk factors. The mother revealed some of her background and difficulties at the antenatal booking appointment and more became apparent late in the pregnancy. 3.4.5. The UCLH midwifery service erroneously thought that the mother’s ante natal booking had been made by the GP, though there are strong clues on the form that it was a self-referral. The main reason given to the review was that ‘the form was typed’, though that is unlikely to be a rare occurrence. The service believed that the information in the section about the mother’s obstetric, social and psychological history indicated that she had no complicating background social problems. The GP was never sent a copy of the form, because the hospital believed that it came from the surgery. The GP was not notified about the mother’s arrangements for antenatal care until the fourth month of the pregnancy and was not asked to provide additional information.  3.4.6. It has been identified that a screen in the antenatal service patient record which triggers information sharing with GPs can be bypassed   36 and the review has been told that Camden GPs have previously registered concerns to the hospital about this happening. 3.4.7. The combination of these factors created two sets of risks which could apply more widely. First, relevant information in the mother’s GP record that might be relevant was not conveyed to those who are caring for the mother and assessing any risk to the infant. Second, the mother’s GP was not provided with full details of her pregnancy and antenatal care for some months. 3.4.8. Maternity services at hospitals which provide the entire package of antenatal care are more vulnerable to gaps in information sharing than hospitals where midwives work closely with the mother’s GP, share responsibility for antenatal care and may even have direct access to GP records. This approach is not possible at UCLH where 70% of mothers live outside of the borough of Camden, or at other large London hospital maternity units. They rely on written means of information sharing. 3.4.9. Although antenatal self-referral may lead to risks in some cases it is an established part of the way in which antenatal care is provided, an established ‘patient right’ and an approach with lots of positives for women. The challenge is to make arrangements as safe as they can be. 3.4.10. The current form is not suitable for self-referral because it provides no guidance to a woman completing it as to what sort of information might be relevant. A form which can be so easily confused is increasing the risk to mothers and infants. There is a very strong case that it should be redesigned, possibly creating different forms which suit different purposes.10 3.4.11. The serious case review recognises that to a degree antenatal services rely on self-disclosure by parents, and that information about risks may be concealed. This underlines the need for GPs to identify relevant information and for antenatal services and GPs to communicate openly. 3.4.12. Currently there is no systematic knowledge about how reliably important information about risk factors is communicated by GPs to the antenatal services and how often this does not happen and results in risk. This could be audited.                                              10 In fact it appears that although UCLH uses the GP referral form for self-referrals, other hospitals in the North Central London Maternity Services group have already replaced this with a much more suitable web-based self-referral mechanism. North Middlesex Hospital http://www.ace4training.com/maternity/Default.aspx and Royal Free Hospital https://www.royalfree.nhs.uk/services/services-a-z/maternity-services/self-referral-form/ Neither risks perpetuating the confusion as they do not ask the patient to comment on her own medical and social history.   37 3.4.13. NHS England is responsible for the quality of GP services. The Clinical Commissioning Group (CCG) has trained GPs to be aware of the value of historical information held in GP records about medical, social and environmental risk factors and to communicate it to the antenatal service. This is evidently a message that needs to be underlined.    Camden LSCB should seek evidence from the health commissioners, GPs and providers of antenatal care in Camden that 1) GPs are consistently including relevant information about psycho-social risk in antenatal referrals 2) Camden’s hospitals and patients’ GPs use reliable systems for sharing information and ask for relevant information about psycho-social risk factors 3) The forms for maternity referral and self-referral are fit for purpose.  3.5. Screening for domestic abuse during antenatal care 3.5.1. Screening for a history of domestic abuse should be normal practice in antenatal services. This arises from research about the common onset or reoccurrence of domestic abuse in pregnancy and the vulnerability of mothers and children during the first months of life.11 There are recommended standard screening questions. 3.5.2. UCLH says that its midwives make these enquiries at the booking appointment if there is an opportunity to do so (i.e. the father is not present) though it does not collect data to monitor compliance. The appointment is not structured to enable this to happen, but relies on the midwife creating an opportunity to be alone with the woman (for example by asking the father / partner to leave the room temporarily and book the next appointment). 3.5.3. It is recognised that this is not an easy issue to broach, however current arrangements seem ad hoc, and not likely to maximise compliance. They risk being viewed as ‘underhand’ in an area where trust needs to be paramount.  3.5.4. In parallel to this requirement there has, since 2009, been a very strong government-led drive to maximise the involvement of fathers /                                             11 Royal College of Midwives (2012) Maternal Emotional Wellbeing and Infant Development.   38 male partners in maternity and early child health services.12 There is inevitably a tension in practice between this and the desire to offer women a confidential opportunity to provide information about domestic abuse. If conflicting social policy objectives are to be reconciled it cannot be done by front line staff and requires clear expectations from senior staff in the hospital which will be reflected in local procedures 3.5.5. Policy at UCLH is that if there is no opportunity to ask the domestic abuse screening questions at antenatal booking, it is not automatically revisited at a later appointment. This is only done if the midwife thinks it may be relevant. It is not known if there is data to confirm how often this in fact happens. The suggestion is that the threshold would be set quite high (i.e. the midwife has identified it as being an area that needs to be covered because she has a concern) rather than it being a routine review of an area not covered.  3.5.6. At UCLH the domestic abuse screening is scheduled only for the booking appointment and is not routinely repeated later in the pregnancy. This is not in keeping with the spirit of professional guidance which indicates that ‘women identified the importance of ... repeated opportunities for disclosure’.13 Policy and practice on this varies between hospitals. Some hospitals routinely repeat the screening as a means of identifying women who are first victims at a later point during pregnancy.    Camden LSCB should seek evidence from the commissioners and providers of antenatal care in Camden that 1) policy, procedures and training enable professionals in the ante-natal service to speak individually to women about possible domestic abuse at their antenatal booking appointment and later in pregnancy 2) policy is complied with 3) this results services being provided and, in appropriate cases, in referrals being made to the local authority                                             12 ‘The contribution that fathers make to their children’s development, health and wellbeing is important, but services do not do enough to recognise or support them. Research shows that a father’s behaviour, beliefs and aspirations can profoundly influence the health and wellbeing of both mother and child in positive and negative ways.’ Maternity and child health services are used to working mainly with mothers, and this has an impact on their ability to engage with fathers. Fathers should be routinely invited to participate in child health reviews, and should have their needs assessed.’ Department of Health (2009) Healthy Child Programme – Pregnancy and the First Five Years. 13 Royal College of Midwives (2012) page 10   39 4) there is consistent practice across Camden, unless there are sound local reasons.    3.6. The availability of perinatal mental health services in Camden Involvement of the perinatal service 3.6.1. Child B’s mother was referred to the UCLH perinatal service at 34 weeks. An earlier referral might have been made if the UCLH antenatal service had had more information about the mother’s history (see section 3.4 above). 3.6.2. Based on the information received, the mother’s circumstances did not meet the criteria for perinatal service provision and a decision was made to advise the mother to go back to her GP to seek a referral for an alternative service such as counselling. A service offer would have been more likely if the perinatal referral had been informed by more detailed knowledge of the mother’s previous mental health problems (see section 3.4). 3.6.3. The mother and the GP were told that the referral had been made and expected it to be progressed. A member of the perinatal service tried to inform the mother of its decision not to offer a service by phone but there is no evidence that correspondence was sent. The mother’s later comments suggest that she continued to believe that she was waiting to hear from the perinatal service. The impression given is that the small team relied on the clinicians to contact service users and write letters to GPs. It is not clear to the review whether the level of administrative support is adequate or this is the best use of limited clinician time. 3.6.4. Shortly before Child B’s birth the perinatal service became involved when messages for the service were left by the mental health crisis team. As a result a member of the perinatal service spoke to the mother and brokered a referral to the YPS.  3.6.5. The UCLH antenatal service, the UCLH perinatal service and the hospital social work service all worked closely and flexibly with a good mutual understanding of roles and the potential value of different services. They all understood what the YPS could offer and valued its work, based on previous contacts.    40 Evaluation of the provision made 3.6.6. There are concerns about the scope and level of resources available to the UCLH perinatal mental health team and the provision of such services across Camden. 3.6.7. The UCLH service has a limited resource in the face of a large number of referrals about women from Camden and other boroughs.14 Perinatal mental health services are designed to address the needs of women during pregnancy and in the first months after birth. Camden’s services only receive referrals during pregnancy making it, in effect, an antenatal service. This may have limited the effectiveness of the provision to Child B’s mother and added to the fragmentation of services described in Section 3.2. 3.6.8. The UCLH perinatal service worked to its current brief, and had limited involvement. All participants in the review spoke very positively about the value of the service, both in relation to its work with patients and role in linking with other services. However professionals who work outside the hospital find the differences in arrangements and referral routes in different parts of the borough confusing.  3.6.9. Colleagues in the mental health crisis team were less familiar with the role and location of the perinatal service. They are based in a different trust and use a different NHS recording system, so cannot automatically share information. They found it hard to identify which perinatal service had been involved and were never able to make direct contact with the team (so left voicemails). No one from outside the service that the review spoke to had an accurate, comprehensive view of perinatal mental health provision across Camden. Wider mental health provision for young parents 3.6.10. The parents had contact with or were referred to the UCLH perinatal service, Emergency Department psychiatric liaison team, Camden and Islington crisis team, YPS and I-Cope in a space of about five months. It is very positive that at present Camden does have services for young parents, at a point in their lives when they are likely to need them, and that they do not need to be suffering from a severe or enduring mental health problem in order to be able to access services. This should be valued and protected. However it is clear                                             14 It consists of the following: sessions from a consultant psychiatrist, whose focus is on patients with previous diagnosed disorders and severe conditions more likely to require medication; a psychologist who will offer psychological treatment programmes; a counsellor offering a service for women with moderate mental health difficulties and complex social needs and a bereavement psychotherapist specialising in pregnancy loss.   41 that these services are fragmented which is not efficient and will not be easy for service users to understand. 3.6.11. The serious case review has been told that a review of perinatal mental health service provision is already under way. 15 The findings of the serious case review strengthen the need for this review and may have highlighted new areas that need to be considered.    Camden LSCB should work with health commissioners and providers to seek to ensure that stablish a perinatal service in Camden that  1) accepts post-natal as well as antenatal referrals  2) is consistent across the borough  3) maintains existing strong links with antenatal services and the borough’s social care and early help services.    3.7. Local authority provision of child and family assessment under Section 17 of Children Act 1989 and the functions of the Multi-Agency Safeguarding Hub (MASH) 3.7.1. This section of the report evaluates the effectiveness of the child and family assessment that took place in relation to Child B and reflects on the current arrangements for such assessments in Camden. 16 It considers the following:  Opportunities for a pre-birth or early child and family assessment  The quality of the child and family assessment and the reasons that there were gaps in it  The implications of the requirement to make child and family assessment ‘proportionate’  The workload of the allocated social worker  Factors affecting the assessment team  The role of the assessment team within the wider service, including the MASH 3.7.2. This section focuses on the local authority. Section 3.8 addresses the involvement of other agencies in social care child and family assessment.                                             15 The 1001 day programme 16 Working Together to Safeguard Children (2015) pages 16-28. The child and family assessment replaced initial and core assessment. Further detail is provided in Section 3.8   42 Pre-birth and early child and family assessment 3.7.3. In 2014 Camden had a policy of undertaking a pre-birth assessment when a pregnant woman who was in touch with services had been a looked after child. This local approach had been agreed as a result of an earlier serious case review. It was not implemented in this case as the referral to the hospital social work team came only very shortly before the mother’s due date. It was also received late on a Friday afternoon, at the beginning of a bank holiday weekend, during which the mother received a considerable amount of support from the mental health crisis team and after which she was referred to the YPS, which began its own assessment. 3.7.4. It is possible that the mother’s status as a care leaver could have been identified earlier if this had been asked as part of the screening at the antenatal booking appointment or if the local authority where she grew up had notified agencies in Camden. 3.7.5. If the local authority considers that having been a looked after child is a good marker for vulnerability in young parents, the practice of routinely undertaking a pre-birth assessment should continue, unless there are good reasons not to do so, which should be recorded in a specific case and authorised by a manager. The local authority recognises that balance that has to be found between identifying parents who need additional support and the risk of stigmatising a person just because they lived in care. Regardless of policy no pre-birth assessment can take place without the informed agreement and engagement of the parent. 3.7.6. There was uncertainty about whether the policy applied only to Camden care leavers. Logically the practice should apply to all care leavers who come into contact with the local authority and not just to Camden care leavers. Obtaining a history from the authority where the young person had been looked after should be obligatory. Consideration should also be given to identifying whether the father or partner has been looked after. Earlier child and family assessment 3.7.7. Although there was no scope in practice for a pre-birth assessment, there could have been an earlier social care child and family assessment. However this would have overlapped with the initial assessment undertaken at the YPS, which bearing in mind the parents had a new born infant and were moving between their home in Camden and their extended family, is unlikely to have been achievable or useful.  3.7.8. The decision for the local authority not to assess the child’s needs at this point was made in the knowledge of the YPS involvement, but   43 without discussion with the YPS. It makes sense that when one form of assessment is abandoned in favour of another, there should be a discussion between the services involved.   Camden should clarify and confirm its policy in relation to the pre-birth assessment of parents who have been looked after. If UCLH antenatal screening at the booking appointment does not currently ask if either parent has been in care or looked after, this should be considered.    3.7.9. Separately the local authority where Child B was looked after has recognised that when a young person who is receiving services from the leaving care service moves to another local authority area or there are significant developments in the young person’s life, it should inform that local authority. There is a similar need to balance the desire to support a vulnerable person with the need to avoid stigmatising a young person just because they have been in care. Child and Family Assessment 3.7.10. A child and family assessment started immediately after the episode of domestic violence. It began on 1 October 2014 and was signed off by the assessment team manager approximately four weeks later. The case remained open to the local authority at the point when Child B was injured as there was a plan to present information to the borough’s early help panel in order to allocate a lead professional. The injuries to Child B meant that this did not happen as other steps were required to protect her.  3.7.11. Camden’s social work service has very comprehensive policy and guidance materials on assessment.17 Its procedure specifies that at the start of the assessment a social work manager gives bullet point directions highlighting the areas to be covered by the social worker. This is done by the duty assessment manager, and because of the way in which the assessment service is organised this will normally be the social worker’s supervisor. It was not in this case, though that was not significant at that point. 3.7.12. The directions given in relation to Child B were comprehensive but not all of the areas specified were covered in the subsequent                                             17 Camden Council (2013) Family Services and Social Work: Assessment policy and practice guidance (revised for implementation December 2014)   44 assessment. As the assessment progressed it became more ‘proportionate’ (the use and meaning of this term is discussed below). Procedure within the team was that the assessment was reviewed by a manager at the half way point, and then authorised by a manager at the end. Both endorsed its findings. 3.7.13. The following gaps have been identified in this assessment:  No check was made with the local authority where the mother grew up  The parents were not seen individually as part of a more formal risk assessment in relation to domestic violence  There was no contact with extended family members  There was no contact with the mother’s GP  No information was obtained about the father’s background from his GP (or from some brief local authority records now known to exist about his younger siblings)  The outcome of the assessment was not shared with all of the agencies who had been involved. 3.7.14. These gaps reflect the thinking of the review team and take account of the directions given at the beginning of the assessment, the local authority guidance documents and thinking about what constitutes a good assessment in relation to a domestic abuse case.  3.7.15. In this case there is no reason to believe that gathering further information on the other areas would have substantially altered the assessment or the plan of service provision. In other circumstances it would do, so it is important to understand the reasons why this happened. As the assessment was endorsed these are gaps in the work of the local authority as a whole. Proportionate assessment 3.7.16. The local authority policy and guidance on assessment is detailed and comprehensive. In turn it references a number of linked documents on specific aspects of assessment and tools to establish the views of children. However based on the assessment produced on Child B, the department’s own auditing and the views expressed to the review, there is often a gap between the aspirations contained in the policy and the day to day reality of the work of the assessment team.  3.7.17. Work is always constrained by capacity and agreement on what in any given case constitutes a proportionate assessment. This concept is found in statutory guidance and requires local authorities to have publish protocols which ensure that ‘assessments are timely, transparent and proportionate to the needs of individual children and   45 their families’.18 This approach replaced the previous distinction between an initial assessment (targeted to be completed within 8 working days) which might lead onto a core assessment (targeted to be completed within 35 working days). It has its origin in the reforms proposed by Professor Eileen Munro.19 3.7.18. The maximum targeted time for child and family assessment is 45 working days, but responsibility is placed on social workers and managers to determine how detailed the assessment needs to be based on the specific issues that need to be explored in the case and to agree a timescale for its completion accordingly. It was recognised at the outset that the assessment of Child B’s case would not be straightforward and an estimate of 15 days was given. At a midway review (13 days into the assessment) the time frame was extended but it was agreed that it should take no longer than 20 days. 3.7.19. Munro’s reforms were largely welcomed because they were designed to enable the issue of proportionality to be addressed by professional judgement, rather than procedural or performance management requirements. In practice procedures, managerial requirements and resource constraints are never absent. Although social care assessment has in theory moved away from adherence to rigid timescales for initial and core assessment, the large number of cases currently requiring assessment in local authorities means that there still needs to be an emphasis on overall efficiency and finishing work in a timely way (which is good for children and necessary for the overall running of the service). Proportionate assessment contains an element of compromise and will not always allow a thorough exploration of every aspect of the child’s circumstances.  3.7.20. Pressure of work in the assessment service in Camden has also made it harder for managers and staff to develop consistent approaches to assessment. By mid-2014 the authority had not decided which of a number of developing approaches to assessment (including innovations such as ‘Signs of Safety’)20 it wished to use as its standard approach. Discussions with social workers and their managers highlighted this uncertainty about the local authority’s preferred assessment framework. By early 2015 the authority was actively developing a Camden model of social work which was addressing this question. 3.7.21. The need for proportionate assessment in the context of a heavy bombardment of cases does not explain every aspect of individual                                             18 Working Together to Safeguard Children 2013 / 2015 19 http://munroturnellmurphy.com/englandinnovations/  20 http://www.nspcc.org.uk/services-and-resources/research-and-resources/signs-of-safety-model-england/    46 practice. There will always be differences between individual workers and some will always be more instinctively curious and thorough than others. However it would be unwise not to note how the weight attached to proportionality is now shaping the way that social workers practice and to recognise that it brings its own risks. Factors affecting the individual worker 3.7.22. Pressures on the allocated social worker were important. In October 2014 the worker allocated the assessment of Child B had a caseload of about 20 children’s assessments. This was fairly typical for her and her caseload remained the same in May 2015. It was the largest in the assessment team. As the caseload is counted by the number of children it can be a poor guide to the actual workload. A caseload of 20 will also include work completed but not fully written up, authorised or closed.  3.7.23. In October 2014 the allocated worker’s caseload was unusually difficult in that it included one very complex case that required preparation for a court hearing and at least two other cases which involved child protection concerns (both of which involved strategy meetings chaired by senior managers). The scope of the work was within the worker’s range of experience but there was an accumulation of more complex work than would have been expected at any one time. 3.7.24. Delays in accomplishing some aspects of the work in relation to Child B were the result of 1) the family staying temporarily with extended family 2) the way in which work was structured within the assessment team as there are inevitably times when workers are on duty when it is difficult to start or progress allocated work 3) other work that was seen as being more risky being prioritised after the initial visit to Child B’s family on 1 October. 3.7.25. There is a wider problem of delays caused by the time it takes to receive information back from other agencies. This is experienced by the assessment team as a whole and is discussed in Section 3.8. Factors affecting the assessment team 3.7.26. The assessment team had less capacity than normal at this time as two of the four managers in the team had periods of absence, disrupting the pattern of supervision of tasks. As a result rather than one manager taking responsibility for all three phases of the set-up, midway review and sign off of the assessment of Child B, three managers were involved. This is likely to have made it more difficult to keep in mind the original referred problem and to identify and challenge gaps in the assessment.   47 3.7.27. The allocated worker had had a consistent supervisor since January 2014 but outside of that relationship there had been a number of changes in management roles in the assessment service in 2014. These followed the decision to create a MASH which led to changes in the existing duty and assessment teams.  3.7.28. All of these individual and team factors will be recognisable to any local authority duty or assessment service, as will the difficulties sometimes experienced in working with other agencies set out in section 3.8. Assessment as part of wider systems including the MASH 3.7.29. The purpose of the MASH is to enable the local authority and partners to be able to pool information quickly and make well informed decisions about the level and type of further assessment or support that is needed. Cases are the subject of checks among participating agencies, once parental consent has been obtained. The referral from the police on the domestic violence incident was triaged in the Camden MASH and given an amber (medium) rating.  3.7.30. The Camden MASH process is deliberately swift. The target is to triage urgent contacts within four hours. Priority for checks with other agencies in the MASH has been given to cases where the RAG rating is more difficult to determine. When – as in this case - it is clear that a child and family assessment is required there is relatively limited gathering of additional information or notification to other agencies and responsibility for gathering information from other agencies passes to the allocated social worker in the assessment team. In this case the MASH identified the health visitor and the YPS as professionals who were involved. It informed them of the domestic abuse incident and of the fact that there would be a social care family assessment.  3.7.31. After the case had been processed by the MASH it took some time for the social worker to initiate further multi-agency information gathering. The allocated social worker also took some time to identify agencies / professionals involved. This is considered in section 3.8 below. 3.7.32. During 2014 - 15 a large proportion (62%) of cases triaged by the MASH were being passed to the assessment team for a child and family assessment.21 The service manager who is responsible for the MASH and the assessment service reported 1507 completed child and family assessments during a 10 month period. As many as 35% of                                             21 Camden MASH management information April 2015   48 child and family assessments are closed leading to no further action at the end of the assessment period. 3.7.33. In summary 1) a very high percentage of the cases dealt with by the MASH lead to a child and family assessment 2) there is a large number of referrals to the assessment service and 3) a high percentage of assessments that do not lead to a service being provided by the local authority or a requirement for allocation of a social worker to coordinate a child in need plan.  3.7.34. The local authority has recognised that some cases opened for child and family assessment do not require or benefit from that assessment, though numbers have not been quantified. The review was told that social workers in the assessment service ‘all have cases’ that in their judgement do not require assessment.  3.7.35. It is outside the scope of this review to evaluate in more detail the nature of these cases and the circumstances that lead them to be referred to the assessment team. This has been identified as a difficulty and steps have been taken to reduce the number of cases being referred for assessment unnecessarily; however there appears to be more scope for this. 3.7.36. This is not necessarily easy because the MASH itself is part of wider systems with other influences. There are very large numbers of domestic abuse referrals to the local authority. Unlike some boroughs Camden uses its MASH as the first point of multi-agency screening. Camden MASH does not make its own visits to families, which would inevitably screen out some cases that are currently being passed to the assessment team.  3.7.37. Diverting work away from the MASH or away from the assessment service relies on the existence of other reliable assessment mechanisms and staff (most likely within early help services) who are able to use them. 3.7.38. It should not be at all surprising to find that there is a need for adjustments in arrangements for triage and assessment following the introduction of the MASH, which has existed for less than a year. Along with similar bodies across London, it is in a state of evolution and learning. The SCR has examined one case. Learning from this review should be taken into account in that wider evaluation. Wider evidence on assessment quality 3.7.39. The local authority has carried out a programme of audit on the quality of assessments since 2012. Two summary reports have been prepared covering 2012-13 and 2013-14. They involve front line staff, managers and reviewing officers with an independent role.    49 3.7.40. Audits and management oversight indicate that in comparison to 2012 – 14 there were (at the time of the review) fewer delays in allocating and commencing assessments and that timescales for the completion of assessments were being reduced. The multi-agency aspect of assessment (receiving information from other agencies and working jointly with other professionals) remains an area in which services still need to be improved, as does assessment work in cases of domestic violence. 3.7.41. Overall however the service manager believes that there has been improvement in the thoroughness and timeliness of assessments and that caseloads in the service are being brought to a more manageable level by enabling workers to close work sooner.  3.7.42. The review has made the following recommendations to the local authority and the LSCB.   The Director of Children’s Services should make expectations about ‘proportionate’ child and family assessment explicit to staff in the local authority and this should be reflected in policy documents and training. The local authority should in turn make these expectations clear to partner agencies.  The local authority should review the current outcomes of work conducted by the assessment team to establish whether a proportion of the assessments were unnecessary or might have been better conducted in another part of the network of children’s services. This should be the subject of regular review. The local authority should consider how it can reduce the number of cases being referred to the assessment team from the MASH. In turn that might lead to review of the activity in the MASH. It is recognised that the MASH is a relatively new service which is learning and evolving, along with other similar services across London. Learning from the case review should be taken into account   3.8. Multi-agency aspects of social care assessment  3.8.1. Working Together to 2015 requires the local authority social worker to ‘lead a multi-agency assessment under section 17 of the Children Act 1989’. When the local authority decides to provide services, ‘a   50 multi-agency child in need plan should be developed which sets out which agencies will provide which services to the child and family’.22  3.8.2. The review has found that there was scope for improvement in the multi-agency aspects of the child and family assessment of Child B’s circumstances. Camden’s own quality audits of social care assessments indicate that this reflects a wider pattern. 3.8.3. Three issues are highlighted by the individual case: 1) the time taken by the local authority to gather information from partner agencies during the assessment 2) how partner agencies contribute to the child and family assessment and whether this is as effective as it could have been 3) how differences in views about decisions made during the assessment are resolved and plans agreed. The role of ‘network checks’ made by the assessment team 3.8.4. The local authority assessment team has arrangements for obtaining information from other agencies prior to and during the assessment, but this information is often not obtained as efficiently as it needs to be.  3.8.5. Parental consent to obtain information from other agencies is obtained from the parent(s) by the MASH. This will be done over the phone. The process will then be repeated by the assessment team during its initial visit to the family. This enables consent to be given in writing and to include all the adults who are seen on that visit. 3.8.6. Early in the assessment the allocated social worker will initiate what are termed ‘network checks’ by phoning or emailing professionals identified from other agencies in order to find out what information they hold about the family and to involve the relevant professional in the assessment. Sometimes at this point social care may not know all the details (or the correct details) of the professionals involved. Records in other agencies are not always immediately available and work providing feedback to the local authority may not be prioritised. 3.8.7. Although there is no systematic evidence, anecdotally this is perceived by the assessment team as frustrating and time-consuming.  3.8.8. In relation to Child B:  The MASH had informed the health visitor about the domestic abuse incident, but there has no contact from the health visiting service for 10 days (though there is now a procedure requiring a faster response time).   The social worker and health visitor only communicated directly about Child B at the very end of the assessment (by which time                                             22 Working Together 2015 (Page 30)   51 the health visitor’s information related to a visit made a month before)  The involvement of YPS was identified by the MASH but the social worker did not make contact with the YPS until 15 days into the assessment period  It was difficult for the social worker to identify the community midwife from the records (because Camden has an unusual way of allocating post-natal midwifery visits which staff in social care did not fully understand) and the check was only made at the end of the assessment period  Checks were never made with the adult mental health service  No checks were made with the local authority where the mother grew up  No check was made with father’s GP 3.8.9. Lack of detailed inter-agency dialogue meant that some assumptions were never tested and discrepancies were not identified. For example the parents gave contradictory information about how positive the role of the maternal grandmother was. This was never revealed as no one knew that other professionals had different information. 3.8.10. These difficulties reflect wider patterns. The 2012-13 quality audit of assessments report noted that ‘there was evidence of good overall interagency working and of permission being sought for network checks. ….Written requests for information (network checks) were usually found on the file but it was not always clear if these had been responded to’. 3.8.11. If the evidence from Child B is correct this has not improved in two years and it has not been improved by the creation of the MASH (in part for the reasons described above). It raises a number of practical questions. If the main initial purpose of the network checks is to establish who is involved and to identify relevant information (rather than to have a detailed professional discussion)  1) does it make sense for the checks with agencies not to be done by the MASH, which is set up for this purpose? 2) if the task sits in the assessment team does the administration of it need to be undertaken by a social worker? The meaning of ‘network checks’ and the nature of the dialogue with partner agencies 3.8.12. The term ‘network checks’ suggests something more superficial than shared working and responsibility. The social care quality audits of assessments have found some very good examples of cross agency working by the assessment team. However if the practice of making network checks is often as described above and the information from other agencies arrives late, there is a risk that it will be given less   52 weight in the assessment, unless it is particularly striking or concerning. When information arrives late there is always a danger that it will be given more weight if it validates the existing view of the case and less when it is at odds with it. 23 3.8.13. The requirement to make assessments proportionate may heighten this danger as there may be a trade-off between receiving all the information and concluding a proportionate assessment. 3.8.14. The review has not established whether there is currently a procedure that says that assessments cannot be completed without full network checks. If there is, the audit suggests that it is not being complied with. If a procedure was introduced it would not in itself solve the problem if there are substantial delays in receiving information or it took a lot of further effort to obtain it. Agencies made assumptions that were never validated 3.8.15. During the social care child and family assessment the critical conversation between agencies was between the YPS worker and the allocated social worker. It took place over the phone, almost three weeks after the beginning of the child and family assessment. 3.8.16. The conversation focused largely on the positive way in which the family had engaged and the services that would be put in place. The YPS worker did not mention that the mother had told her that there had been earlier, similar episodes of violence. She may have assumed that the social worker and / or the police already knew this.  3.8.17. This is a very natural thing to do, made more likely when a discussion has to be hurried. There are ways of structuring conversations (for example by favouring the use of open questions) which reduce the likelihood of discussions which confirm what you already think or fail to challenge the false assumption that someone else already knows what you know. These gather more reliable information but they take more time. 3.8.18. The social worker formed the view that the YPS would be able to work on the domestic violence problems by offering joint and individual sessions, as well as supporting their parenting. The worker had made moves to arrange all of those services, but the package had only just begun to be put together and relied on referrals to a number of other agencies. There were limited family support services available from the children’s centre and the parents had been referred to Homestart, but had not yet engaged. The YPS worker was ‘holding the ring’                                             23 See for example Daniel Kahneman (2011), Thinking, Fast and Slow, Penguin, also Eileen Munro (2008) Effective Child Protection   53 trying to address a range of needs and coordinate provision from a number of sources.  3.8.19. The distinction between a package of services that was in place and just needed to be coordinated and a package of services that had yet to be arranged was not apparent at the time. 3.8.20. It is also clear, but only with the benefit of hindsight, that the YPS assumed that local authority was carrying out a much more comprehensive assessment than was in fact happening. On the basis of previous positive experience it was assumed that the assessment would include discussion with extended family members, comprehensive background and agency checks and several visits to the family. Other professionals held similar assumptions. In fact this assessment comprised of one lengthy initial visit, one unsuccessful visit and one final visit during which the family confirmed that they were finding the help they were receiving useful and would continue to engage.  3.8.21. From the perspective of multi-agency working it is important that professionals in all agencies have realistic expectations about how social care is currently approaching assessment. In discussion between different agencies professionals need to be able to test and challenge assumptions about what others are doing. 3.8.22. Discussions during the review have identified the value of professionals meeting face to face during the course of the child and family assessment. This would make it more likely that assumptions about what others were doing were tested in practice. It would allow the findings of assessments to be discussed and challenged. It would assist in planning the allocation of a lead professional in those cases that were going to be coordinated through the early help arrangements, not least by enabling social care to have an accurate understanding of the level and nature of involvement of other agencies with the family.  3.8.23. The LSCB and member agencies will want to consider whether this is realistic, how it could be achieved and to which cases it should apply.  The local authority should review how the assessment team undertakes network checks and consider whether the burden of this work can be shared with the MASH, or undertaken with less substantial use of professional time.  Partner agencies should agree specific standards for the return of information required by the local authority assessment team, as they do with the MASH.  Agencies should consider how they can increase the role of face to   54 face meetings during the child and family assessment to make the assessment a more shared process and to plan support following completion of the assessment, especially in cases that are going to be ‘stepped down’. It will not be possible to hold such meetings in all cases, so agencies should agree on the sort of cases that should be prioritised.  3.9. The assessment of risk to children following episodes of domestic violence and abuse Overview 3.9.1. Child B’s parents had both had unsettled times as teenagers and they were living in housing that was not ideal. The mother had a history of mild mental health problems. These are commonplace difficulties for many young parents, which in the majority of cases do not adversely affect their capacity to be good parents. Prior to her being seriously injured, the only significant, specific indicator of potential risk to Child B was the incident of domestic violence that took place approximately five weeks earlier. The review has evaluated how this was understood and how agencies responded. The assessment of Child B needs to be considered in the context of the challenge posed by the very large numbers of children referred to the local authority because of concerns about domestic abuse.  3.9.2. Screening and identification of risk from domestic abuse in antenatal care are addressed in Section 3.3 above. Police involvement 3.9.3. The police response to the reported single domestic abuse incident was entirely in keeping with the nature of the incident and police and multi-agency expectations. Information was shared by the police with the MASH and Camden Safety Net in line with procedures and in a timely fashion. The police officer responsible for the intervention gave a very clear account of how he and colleagues deal with domestic abuse. This relied on the involvement of experienced officers and close scrutiny and oversight by more senior officers. His experience was that formal training of constables in response teams was very limited. Information sharing about domestic abuse 3.9.4. The police referred the incident to the local authority and to Camden Safety Net (CSN), the voluntary organisation which offers support for victims of domestic abuse. The local authority received the information summarised in a MERLIN notification. The full details of the CAADA-DASH domestic violence risk assessment are not included   55 in this. The local authority expressed a desire that this should happen in future. This should be explored, though it is recommended that that discussion should take account of wider considerations, set out below, about the huge numbers of MERLIN notifications already made by the police in London. 3.9.5. There was no contact between CSN and the local authority (which was carrying out the child and family assessment). The evidence is that this is a wider pattern as CSN will only communicate with the local authority when it believes that there are safeguarding concerns about a child.  3.9.6. The Royal Free Hospital midwife, who made her final visit after the incident, was not aware that it had taken place. Nor was the mother’s GP who saw her two weeks later. Other than that, information about the incident was known to key staff who were involved around the time of the episode (YPS, social care, health visitor). 3.9.7. The mother gave the YPS worker a fuller account than she gave the police or social care, which confirmed that there had been previous incidents of violence predating the birth of Child B. This was not shared in the one phone call between the YPS worker and the social worker. The possible reasons for this have been discussed in section 3.8. Connecting the assessment of risk from domestic abuse to the assessment of risk to the child – the individual case 3.9.8. The potential risk arising from this incident for Child B was not overlooked or underestimated. Everyone who was aware of the incident viewed it as being serious because of the vulnerability of the baby. No one viewed it as unimportant or not a risk to the child because the assault had only been a slap, though they would have viewed it as being more concerning and even more important if it had been a very violent assault.  3.9.9. The serious case review was challenged at an early point to consider whether the work that was subsequently done had been too focused on the adults’ needs, allowing the focus on the child to be ‘lost’. There is no evidence that this happened. 3.9.10. It is now known that the first reported incident of domestic abuse was not the first. Key staff involved confirmed that they understood that this was likely to have been the case. There is no reason not to believe them; but there is no agency record where this concern is explicitly stated. This is a well-established point of research that is often made in very introductory training about domestic abuse. It is harder to evidence that professionals are always mindful of this knowledge and actively apply it in practice.   56 3.9.11. Common sense dictated that the mother had made the incident worse by hitting the father back, exposing Child B to more risk, rather than immediately protecting her. Professionals were aware of this, but again it was not recorded as an explicit concern which indicated something about her personality and capacity for violence. In one account the mother admitted that there had been episodes (pre-dating the birth of Child B) in which she had hit the father first. 3.9.12. There is reference to the father having ‘anger issues’ and a referral was made for further individual help over this. The referral had been accepted, but he had not been seen by the time Child B was injured. 3.9.13. After the initial management of the incident by the police and screening by the MASH, there was a social care assessment in which the domestic incident was discussed and considered. However no one ever formally revisited the DASH - CAADA domestic violence risk assessment that the police had made. This is important because victims will often give fuller accounts to different professionals or at different times, so risk factors might have been missed. The parents were not seen separately by the local authority. YPS had individual interviews with them, though this was because the father did not attend one session, rather than by design. Connecting the assessment of risk from domestic abuse to the assessment of risk to the child – wider policy and practice 3.9.14. There are very large numbers of referrals to local authority social care services in Camden as a result of domestic abuse. This is a result of the wider identification and lower tolerance that there is for domestic abuse and it is a feature of services everywhere. 3.9.15. In Camden domestic abuse was a presenting concern in 21% (983) of a total of 4677 contacts with the Camden MASH in 2014-2015 and a factor in over 40% of the MASH contacts initiated by the police. Only allegations of physical harm and chastisement occurred more frequently. Many of the incidents that professionals must assess are severe, including very serious injuries being inflicted on women and grave threats to the lives of women and children. 3.9.16. The very large number of MERLIN referrals on domestic violence has implications for services that go beyond the management of individual cases. The need to assess risk in these cases is placing a considerable strain on services and there is a concern that it is disproportionately influencing service provision. In contrast the local authority does not automatically receive information about, screen or assess every child whose parent has a mental health problem, takes drugs, drinks heavily, commits a violent crime or has a learning difficulty. Without downplaying the significance of domestic abuse as a marker for safeguarding concerns about children, there is a case for   57 cautiously revisiting the arrangements for referring such large numbers of contacts over domestic violence to the MASH. If there is a case for that in Camden, the same arguments are likely to apply across London. 3.9.17. Having a general understanding that living with domestic abuse can be harmful for children does not automatically enable professionals to identify the relatively small number where domestic abuse may either directly place children in danger or where it is a marker for other forms of behaviour which may lead to a child being seriously harmed. As domestic violence is very common, but only a proportion of cases will have a severe enough impact to merit a high level of intervention, the challenge is to develop an approach to risk assessment which is sensitive and specific enough accurately to discriminate between children who are at risk and those who are not.  3.9.18. In most local authorities domestic abuse is a significant feature in the lives of a large proportion of the children who are made subject to child protection and child in need plans. In screening and risk assessment terms these can be considered ‘positives’. It is hard to distinguish ‘true positives’ (cases where there was well founded concern) from ‘false positives’ (cases where the concern may have been overstated because those undertaking the assessment have been cautious). The critical thing is that the child remains safe until the perceived risk has been addressed. 3.9.19. Many cases are screened or investigated and although there has been domestic abuse there is judged to be no immediate or serious risk to children. If this proves to be correct, then in terms of screening and risk assessment these can be considered to be ‘true negatives’ (cases where no further substantial intervention was judged to be necessary and the child was not subsequently harmed).  3.9.20. Child B’s case is much more unusual in that the potential impact of an incident of domestic violence which was a marker for risk to the child, may have been underestimated (a ‘false negative’). 3.9.21. The challenge faced by professionals is to improve the sensitivity of assessment of risk in relation to domestic abuse in the context of the very large numbers of children referred because there has been an episode of domestic abuse. This is extremely difficult and it is clear that none of the existing procedures and protocols guarantee success.  3.9.22. The CAADA – DASH risk assessment is designed to identify women who are at a high risk of domestic violence, but only offers the broadest possible indication about risk to children.  3.9.23. The London child protection procedures recommend that the Barnardo’s risk assessment framework should be used where   58 domestic abuse has potential implications for the wellbeing of children. A number of staff and managers involved with Child B referred to this framework or had it in mind, but it was not used. One manager recognised that she had not used the Barnardo’s matrix on the case but stated correctly that if applied it would have strongly suggested provision at the Common Assessment Framework or Child in Need risk level. Even using all of the information that is now available from the case history, this is a correct reading of the matrix and the associated guidance.  The need for a model of service provision that is helpful and safe when couples wish to continue living together. 3.9.24. After the domestic violence episode Child B’s parents wanted to continue to live together.24 A number of the staff and managers interviewed told the review that this as an increasingly common pattern in referrals to their services. 3.9.25. Individual professionals and agencies react to this in different ways. In some circumstances this would be viewed as creating an unacceptable level of risk. In this case this was not so as the parents both appeared to possess a degree of insight into the reasons for their behaviour and a commitment not to act in a way that might place Child B at risk. The YPS accepted this as a legitimate starting point and, as part of its intervention, sought to find ways of working with the father in order to help him understand his anger and control it and with the couple in order to improve their behaviour towards one another.  3.9.26. Other agencies see this as not taking sufficient account of the imbalance of power in relationships where there is abuse and would not engage with the couple. That might be a principled position, but it will leave many individuals unsupported and unprotected, so it is not a position that a service which is part of the statutory network can adopt. It has also led to the commonly recognised problem that couple’s ‘pretend’ to have separated when in reality they continue to live together or see one another regularly, sometimes posing greater risks. 3.9.27. In reality, given the large numbers of referrals in which domestic abuse is a factor, agencies need to develop strategies which will cope safely with a variety of circumstances, informed by research about domestic abuse.                                              24 They did so intermittently even after Child B had been seriously injured.   59 Summary of findings in relation to domestic abuse  3.9.28. In 2009 Camden published a serious case review which focused in part on the risks posed by domestic abuse. Since that review, agencies in Camden have devoted a great deal of service development and training on domestic abuse and its impact on children. This review has identified a series of further issues which the board and member agencies need to address.   The LSCB should consider what further steps should be taken to improve the effectiveness of risk assessment of children affected by domestic abuse and whether these should be included as standard elements in the work of agencies. For example 1) whether as part of the child and family assessment parents should always be seen alone in cases where there has been domestic abuse 2) whether to enable more staff to understand and use the CAADA DASH risk assessment 3) whether more staff should be trained to use the Barnardo’s risk assessment 4) asking the police to share the entire CAADA DASH assessment along with the MERLIN notification in some instances. Camden should initiate a review of the current pathway whereby very large numbers of incidents of domestic abuse which may have impacted on children are referred to the MASH or the local authority, screened and assessed, resulting in a tremendous workload. It may be that such a review is better undertaken as a cross London exercise, particularly as the majority of contacts and referrals are made by the MPS.   3.10. Whether the parents’ positive presentation may have distorted the assessment made by professionals 3.10.1. The review has considered whether what is known as the ‘halo effect’ applied in this case and shaped the assessment in an unhelpful way. The halo effect describes the common human bias which leads individuals to form judgements about other people and situations from early impressions and limited information, which then become difficult to shift. 25 3.10.2. This is a discrete and relatively brief aspect of the evaluation. It reflects the fact that assessment in safeguarding has a strong                                             25 Hence the idea that job interviews may be decided in the first few moments. See for example Daniel Kahneman, Thinking Fast, Thinking Slow (2011) Penguin   60 intuitive element and that awareness of biases that can cause distortion is of value. This will apply to professionals regardless of their professional background. 3.10.3. The over-riding impression that professionals formed of this family was of the parents’ desire to focus on Child B’s needs; their cooperativeness and willingness to engage; their apparent insight into their problems and their willingness to take responsibility for what had happened. Although the extent and nature of professional contact was different, these impressions were shared across agencies.  3.10.4. The critical thing is that this is extremely unusual in comparison to the service users encountered when dealing with domestic abuse and safeguarding, many of whom are much more difficult to engage. Along with other factors, this influenced the extent of the assessment that was undertaken, making professionals satisfied with a less detailed assessment than they might normally have expected to undertake. It may also have made professionals less worried when appointments were not kept.  3.10.5. However this was not a case where progress was illusory and assessment was based on only very superficial observation. Viewed dispassionately this was a case where there was much genuine, positive evidence.  3.10.6. It is useful for knowledge of this potential bias to be integrated into training of practitioners and supervisors.   LSCB and single agency safeguarding training programmes should in future take account of the potential impact of the ‘halo effect’ and other identified biases that may impact on assessment  3.11. Arrangements in Camden for the provision of early help services and the allocation of a lead professional worker Role of the Young Parents Service 3.11.1. Child B’s parents attended a series of appointments with an experienced and qualified worker from the YPS, which is part of the borough’s early help provision. The referral had been made as a result of the involvement of antenatal services, perinatal mental health team and the hospital social work team. All understood what the YPS could provide and, based on experience with other cases, valued its contribution. The parents engaged well with the YPS. This aspect of the borough’s early help service worked well.   61 3.11.2. In 2014 the YPS service was recommissioned on a lower budget, resulting in a reduced management capacity. Staff and managers are disappointed about the reduction in budget to a service that was perceived as being very effective. At the time when this case was open to the service the YPS also had less than normal capacity, resulting from a personal staffing matter. Both were additional pressures on the service though there is no suggestion that either matter impacted directly on the work on this case. Family support capacity 3.11.3. At the second contact with the parents the YPS worker arranged a joint appointment with the children’s centre duty family support worker in order to make a referral for a family support worker. The duty worker stated that there was a long waiting list (which the YPS worker took to mean about two months) before a family support worker could be allocated. Instead the family were signposted (and then referred) to Homestart and a young parents group, though they did not subsequently work with either.  3.11.4. The manager with overall responsibility for family support services expressed disappointment with the response to the potential referral for Child B, recognising that while there are cases that cannot be allocated, it is not the policy of the service to refuse a referral in this way and that there are arrangements for prioritising waiting lists both within the teams linked to individual children’s centres and across the Camden service as a whole.  3.11.5. The YPS worker recognises in hindsight that she should have challenged the response. However none of the professionals interviewed for the case review was surprised that there was a waiting list and none knew of any arrangement for prioritising cases, or the criteria that would be used. Information about this needs to be made clearer. 3.11.6. In September 2014 there were 53 children cases waiting for the allocation of a children’s centre family support worker. The figure had fallen to 33 in mid-June 2015. The number of unallocated cases is highest at the centre that the parents attended and increased during this period. The number of unallocated cases is largely due to the heavy demand for the services, together with the difficulty in attracting and retaining staff and managers. Other managers have been seconded within Camden. There has been a particular difficulty caused by the fact that staff in other services have until recently been paid on higher grades than the children centre staff. This had been resolved by June 2015 so will gradually be less of a factor.    62 3.11.7. The allocation of a family support worker would have been very useful in this case as it would have enabled a worker to spend more time with the family and enabled the YPS worker to concentrate on tasks that required her skills and knowledge. Allocation of lead professional responsibility 3.11.8. The agreed outcome of the social work assessment was that there was no need for an allocated social worker in the children and families social work service and that a lead professional would be allocated at the Early Help Panel (i.e. work with Child B would be ‘stepped down’). Part of the lead professional role is to convene meetings of other professionals involved (referred to as the ‘team around the child and family’). The unstated assumption was that the YPS worker would adopt the lead professional role, though this was never discussed with her. Child B was injured before the panel meeting so it is not clear what would have emerged from this discussion.  3.11.9. It is clear that the YPS worker was the only person who could have been asked to undertake this responsibility. It is much less clear in practice which other professionals would have constituted the ‘team’. The health visitor’s original intention had been to make one more visit before allocating the case to the universal level of provision. This changed after the domestic violence episode. The health visitor had seen the family once and was leaving his post. He had indicated that his successor should make monthly visits. 3.11.10. The review has been told that Camden health visitors and school nurses currently only take on the role of lead professional in a limited number of cases, where the health visitor has identified extra health-focused support needed for a family such as feeding support, a premature baby, child with health or developmental needs or a mother with post-natal depression. Child B’s circumstances would not have matched these criteria. The health visiting service has no internal documents or policies in relation to the lead professional role and no data on how many health visitors or school nurses are taking on the role. 3.11.11. Other services, such as more adult mental health services and Homestart, might have become involved with Child B’s family, but had no current role.  3.11.12. Child B’s circumstances illustrate the difficulties in identifying and allocating a lead professional from family support or other universal services once the social work assessment is completed. This needs to be addressed, and would be assisted by the proposal to introduce a multi-disciplinary meeting during the child and family assessment (see 3.9 above).   63 3.11.13. It is sometimes said or assumed that ‘any professional should be able to take on the lead professional role’ and that it should be a normal expectation for all professionals working with children and young people. There are examples of a range of professionals adopting the role successfully. However there are also significant institutional and practical barriers, not least the increasingly common model of service delivery (referred to in Section 3.2) which dictates that professionals are likely to stay involved with families only while they are carrying out defined tasks.  3.11.14. Review of the training and induction materials used in the children’s centre family support services and discussion with the local authority family support service manager confirm that acting as lead professional requires training and sound support structures, particularly as services are asked to work with more complex families. At the time of writing it is not clear in Camden that this is happening routinely other than through the work of family support workers.  Managing higher levels of risk in early help services 3.11.15. The YPS worker had the most intensive contact with the family and in the absence of a family support worker ended up holding a number of roles with the family. The parents had a range of needs: both parents had experienced some difficulties in their families; there were stresses in environment, housing and neighbourhood; problems of domestic abuse and marital problems; and both parents had mental health problems in the mild to moderate range. The YPS worker was single person therapist, couple therapist, advocate, investigator of services and sign-poster as well as having the core responsibility of helping a vulnerable couple to be better parents.  3.11.16. Early help services in Camden already play a significant role in working with families where there are high levels of need and risk. Given the pressures on social care services previously described there is an aspiration that early help services could and should play an even greater role. As well as being linked to pressure on other services this arises from the legitimate concern to ensure that children and families receive help at the earliest point and in the least intrusive way, i.e. without undue need for assessment by social care. 3.11.17. Depending on the model of service provision this might mean three things in practice:  Early help could be asked to triage or assess cases prior to referral to the MASH    64  The MASH might refer more cases to early help and fewer for children and family assessment   More children and family assessments might lead to a referral to early help, rather than allocation to a social worker as a child in need  3.11.18. Family support service managers told the review that it is becoming more common for the service to be acting as lead professional for children in families with problems of domestic abuse, including families where couples have decided to stay together. This highlights the need for there to be a clear strategy as to the responsibilities of lead professionals linked to strong arrangements for training, support and professional supervision. At present children’s centre family support workers receive induction training on safeguarding, a mandatory one day programme per year on safeguarding and training on working as a lead professional and domestic abuse. Many will attend more safeguarding training and there is regular supervision of work. However if there is an expectation that staff from a range of agencies in the early help service will take on a higher proportion of more difficult and risky work, further consideration needs be to given – across all agencies – to their training needs.  It is noted that a full review of the family support and early help services is taking place and that there are plans to integrate a number of services. Future planning for services should take account of the findings of the SCR, in particular recognising:  The value of skilled professional psychological help for young parents  The value of family support workers and the need to maintain and build capacity  The need for work to overcome the barriers that face some professionals in becoming lead professions and the danger of underestimating the skill and knowledge needed  The need for a clear mechanism for allocation of a lead professional that takes account of actual pattern of agency involvement with children and families There needs to be a recognition that if early help services are to take further responsibility for the assessment of families where there are higher levels of risk as well as coordination of provision, training and supervision need to be further enhanced to match.    65  Appendices Appendix 1 Principles from statutory guidance; Terms of reference and method for carrying out the review Appendix 2 SCR review team and panel members Appendix 3 North Central London antenatal referral form Appendix 4 Designations of staff and managers involved in the SCR Documents and materials considered Appendix 5 References   Appendix I Principles from statutory guidance informing the Serious Case Review method The approach taken to reviews should be proportionate according to the scale and level of complexity of the issues being examined. Reviews of serious cases should be led by individuals who are independent of the case under review and of the organisations whose actions are being reviewed Professionals must be involved fully in reviews and invited to contribute their perspectives without fear of being blamed for actions they took in good faith.  In addition Serious Case Reviews should:  Recognise the complex circumstances in which professionals work together to safeguard children.  Seek to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did.  Seek to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight.  Be transparent about the way data is collected and analysed.  Make use of relevant research and case evidence to inform the findings.    66 Working Together to Safeguard Children 2015 (Sections 4.9 and 4.10)  Scope and focus of the SCR on Child B, updated on 16 February 2015 Time period to be covered This will begin with the mother’s presentation for ante-natal care (December 2013). Earlier events will not be reviewed in detail but professionals will be asked to consider how much additional background information they obtained about the parents. The review period will end when the possibility of serious injuries was identified (November 2014). It will not include subsequent events in detail, however it will take account of additional information obtained in enquiries and assessments that took place after this. Key terms of reference The purpose of the review is to undertake a ‘rigorous, objective analysis…in order to improve services and reduce the risk of future harm to children’. The LSCB is required to ‘translate the findings from reviews into programmes of action which lead to sustainable improvements and the prevention of death, serious injury or harm to children’.26 The key areas to understand are: 1. Did the assessment of need and risk in relation to Child B properly reflect the risks to her? 2. Did the assessment obtain and consider all of the information that could and should have been taken into account? 3. Was the focus of work sufficiently child-centred? 4. What factors influenced the assessment?  Point 4 should be interpreted to include all relevant factors including: 1) presentation of the parents and professional perceptions of need, risk factors and protective factors 2) interaction of the parents with professionals  3) the level of assessment that it was possible and reasonable to undertake 4) movement of the mother and family between Camden and the mother’s home authority  5) availability of relevant background history and steps to obtain it 6) response to the incident of domestic violence  7) supervision and management input  8) the role of the MASH 9) How equipped early help services are to deal with presentations at different levels of need and risk? 10) What if anything was the impact of capacity and workload on the decisions and actions taken? 11) Are there any other professional and organisational factors that made an impact?                                              26 Working Together to Safeguard Children (2013),  4.1 and 4.6   67 Areas for specific enquiry Interviews with staff will attempt to provide a better understanding of the following aspect of service provision Information provided to ante-natal services by GP when booking Information gathering on social and background factors during the ante-natal period The screening for domestic abuse was not carried out at ante-natal booking. Could that have been addressed later in the pregnancy? It would be important to understand the wider level of compliance with this expectation. How effective was the identification of mental health concerns during pregnancy and the response of professionals (to include both ante-natal care and the ED presentation on 28/8/2014)? How were different mental health services (peri-natal, crisis team and later Tavistock staff) working together? What was the relationship between mental health services and hospital social care team during the pregnancy? How did the movement of the parents during pregnancy and after birth affect the provision of services? Do we fully understand the reasons for the mother discharging herself from UCLH after the birth? What were expectations of early help / psychological services in the case? How thorough was the new birth visit on the family? Was this affected by availability of information or movement of the family? What additional service became available as a result of Child B being identified as vulnerable at the new birth visit and did they correspond with the level of need identified? How effective was the response to the domestic violence incident? Was it in keeping with the expected level of response and if not is this a concern more widely? How effective was the response of the MASH? Was it in keeping with the expected level of response?  How did the parental presentation change after the domestic abuse incident? How did the father’s engagement change? Did services deal appropriately with the impact of the domestic abuse incident? How did the professionals perceive the parents’ behaviour – risks and protective factors – and did this impact on professional responses? What was the professional expectation of provision available from “early help” level? Are these services equipped to deal with cases where there is identified risk?   68 How the review was undertaken 1. The review compiled a chronology of key events based on the written and electronic agency records.  2. Terms of reference and initial lines of enquiry were agreed 3. The review team met with professionals and managers who had been involved in the review to explain how it would be conducted 4. Individual interviews were conducted with involved professionals and managers 5. The review team drafted a narrative of events which was discussed with involved staff and amended 6. The review team discussed themes and potential learning arising from the review 7. A document based on this was drafted and presented for discussion with the full review panel, along with the narrative document 8. Themes and potential learning from the review were discussed with the involved professionals and manager 9. Draft report was prepared and circulated to the review panel 10. The Serious Case Review Panel discussed and agreed drafts of the report and recommendations  11. Presentation to the LSCB     69 Appendix II SCR REVIEW TEAM MEMBERSHIP  Keith Ibbetson Independent Lead Reviewer Camden Clinical Commissioning Group Designated Nurse Tavistock and Portman NHS Foundation Trust Consultant Child and Adolescent Psychiatrist  Camden Council Family Support and Social Work Head of Children’s Quality Assurance Camden LSCB LSCB Business Manager  SCR REVIEW PANEL MEMBERSHIP Independent members Laura Eden  (Islington Council) Independent Panel Chair Keith Ibbetson Independent Lead Reviewer  Camden Safeguarding Children Board Development Officer  Camden Safeguarding Children Board Business Manager Agency Designation Clinical Commissioning Group Designated Nurse Designated Doctor Camden Council Assistant Director, FSSW  Head of Children’s Quality Assurance  Head of Service, Children in Need  Team Manager, MOSAIC (Disabled Children’s Team) * Tavistock & Portman NHS Foundation Trust Consultant Child and Adolescent Psychiatrist Another local authority Team Manager, 13+ LAC / Leaving Care Team Detective Inspector  Metropolitan Police Review Group Detective Inspector Child Abuse Investigation Team (CAIT)   70 Appendix III This form can be accessed at the UCLH website  https://www.uclh.nhs.uk/OurServices/ServiceA-Z/WH/MAT/Pages/refer.aspx It is not longer used for self-referral to the North Middlesex Hospital and the Royal Free Hospital   North Central London Maternity Services Referral Form  DATE OF REFERRAL: Please the corresponding box for the hospital the referral is being made to:  Barnet & Chase Farm Fax: 020 8216 5136 Tel:  020 8216 5137 antenatal@bcf.nhs.uk  Edgware Birth Centre Fax: 020 8732 6773 Tel:  020 8732 6777/6669 birthcentre.ech@bcf.nhs.uk   North Middlesex Fax: 020 8887 2934 Tel:  020 8887 2000 # 3055   Royal Free Fax: 020 7830 2752 Tel:  020 7794  0500 # 36169   UCLH Fax: 0203 447 9354 Tel:  0203 447 9400 - ‘Option 1’ antenatalreferrals@uclh.nhs.uk   Whittington Fax: 020 7288 5576     Tel: 020 7288 5586 Whh-tr.maternityreferrals@nhs.net    PLEASE ANSWER ALL QUESTIONS IN BLOCK CAPITALS Surname:  First Name:   All previous surnames: Title: Mrs/ Miss/ Ms/ Other  Date of Birth:                         Age:  NHS number: Address:   Post Code:  Preferred contact tel no: Details of GP:  (name, address, telephone and fax)    Ethnicity:                                                                                                                                                                                                  Interpreter required:   yes / no    Language:                                                                                                      Name and details of referrer if not GP: Signature: LMP:  EDD: Gestation (Wks): Urgent: Yes / No Specify:  Office Use Only  Urgent   Routine  High Risk   Low Risk    71 Past Obstetric history:      Past Gynaecological History:     Past Medical and Surgical History:      Significant psychological history:     Current medication:      Allergies:     Significant family history:     Social concerns and details of social worker if applicable: Other comments  (include letter if needed):    MEDICAL RISK ASSESSMENTS Auscultation Heart:  Auscultation Lungs: Weight (Kg):  Height (cm): BMI: Alcohol History:  Smoking history: BP:  Urine  (protein and glucose):                                                                           The patient should be offered an appointment at the latest by 12/40 or within 2 weeks, if they are referred after 12/40.    72   Appendix IV  Documents and material considered by the Serious Case Review panel Camden Council (2013) Family Services and Social Work: Assessment policy and practice guidance (revised for implementation December 2014) Camden MASH management information April 2015   Designations of staff interviewed or involved in group discussion  Front line staff and managers   Camden Council Family Services and Social Work   Primary care health services (family GPs)  University College Hospital NHS Foundation Trust  Camden and Islington NHS Foundation Trust   Tavistock and Portman NHS Foundation Trust  Royal Free Hospital NHS Foundation Trust   Central and North West London NHS Foundation Trust, which provides the health visiting service for Camden (CNWL)  Other local authority and health trust staff   Staff in policy and strategic roles     Appendix V   73 References  HM Government, (2013 and 20155) Working Together to Safeguard Children  David Woods et al (2010) Behind Human Error, second edition Royal College of Midwives (2012) Maternal Emotional Wellbeing and Infant Development. Department of Health (2009) Healthy Child Programme – Pregnancy and the First Five Years. Daniel Kahneman (2011), Thinking: Fast and Slow, Penguin Eileen Munro (2008) Effective Child Protection Signs of Safety England Innovations Project http://munroturnellmurphy.com/englandinnovations/    Signs of Safety® in England http://www.nspcc.org.uk/services-and-resources/research-and-resources/signs-of-safety-model-england/  