Death of a 7-month-old girl in September 2013; inquest concluded with a finding of unlawful killing. Mother pleaded guilty to infanticide and was made the subject of a hospital treatment order under the Mental Health Act 1983. A psychiatric assessment completed during criminal proceedings described mother to be suffering from the following at the time of the incident: schizoaffective disorder for which mother had avoided treatment through her lifestyle choices and use of alternative coping mechanisms; personality disorder; and mental and behavioural disorders due to use of alcohol-dependence syndrome. Child H was living with mother, father and sibling at the time of the incident. Mother was American and had met father, a British citizen, in India before moving to the UK. Father was considerably older than mother and was receiving ongoing treatment for chronic obstructive pulmonary disease (COPD). Mother had a history of anxiety and depression and was noted to have little support in England; mother was father's sole carer. Identifies themes arising from the SCR, including: insufficient assessment with regard to the impact of mother caring for father upon her and her care of the children; focus of the discussions between agencies in relation to Child H focussing on the mental health needs of mother and physical health needs of father; recognition of symptoms of emerging mental health issues; lack of understanding and use of assessments; and lack of consideration of mother and father's self-identification as 'Spiritual Teachers' on family functioning and family culture/norms. Makes various single and multi-agency recommendations, including: revisions to the Family Support Pathway; and recognising the impact of the presentation of families on professional judgments.
      
 Title:  Serious case review: Child H: overview report. LSCB: Nottingham City Safeguarding Children Board Author: Hayley Frame Date of publication: 2015  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  NCSCB Submission Copy            Serious Case Review  Child H  Overview Report  STRICTLY CONFIDENTIAL        Independent Reviewer: Hayley Frame   Date: 27th February 2015    2  NCSCB Submission Copy   Contents  1. Introduction   2. Methodology   3. Key  4. Summary of Information Known to Agencies and Agency Involvement in Respect of Child H  5. The Family’s experience   6. Analysis including Themes arising from the SCR   7. The experience of the child  8. Expert opinion   9. Changes in Practice and Actions Already Taken  10. Conclusions   11. Recommendations  Glossary of terms Appendix 1: Terms of reference Appendix 2: Single agency recommendations Appendix 3: NCSCB Action Plan               3  NCSCB Submission Copy  1. Introduction 1.1. Serious Case Reviews are always carried out by a Local Safeguarding Children Board (LSCB), when a child dies and abuse or neglect is known or suspected to be a factor in the death. This procedure is laid out in the NCSCB Safeguarding Children Procedures and is in accordance with the expectations set out in the Government guidance, ‘Working Together to Safeguard Children’ 2013.  1.2. This report summarises the findings from a Serious Case Review that was established to consider the professional interventions in respect of a child, who will be referred to as Child H, who died suddenly at the age of 7 months whilst in the care of her mother. Her mother pleaded guilty to infanticide and was made subject of a hospital treatment order under the Mental Health Act 1983.   Reason for Establishing the SCR  1.3. As a result of Child H’s death, the Nottingham City Safeguarding Children Board (NCSCB) Serious Case Review Standing Panel met on 16th October 2013 and considered her case. The Panel agreed that as abuse and neglect were suspected to have been factors in the child’s death, a recommendation should be made that a Serious Case Review (SCR) be undertaken in accordance with ‘Working Together to Safeguard Children’ 2013. This recommendation was agreed by the NCSCB Independent Chair on 29th October 2013.  2. Methodology   2.1. On 14th November 2013, the Serious Case Review Standing Panel met to consider the scope and terms of reference of the SCR.   2.2. In light of the principles outlined within Working Together to Safeguard Children 2013, a bespoke model was developed for the completion of this SCR incorporating agency reports and practitioner participation.   2.3. The model incorporated the principles of chapter 4 of Working Together 2013; namely those contained within paragraph 9 and 10:  • 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 should be involved fully in reviews and invited to contribute their perspectives without fear of being blamed for actions they took in good faith;  • Families, including surviving children, should be invited to contribute to reviews. They should understand how they are 4  NCSCB Submission Copy  going to be involved and their expectations should be managed appropriately and sensitively. • SCRs should be conducted in a way which recognises the complex circumstances in which professionals work together to safeguard children;  • seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did;  • seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight;  • is transparent about the way data is collected and analysed; and makes use of relevant research and case evidence to inform the findings.    2.4. An Independent Reviewer, Hayley Frame, was commissioned to undertake the SCR. Miss Frame is an independent safeguarding consultant and as such is independent of all agencies contributing to the SCR. She has 19 years’ experience within safeguarding, as a practitioner and as a manager at various levels, and is a qualified and registered Social Worker. Miss Frame is experienced in completing serious case reviews and reflective learning reviews.   2.5. A Serious Case Review Panel, to be chaired by Miss Frame, was established consisting of senior managers from the agencies involved in the case. It was agreed that written material would be required from agencies, and as such a combined multi agency chronology was produced and agencies submitted a short agency report outlining the nature of their involvement and considering key issues identified in the case (see below). A briefing event was held to explain the process and the requirements of agencies.   2.6. Reports and chronologies were requested from the following agencies that had knowledge of Child H:   • East Midlands Ambulance Service (EMAS) NHS Trust  • Nottingham CityCare Partnership • NHS Direct • NHS Nottingham City  • Nottingham City Council Children’s Social Care  • Nottingham University Hospitals NHS Trust  • Nottinghamshire Police • Metropolitan Police  2.7. In addition, the school of Child H’s sibling provided a chronology.   2.8. In order to ensure that the SCR considered not only what happened but why, the SCR panel agreed to adopt an approach that engaged directly with practitioners involved in the case. The aim was to ensure that the SCR process enabled an analysis of what the case might be 5  NCSCB Submission Copy  telling us about the wider multi-agency system to ensure that any improvements had a wider impact and that learning was not just focused around issues that were purely case specific. As a result a practitioner panel was held, to which all practitioners and their line managers who had direct involvement in the case were invited. The practitioner panel ensured that opportunity was given to fully understand practice from the viewpoint of the individuals involved at the time. One practitioner, the Health Visitor, was seen separately due to her being on extended leave at the time of the practitioner panel. In addition, the practitioners were asked to give feedback on the overview report, which was considered and incorporated into the final draft.    Serious Case Review Panel   2.9. The SCR Panel membership was as follows:  Hayley Frame Independent Reviewer Head of Safeguarding  East Midlands Ambulance Service NHS Trust Safeguarding Children Lead  NHS Direct Detective Inspector  Nottinghamshire Police Detective Inspector  Metropolitan Police Named Nurse  Nottingham CityCare Partnership Assistant Director of Quality Governance  NHS Nottingham City Service Manager  Nottingham City Council, Children and Families, Social Care  Team Manager Nottingham City Council,Family and Communities (children’s centres)  Named Nurse  Nottingham University Hospitals NHS Trust  Named Midwife Nottingham University Hospitals NHS Trust Solicitor  NCSCB Legal Advisor Service Manager  Safeguarding Partnerships (NCSCB) Children’s Board Officer  NCSCB Administrator  Safeguarding Partnerships   Expert Opinion:  A Consultant Perinatal Psychiatrist was invited to provide expert advice and opinion in relation to this case. The Consultant has had no previous contact with the family. The review has also taken account of the psychiatric assessments of the mother undertaken within the criminal trial, as a source of relevant expert opinion.     6  NCSCB Submission Copy  The time period over which events were reviewed 2.10. The time period covered by the SCR is from 1st June 2012 (to cover the period of pregnancy) to the date of Child H’s death, 1st September 2013. Any relevant information from the time preceding the date of birth is summarised. This period was agreed to ensure learning would focus on the specific issues relating to the mother’s mental health, the impact of her pregnancy and Child H’s birth whilst allowing broader issues to be considered within summaries.  Key Issues 2.11. The scoping of the Terms of Reference identified the following key issues  to be examined by the SCR:  2.12. With regard to the mother: • Support received before and after the birth of Child H  • Any assessments undertaken of her mental health • Her role as a carer for the father and the impact of this upon her parenting and/or mental health • Her presentation and practitioner’s perception and analysis of this  2.13. With regard to the father: • His role within the family including his occupation and beliefs • His physical and mental health and any assessment of the impact of this upon the safety and welfare of the children • His presentation and practitioner’s perception and analysis of this  2.14. With regard to the family: • Evidence of domestic stress relating to parenting, health or finances • Opportunities for early intervention, in particular during March 2013 • Quality of assessments, decision making, referral and communication • Responses to events on the weekend of Child H’s death  Child H’s siblings support needs were also considered by the panel. Very little information relevant to the issues under consideration were identified and therefore, in order to deal sensitively with her confidential information and promote wherever possible her anonymity, only information already in the public domain regarding Child H’s Sibling has been included in this report.   2.15. With regard to agency involvement in the case: • How sensitive were practitioners to the needs of Child H and how equipped were practitioners to work effectively with the family? 7  NCSCB Submission Copy  • Was practice sensitive to the racial, cultural, linguistic and religious identity and any issues of disability within the family? • What was in place to ensure management accountability for decision making and management oversight of the case? Was this effective? • Was work consistent with the agency and the LSCB’s policy and procedures? Were professional standards met? • Were staff involved trained to the appropriate level in safeguarding?  • Were there any contextual issues that impacted upon work in the case i.e. staffing, capacity, sickness, organisational change, resources? • Is there evidence of positive practice?  2.16. With regard to the multi agency system: • Whether the issues identified above have resonance with other similar cases • What the case tells us about: � Any underlying patterns that either support good practice or create conditions in which problematic practice is more likely � How the wider multiagency system is operating  SCR Panel Process and Timetable 2.17. The SCR Panel met on five occasions. The initial meeting was a briefing to provide an overview of the case and agree the process to be used and the expectations in relation to reports and panel meetings. Further panels considered the agency reports; discussed the case in full to analyse the information presented; considered the findings of the SCR and established the learning.   2.18. A Project Plan has been maintained throughout the SCR to ensure clear deadlines. Any changes to these, including completion and submission dates have been communicated to the NCSCB Independent Chair and the Department for Education.   Parallel Processes and Investigations 2.19. Child H’s mother pleaded guilty to infanticide and following the completion of psychiatric assessments was made subject to a hospital treatment order under the Mental Health Act 1983. 2.20. The inquest by the Coroner into Child H’s death concluded on 27th February 2015 with a finding made of unlawful killing.    8  NCSCB Submission Copy  Overview Report Structure  2.21. The Overview Report provides a summary of the information contained within the agency reports, ensuring that key events and issues are captured and analysed. Author’s comments are set out in bold.   2.22. The analysis includes a summary of the author’s comments, analysis of the case against the identified key issues and the themes that have emerged from this SCR.   2.23. There have been a number of developments and actions already taken and these are set out in section 9 prior to the conclusions and recommendations of the report.  3. Key:  Role Key Subject Child  Child H Sibling S1 Mother  M Father  F   4. Summary of Information Known to Agencies and Agency Involvement in Respect of Child H  (Author comments are highlighted in bold)  Information of Relevance prior to the Scoping Period:  4.1. M is an American woman who met F in India. They married in Minnesota USA in 2009. M declared a history of anxiety and depression when she registered with a GP in Nottingham, for which she had been taking diazepam, but did not declare any other mental illness or drug or alcohol abuse, or medical condition. She did not request any prescriptions for diazepam either.   4.2. F is an English man, some considerable years older than M, who spent some of his childhood in India and then again as an adult. F has been known under three other names. It is recorded that F was admitted to hospital in Bristol in 1995 with ‘hysteria’ and a history of heroin addiction in his youth. On registering with the GP in Nottingham, F described his occupation as an aid worker and healer and claimed to have grown up in a ‘tantric’ house, although what was meant by this is not documented.    4.3. F has had ongoing care and treatment of chronic obstructive pulmonary disease (COPD) under the care of respiratory services at since 2010. This has involved inpatient admissions and outpatient appointments. 9  NCSCB Submission Copy  4.4. There has been no prior involvement of the police or children’s social care. The family have not been known to mental health services in the UK.   Summary of Information during the Scoping Period:  4.5. On 19th June 2012, M attended an initial midwifery appointment. M stated during screening questions that there was no history of domestic abuse, mental illness, or drug/alcohol misuse. It was noted that M was a full time carer for F but no discussion regarding his ill health or the impact of caring responsibilities was recorded.   4.6. A request for F to be assessed for a lung transplant was made on 12th July 2012. The outcome of this was that F was not suitable for transplant due to his age. F was admitted to hospital on 26th October 2012 with difficulty breathing, exacerbated by chronic obstructive pulmonary disease (COPD). He was discharged the following day with telephone follow up provided by community nurses. Further correspondence took place in November 2012 regarding potential procedures for F, noting a rapid decline in his condition over the last 2 years.   4.7. A home visit was undertaken by a community nurse on 29th November 2012 following contact from M stating that F was breathless. Red areas to pressure areas were noted. The following day the nurse spoke to M who reported that F was breathing more easily and that the pressure areas looked less inflamed. A referral was made for pressure relieving aids.   4.8. On 12th December 2012, an Occupational Therapist undertook a home visit in order to complete an assessment. M was documented as the carer for F, who assisted him with the majority of activities of living and personal care, including assisting F to transfer. Pressure area damage were noted to F’s elbows and wrists and an agreement was made to order an overlay mattress. On 14th December 2012, M asked that the overlay mattress and perching stool be collected as F did not want them. A visit was offered for that day to apply the mattress but this was declined by M who became upset and put the phone down. A return call was made to M to advise her of the need for the pressure relieving mattress, and M stated that F no longer had pressure sores. Arrangements were made to collect the mattress.   Comment: Two days after pressure sores were noted, M was reporting that they were gone. It does not appear that direct contact took place with F regarding the pressure sores. M’s reaction to the offer of assistance with applying the mattress was one of distress, the reason for which is not explored. In addition, given that M would have been heavily pregnant, a referral for a carer’s assessment could have been considered at this stage.   10  NCSCB Submission Copy  4.9. A midwife undertook a home visit on 18th December 2012 to assess the home for suitability for a home birth. F was noted to be chronically unwell and in bed for the duration of the visit. M stated that a carer would be needed for F if she were to be transferred to hospital. There was little documented discussion regarding F’s ill health or that impact upon M of being his carer.    Comment: Again this was opportunity for a referral for a carer’s assessment for M. The reason for this not being considered is explored within the analysis.   4.10. M was seen at the maternity assessment suite on 26th January 2013 with a rupture of membranes. She was still keen for a home delivery and was allowed home with advice given.   Comment: It would appear that M was keen for a home birth given her caring responsibilities at home and this was reflected within her midwifery records.   4.11. The following day M contacted F’s nurse to state that her waters had broken; that she needed to go into hospital and that F needed a carer.  The nurse made some initial enquiries however, M later made alternative arrangements and found someone to stay with F whilst she was in hospital.   4.12. Later on the in morning of 27th January 2013, M was admitted to hospital for induction of labour. Child H was born at 4.21pm. M stated that she could not remain in hospital as she needed to go home to care for her husband. M was advised to remain in hospital for observation due to prolonged rupture of membranes (as this increases the risk of infection to the newborn) but declined and went home at 7.00pm.   Comment: M was clear that she needed to go home to care for her husband immediately after giving birth, and against clinical advice. This could have triggered a referral for a carer’s assessment to consider M’s support needs or liaison with the health visitor and community midwives regarding the home situation in addition to the routine notification regarding discharge.   4.13. M and CHILD H were visited by the community midwife on 28th January 2013 and 29th January 2013. No concerns were raised. On 1st February 2013, M and CHILD H were seen in clinic. M was feeling well and CHILD H was gaining weight. M and CHILD H were seen again in clinic on 11th February 2013. Excellent weight gain was documented. M and CHILD H were discharged from maternity care.   Comment: The midwifery notes did not contain any record about M’s mental health, or consideration of the implications of her caring for her husband and children.  11  NCSCB Submission Copy   4.14. On 14th February 2013 a home visit was undertaken by the Heath Visitor. A physical examination of CHILD H was completed and no abnormalities were detected. M was recorded as being F’s full time carer.  It was also recorded that M was American . M was noted to have little support in England and disclosed having experienced depression a few years previously although feeling well at present. M agreed to attend clinic and the health visitor planned to see CHILD H again at the 12 – 16 week review.   Comment: It is noted within the agency report that during this visit where M disclosed previous depression there does not appear to have been any exploration by the health visitor regarding whether this had been postnatal depression or reactive depression.    4.15. On 27th February 2013, F was taken to hospital via ambulance with respiratory arrest. Whilst in hospital F spent time in intensive care. It is recorded that F was dependent upon M for care and that they had an 8 week old baby.  F was transferred to the City hospital on 20th March 2013.   Comment: It would appear that hospital staff were now aware of the home situation. The agency report indicates that there was minimal information in F’s records regarding his home life.   4.16. On 1st March 2013, M sent an email to S1’s school apologising for S1’s absence and explaining that F’s illness and hospital admission meant that she was unable to get S1 to school. In the email, M asked for additional support for S1 as she felt that she was being affected by the family situation. The head teacher replied, agreeing to put in extra support for S1 within school and offering to meet with M to discuss how the school could help.   4.17. On 14th March 2013, M rang the emergency services to report that CHILD H had a watering eye. The call was transferred to NHS Direct. When the nurse advisor called M back, she stated that she was really calling about herself and felt that she was having a breakdown. M reported that F was seriously ill in hospital and had nearly died 2 weeks previously. She stated that she felt paranoid, confused and was unable to remember things, and unable to get out of the house. She reported a history of anxiety and depression. The nurse advisor informed M that she would ring her GP, which she did and reported that M sounded psychotic. The GP commented that this was out of character.   Comment: The nurse advisor checked that all of the family members within the household were safe. However a separate record was not created for the mother and her details were recorded on the child’s record. The agency report indicates that a record for M should have been created and a fuller and formal 12  NCSCB Submission Copy  assessment of her mental state should have been carried out using assessment tools from the NHS Direct mental health training and by use of an appropriate algorithm. Had the paranoia algorithm been used, then the likely outcome would have been to attend the Emergency Department as soon as possible.   4.18. The GP rang M immediately and assessed her over the telephone. By this time M was reported as feeling settled and back to her normal self with no psychotic signs. She said that she was stressed due to F being in hospital and was struggling to cope but that she was ‘alright’. The GP recalled that S1 did go to school that day. The GP offered to visit M but she said she did not want a visit and was feeling much better.   Comment: It is stated within the agency report that it is not usual for GPs to visit healthy adults at home for stress related symptoms. The call from NHS Direct stated that M was psychotic, which would have required a visit, and it was the primary concern of the GP to establish if this was the case or not. When GP had satisfied herself over the telephone that M was not presenting as psychotic, then a plan to see her in the surgery was a reasonable response. The GP offered to visit her but this was declined. It is noted that it is unusual to recover so quickly and with no treatment from a psychotic episode. This unusually sudden recovery seems to have led the GP to assume that M could not have been psychotic just an hour or so previously and thus the professional who thought she had been psychotic must have been mistaken.  4.19. Following a discussion between ambulance control, a senior clinician with NHS Direct and the NHS direct Nurse Advisor, it was agreed that the nurse advisor would make a safeguarding referral which she did that day. The referral was followed up in writing. The nurse advisor contacted M again and M informed her that the GP was not going to visit but was going to get the health visitor to ring M. The GP did not speak to the health visitor however the health visitor coincidentally rang M who described the last few weeks as a nightmare. The health visitor arranged to visit on 20th March 2013.   Comment: During this contact, M did not inform the health visitor of her earlier contact with NHS Direct, however given the fact that the nurse advisor had told M that the health visitor was going to ring, it was likely that M presumed that the health visitor was already aware.   4.20. On 19th March 2013, an ambulance was called to M who reported medical symptoms of a stroke (facial twitching and right sided weakness). Although the symptoms were resolving by the time that ambulance clinicians arrived, M was accepted and transferred to NUH Stroke Unit for further assessment. At hospital, a full social history was obtained, including that M was full time carer for F and two young 13  NCSCB Submission Copy  children and reported recent emotional stress and symptoms of anxiety. Both children were present with M in hospital. She was diagnosed with a migraine and sent home. The information gathered was shared with the GP via a letter.  Comment: This was opportunity for discussion with the health visitor and consideration of a referral for a carer’s assessment. NUH has liaison health visitors who could have been contacted given the concerns evident from the social history provided and M’s emotional health. It was unusual for children to be on the ward with their mother and this too could have been raised with the liaison health visitors.   4.21. The health visitor visited as planned on 20th March 2013. Both children were seen and the health visitor was informed that M had been in hospital until the early hours of the morning as she had experienced numbness down one side of her body. M reported feeling helpless with regards to F whom she was visiting every second day. She reported being in a constant state of fear regarding what was going to happen to the family. M was noted to be isolated and spoke about her children going into care for a month so that she could ‘get herself together’.  M reported being prescribed medication by the GP for panic attacks. Some support services were discussed, including a children’s centre and Homestart, as well as the contact number for ‘let’s talk’ wellbeing service. The health visitor documented that she felt that M was at crisis point and that the numbness experienced the previous day was a manifestation of stress.   Comment: M was clearly stating to the health visitor that she was not coping. Discussion with the GP would have been pertinent at this stage as well as consideration of a CAF or indeed a referral to children’s social care.   4.22. Later that day, a Screening and Duty Family Support Worker (FSW) spoke to the health visitor, after having received the referral from NHS direct. The health visitor provided the social worker with information gained from her earlier visit. It is recorded in the  health records that the FSW suggested liaison with the Family Information Service; advised that liaison with the school would occur and suggested the involvement of a family support worker. The FSW recorded the health visitor’s view that M was reaching breaking point. It was also recorded that the GP had prescribed panic attack medication and that the health visitor had provided M with information regarding support services. A telephone message was left for S1’s school by the FSW. The FSW recorded that no further action was required.  Comment: The screening and duty worker appeared to be reassured by the information provided by the health visitor and by the fact that the health visitor and G.P. were aware of M’s difficulties. There is no record of contact being made with the GP 14  NCSCB Submission Copy  or with M herself. There is no record of a discussion regarding the appropriateness of a CAF.   4.23. Some hours later, the FSW spoke to S1’s school who reported that she had not been seen in school since 8th March 2013 and that her attendance was 82.4%.  4.24. On 21st March 2013, the health visitor recorded that she liaised with the children’s centre who advised a referral to the carer’s federation. She then visited M to provide a leaflet and a referral form as well as contact numbers for the Family Information Service. S1 was still not in school although M reported that she was feeling much better. There was no record of a discussion with M regarding the NHS Direct referral or the health visitor’s discussion with Children’s Social Care.   In interview, the health visitor recalled the contact with the children’s centre as being an informal discussion with the children’s centre worker regarding making a referral to the service (for a family support worker). She recalled that the children’s centre worker did not feel that the case would meet the threshold criteria for family support worker involvement and that they were oversubscribed. This aspect of the conversation is not recorded in the health visitor records. There is no record of the conversation between the health visitor and the children’s centre worker within the children’s centre files. The children’s centre worker in question does not recall the conversation as this was an informal chat due to the two professionals being based in the same building.   4.25. M visited the GP on 27th March 2013. Although she was stated to be much brighter, she was given lorazepam (a minor tranquilliser and benzodiazepine) for the immediate relief of stress. She was not considered to be depressed or offered antidepressants.  Comment: F was still in hospital at this point. There is a discrepancy within the records as M had shared with the health visitor on 20th March 2013 that she was being prescribed medication for panic attacks but the first recorded prescription was issued on 27th March 2013.   4.26. On 27th March 2013, the health visitor received a copy of the NHS Direct Safeguarding Child Concern form. The form referred to paranoid thoughts and confusion. Receipt of the form appeared to prompt the health visitor to ring M that day; who reported that the home situation had much improved.   4.27. F was discharged from hospital on 31st March 2013. M was spoken to by a discharge co-ordinator during F’s admission and asked specifically about support needs. M stated she did not need any input and was fine 15  NCSCB Submission Copy  to care for F. She was not asked explicitly about caring for the children as well as her husband.  4.28. In a telephone call from the Health Visitor on 25th April 2013, M stated that CHILD H was well and F was at home. M reported feeling well in herself.   4.29. On 2nd May 2013, F was visited by a physiotherapist for the purpose of assessment. M was documented as F’s carer. Although F reported that he was struggling with activities of living he declined the offer of referral to Occupational Therapy and the District Nurse.   Comment: A pattern is emerging of the parents declining help that is offered.  4.30. The health visitor visited on 9th May 2013. M reported not being able to leave the house for prolonged periods due to F’s ill health. M stated that she was feeling well and managing home life. 12 – 16 week review of CHILD H was completed and no concerns were noted.   4.31. On 13th May 2013, M was seen by her GP who recorded that she had a ‘stress related problem’ related to her husband’s health and having a new baby. It was recorded that M ‘does everything even if [F] is able’. Medication was discussed however no prescription was issued. On 15th May 2013, F was prescribed lorazepam for his breathing difficulties.   4.32. The physiotherapist visited F again on 30th May 2013. F reported to feeling very breathless and reported having to call an ambulance twice over the weekend for chest pain. F felt that he had everything he needed therefore was discharged from the service.   4.33. On 10th June 2013, M was prescribed 12 lorazepam tablets without having been seen by a GP. The prescription was printed out by the surgery receptionist and submitted to the GP who then signed it. On 18th June 2013, M was prescribed 12 further tablets without being seen by the GP. This happened again on 21st June 2013, and on 4th July 2013, however on this occasion the number of tablets was increased to 28.   It is of concern that the GP issued prescriptions for a benzodiazepine without seeing M, given the recent history of concern regarding her mental health (of which the GP was aware) and the fact that she had a young infant at home. In interview the GP stated that M would have put her requests into the surgery and they were then issued.  The gap between the first prescription and the second, some 10 weeks, remains unexplained and a review of M’s health would have been pertinent prior to issuing the second prescription. There is no record of what discussions took place between the receptionist and the GP when the prescriptions were signed.  16  NCSCB Submission Copy   4.34. Further prescriptions for 28 tablets were issued by the GP on 19th and 31st July 2013, without M having a scheduled appointment with the GP.   In interview the GP stated that at the end of July 2013, reception staff had noted the amount of repeat prescriptions.  4.35. On 21st August 2013, F visited the GP requesting 3 prescriptions for lorazepam. M and CHILD H were with him. It was recorded that the family were moving to the USA and that F was hoping for a lung transplant. The family were described as optimistic regarding their future in the USA and excited about the move. It is also recorded that they were ‘stock-piling’ lorazepam to take to the USA. The requested prescriptions were not issued.   It is evident that the prescriptions for lorazepam were issued to M repeatedly without her being seen by the GP. In addition, the numbers of tablets prescribed increased. There is no robust trail from the GP records of the clinical decision making process. In interview, the GP confirmed that they were not following any specific guidelines with regard to the prescription of benzodiazepines. Guidance in the BNF (British National Formulary) states that benzodiazepines are indicated for short-term relief of anxiety (two to four weeks only).   Whether M was requesting the medication as her mental health was deteriorating or whether the family were stock-piling the drug is not known. It is significant however that only the GP was having contact with M during this period, albeit indirectly and therefore the only one with reason to make enquires of her wellbeing.   4.36. On Saturday 31st August 2013, at 6.00am, F called an ambulance as he had chest pains and was having difficulty breathing. F informed the crew that M had run off with CHILD H leaving him with the care of S1. F was concerned that M might self harm. An immediate safeguarding referral was made by EMAS to the police and to social care.   The referral is not recorded in the social care records, although reference is made to it in subsequent recordings made of the day’s events.  4.37. Police Officers attended the address at 8.20am following the report from EMAS. Whilst at the address, F informed officers that M had left the address during the night with the baby, CHILD H, in the family car.  F reported that he was concerned because M suffered with anxiety. The ambulance crew at the scene informed the officers that they had already been in contact with M by telephone and that she was currently in London but would start making her way back to Nottingham once she had taken her medication for anxiety.  She had informed them that 17  NCSCB Submission Copy  it would take her approximately three hours to get home. S1 was taken to the police station and F was conveyed to hospital where he was admitted.   4.38. A car was later reported to the police as having been abandoned. The car was registered to M. CCTV footage later identified that M had left the car and got into a taxi at 04.30am.   4.39. At 9.50am, M approached a police officer outside Ealing police station and asked if he could help her carry her luggage to the train station. The officer could see that M was struggling and so agreed to help her, along with a colleague. Once the officers determined that M was trying to get back to Nottingham, they arranged for M to be given a lift to Kings Cross Station due to concerns that M would struggle on the tube with a young baby and all of her luggage.    4.40. By this stage, Nottinghamshire Police decided that a high risk missing enquiry be raised in respect of M and CHILD H. Nottinghamshire Police contacted M who informed them that she was in the company of Metropolitan Police Officers. M handed the phone to the Metropolitan Police Officer and the Nottinghamshire Police Officer explained that M and CHILD H were missing and there were concerns for their safety. At approximately 10.30am, both police forces then agreed to drive to Newport Pagnell Service Station which is half way between London and Nottingham; so that the Metropolitan Police Officers could hand M and CHILD H over to officers from Nottinghamshire Police.   Comment: It is reported by Metropolitan Police Officers that during the time spent with M, they did not have concern regarding her mental health.   4.41. At 12.36pm, it is recorded by the social care emergency duty team that Nottinghamshire police informed them that M and CHILD H had been located in London; having travelled there by taxi after M abandoned her car in Nottingham. M was intending to travel on to Holland where she intended to live following a dispute with F. It is recorded that M had visited the police station in Ealing stating that she was suffering an anxiety attack. It is recorded that the Nottinghamshire police officer was concerned about M’s mental health given that she was unsure whether she had a passport to travel to Holland and had limited belongings.   Comment: There is a discrepancy here with regard to the reported anxiety attack. The Metropolitan police reported that M approached them to request help with her luggage.  However Nottinghamshire police were aware of M’s earlier conversation with EMAS where she stated that she was going to take medication for anxiety before heading back to Nottingham.   4.42. Nottinghamshire police officers collected M and CHILD H at 2.00pm. During the second part of the return journey, the two Nottingham Police 18  NCSCB Submission Copy  officers found that M appeared well, both physically and mentally. She was described as calm, coherent and very well organised.  Throughout the return journey she was very attentive to the needs of CHILD H who was happy and giggling.  During the conversation with M she stated that she did suffer with anxiety and that she was receiving medication. When asked if she had suffered previously with any mental health problems, M informed the officers that four or five years ago whilst in America she had followed a step system recovery having been admitted to a health care facility for thirty days.  She stated that she was drinking heavily at that time but not anymore.  4.43. At approximately 4.00pm, M and CHILD H arrived back in Nottingham  with Nottinghamshire police officers and were taken to collect S1 from the police station. At 4.26pm, Nottinghamshire police officers spoke again with EDT with an update on the situation. The officer had been inside the family home and reported it to be clean and unlike a number of families in the area, the home had expensive household items. In relation to M’s mental health, it is recorded in the EDT records that the police officer was satisfied that M could be left with her children although the rationale for this is not recorded.  The police records state that they recommended that a visit was needed by social care that evening. The police officer understood from the EDT social worker that this was not possible as there were no social workers available, but that a social worker would make contact with M on Monday morning, with a view to completing an Initial Assessment. It was agreed by both agencies that a safe and well visit would be completed by the police the following day.   Comment: As a result of the Practitioner Panel it became evident that during the car journey, M informed Nottinghamshire Police Officers that she had left home following an argument with F who had asked her to leave. During the car journey, the Nottinghamshire police officers completed a full DASH RIC assessment which identified M as standard risk of domestic abuse. There had been no previous police callouts to the family in respect of domestic abuse.    S1 had remained in the police station given plans for her to return to M’s care when she arrived back in Nottingham although it is noted that this was for a considerable period of time. However, Police Officers described her as relaxed and not distressed.   With regard to the request for a visit to be undertaken by EDT, it has become evident that there was a degree of misunderstanding regarding this issue. Had the requested visit been as a result of child protection concerns, a visit would have been undertaken by EDT.  However, at the time of the reported request, the police were not expressing concern regarding M’s ability to care for the children.   19  NCSCB Submission Copy  4.44. CHILD H died on 1st September 2013.    5. The Family’s Experience   5.1. Due to the criminal proceedings, the SCR Panel were advised by the Police that it was not appropriate to engage the parents or extended family in the process of this SCR. In addition, both parents were in receipt of support in relation to mental health issues and there was a concern that information from the SCR may impact negatively upon their health.   5.2. The decision regarding family engagement was reviewed following the conclusion of the criminal proceedings. Both parents were contacted but did not wish to contribute to the SCR.    6. Analysis including Themes arising from the SCR   6.1. Analysis of the case against the key issues:  6.2. With regard to the mother: • Support received before and after the birth of Child H  • Any assessments undertaken of her mental health • Her role as a carer for the father and the impact of this upon her parenting and/or mental health • Her presentation and practitioner’s perception and analysis of this  6.3. M received routine support from midwifery and health visiting services. She was seen by different midwives and although it was recorded that she was F’s carer, there was a lack of assessment with regard to the impact of this upon her and her care of the children.   6.4. With regard to the support provided by the health visitor, at the time cases were initially classed as either being ‘Universal’ or ‘Safeguarding’. CHILD H’s case was held within the Universal caseload therefore suggesting that no additional needs had been identified regarding this family. Placing CHILD H within the Universal caseload would result in the minimum required contacts.  The agency report states that a number of indicators of need were highlighted during the new birth review visit conducted on the 14th February 2013 and during subsequent contacts, which would have suggested placement within the Safeguarding caseload and therefore resulted in additional intervention and support.  6.5. Following reconfiguration of health visiting caseloads to a 4 tier model (Universal, Universal Plus, Universal Partnership Plus and 20  NCSCB Submission Copy  Safeguarding), CHILD H remained in the universal caseload. The agency report suggested that as more concerns were evident, such as the history of depression; full time carer responsibilities, lack of support and isolation, plus the care of a new baby and a primary school age child, transfer to the Universal Partnership Plus caseload was indicated, which would have prompted additional contact and the consideration of initiating a Common Assessment Framework (CAF).  Initiation of a CAF would have facilitated a co-ordinated approach to supporting the family and would have created an opportunity for adults and children’s services to share information and fully consider the needs of the family.    6.6. In interview the health visitor stated that she had considered initiating a CAF, but perceived the only involved agencies as being herself and S1’s school and therefore believed that a CAF would not be effective. Of course there were other agencies involved but the focus appeared to be upon agencies involved with the children as opposed to the adults in the family.   6.7. Nottingham City has a Family Support Strategy and Pathway which was launched in 2011 including guidance for practitioners. This document is currently being refreshed. Both documents were developed in consultation with key partner agencies across the Children’s Partnership. The purpose of the Family Support Pathway is to ensure children and families receive the right help at the right time and highlight the level of support that may be needed by children and families from universal through to specialist services. The CAF is integral to the effective delivery of the Family Support Pathway, to ensure that the needs of children and families are assessed and identified earlier and that coordinated multi agency action plans are produced and implemented where needed.  6.8. The current Family Support Pathway integrates the CAF process and Nottingham City’s Access to (and exit from) Social Care protocols. This is in effect the threshold for services, although the message is that services need to be joined up and work together to provide a continuum of support rather than working in isolation.   6.9. It is evident from the chronology of this case that there was opportunity for a CAF to be considered. The assumption was made, erroneously, that there were too few agencies involved to make the process effective. This should not have prevented the assessment commencing in any event given that additional needs within the family had been identified.  6.10. The health visitor made informal enquires with the children’s centre regarding the involvement of a family support worker but was reportedly told that it was unlikely that the threshold for this service would be met. In addition, she made a referral to Homestart and was told that they did not have any spaces and were struggling with funding 21  NCSCB Submission Copy  issues. The health visitor shared that she felt blocked at every turn. She reflected that although she was concerned enough to want to ‘unblock’ the issues, she did not consider moving the case into the safeguarding tier or discussing the case with her safeguarding manager. This would appear to be due to the fact that the issues were deemed to be support rather than safeguarding issues. In addition, the health visitor was reassured when M informed her that the situation was much improved. When a space later came up at Homestart, the health visitor declined the service for the family feeling that it was no longer required.   6.11. With regard to M’s mental health, M disclosed a history of depression and anxiety to a number of professionals. This included during the new birth review visit undertaken by the health visitor. However this was not explored further. Health visitors are required to complete the maternal health needs assessment at the new birth review, however this was not done. Completion of this would have allowed for further exploration of maternal mental health needs.    6.12. The NHS Direct Nurse Advisor was extremely concerned regarding M’s mental health and was proactive is raising her concern.  However, the agency report indicates that a record for M should have been created and a fuller and formal assessment of her mental state should have been carried out using assessment tools from the NHS Direct mental health training and by use of an appropriate algorithm. Had the paranoia algorithm been used, then the likely outcome would have been to attend the Emergency Department as soon as possible.  6.13. The GP was contacted by the Nurse Advisor and promptly spoke to M by telephone, who declined a home visit. It is recorded by NHS Direct that the GP was to liaise with the health visitor but this did not occur at this stage or at any point during CHILD H’s life. Whether the GP should have undertaken a home visit in any event given the severity of concern raised by the Nurse Advisor has been debated as part of this SCR. Given the capacity of GPs, and more importantly the telephone assessment the GP completed of M, this was an unlikely outcome.   6.14. During the visit undertaken on 20th March 2013, M disclosed to the health visitor that she was feeling lost and frightened and spoke of having her children placed into foster care for a month. The health visitor was informed of M’s admission to hospital the previous day which she assessed as being as a result of a physical manifestation of stress. M stated that the GP had prescribed her medication for panic attacks. As a result of the discussion, the health visitor provided M with the contact details for the ‘Let’s talk wellbeing’ and the family Information Service in order that M could obtain additional support.  It is queried within the agency report whether M’s capacity and motivation to be able to self-refer to services and ask for support was considered given that she was presenting as being at crisis point. This was also 22  NCSCB Submission Copy  further opportunity for a discussion between the GP and the Health Visitor but this did not occur.  6.15. In interview, the health visitor spoke of the difficulties she experienced in collaborative working with the GP. She felt that this was further hindered by the fact that the surgery did not have a practice manager, who might act as intermediary; the surgery had never had a linked health visitor before and she did not feel as though the role of the health visitor was embraced within the surgery.   6.16. The GP prescribed M Lorazepam for panic attacks. In interview the GP stated that M had said she had taken Lorazepam when anxious previously and this had worked for her. This discussion appeared to be the basis of the drug choice. F was also prescribed the same medication for lung disease.   6.17. Lorazepam is a benzodiazepine, a minor tranquiliser. Lorazepam is a very short acting drug, with almost immediate effect when put under the tongue, and peak effects 90-120 minutes after swallowing a tablet. This makes it the first choice for the symptoms of breathlessness and the panic that this causes in end stage lung disease. Side effects include amnesia, and paradoxical effects of increased agitation. Withdrawal can cause a long list of symptoms including anxiety, insomnia, tingling fingers and toes, and psychosis.   6.18. M was prescribed Lorazepam, in increased numbers, without being seen by the GP and for a period much longer than that recommended in the guidance issued by the BNF (British National Formulary). There were gaps in the prescriptions although it is unknown whether she was using F’s medication at other periods. It is clear that they were at one stage attempting to obtain large quantities of the drug from the GP, apparently stock-piling, to take back to America but these prescriptions were not honoured. There is no evidence within agency records of any suggestion of drug dependency however closer monitoring by the GP, given the concerns regarding M’s wellbeing and the fact that she had a young infant at home, should have occurred.   6.19. It has been suggested within this SCR that M became more stressed when F was in hospital, suggesting that he brought stability to the family and was helpful to M rather than a burden to her. Indeed, both episodes of deteriorating mental health occurred whilst F was in hospital. This does not appear to have been a factor that was considered by the professionals involved with the family during the scoping period.   6.20. With regard to M’s mental health on 31st August 2013, it has been reported that officers from both police forces were satisfied that M was emotionally well and that there were no indicators of concern. The officers all comment that M was loving and attentive to CHILD H who appeared well cared for. Officers spent considerable time with M and 23  NCSCB Submission Copy  CHILD H, and did not have any concerns about her current mental health state or her ability to care for CHILD H. At the practitioner panel, officers shared that they spoke with M regarding what support she felt that she needed at home, and she stated that provision of child care, such as a babysitter, would allow her to return to pilates or enable her and F to spend time together. At no stage did officers feel that this was a family in crisis.   6.21. It has been raised within the SCR, including at the practitioner panel that the details of the referral made to children’s social care in March 2013 were not shared with the police on 31st August 2013. However, given that this referral resulted in no further action and there had not been any subsequent referrals, it is unlikely that this would have altered the professional views formed that day. The record of the referral has been viewed and it is clear that this did not indicate an overly worrying picture.   6.22. Given that 31st August was a Saturday; information could not have been easily obtained from health services, such as the GP and health visitor. This does highlight the limitations of provision by some agencies at weekends and out of office hours. There is a lack of clarity regarding how information is obtained out of hours and outside of the remit of the child protection process where issues of consent come in to play. Work is being taken forward to address this.   6.23. With regard to M’s role as the carer and the impact of this upon her parenting and mental health, it is clear that this was unassessed by all of those professionals in contact with the family. The chronology of this case has highlighted that there were a number of opportunities to ask further questions or enquire as to the demands upon M as a carer. Even without this exploration, the facts indicated that this was a mother with considerable demands placed upon her. There is some evidence of the parents declining support and returning equipment but there was no exploration of the reasons for this, and there appeared to be an assumption that M was coping with her caring responsibilities. Critically, consideration was never given to referring M for a carers assessment to be completed by Adult Social Care. This would have identified any support needs that M had in her role as carer for F. Those attending the practitioner panel, including staff from both adult and children’s services, as well as the health visitor in interview; all openly shared that they were not aware of carers assessments and what they consisted of; their purpose etc. It is therefore unsurprising that a referral for a carers assessment was never made.   6.24. The health visitor discussed a referral to the Carers Federation but it would appear that a referral was never made, no doubt due to M reporting an improved home situation. A referral to the Carers Federation could have provided support to M and informed her of her right to a carer’s assessment.   24  NCSCB Submission Copy  6.25. With regard to M’s presentation to agencies, she presented positively to all those agencies that had contact with her. M was described as very involved in the care and decision making around care and treatment of F, and appropriate in the care of CHILD H and S1. The health visitor described M as very caring, welcoming and child focused in her discussions. The family have been described as very together as a family unit. The school reported that M was always well presented, well groomed, attended parents evenings and liaised well with the class teacher. At the practitioner panel, M was described by the practitioners in the following terms: calm; articulate; sensible; ‘alternative’; well dressed; confident; coherent; loving; positive in attitude; a decision maker; friendly. Such positive presentations undoubtedly served to reassure practitioners that all was well.   6.26. With regard to the father: • His role within the family including his occupation and beliefs • His physical and mental health and any assessment of the impact of this upon the safety and welfare of the children • His presentation and practitioner’s perception and analysis of this  6.27. There is very little information with regard to F. Although he had a number of services involved with him in his own right given his heath needs, these services focused upon him as an elderly patient as opposed to a father with caring responsibilities.  6.28. It is not evident from the information gained from this SCR, what role F played within the family. It is known that he had reduced mobility and had a bed in the living room. He was dependent upon M for physical care. The role that he played as a parent is assumed to be minimal but this was not assessed by professionals working with the family and there is no evidence of respectful challenge to his responsibilities as a parent. There is however evidence to suggest that he was a great emotional support to M, and that she struggled when he was away from the family home due to hospital admissions. The GP’s view was that when F was seen with M and both children, he seemed to have a good relationship with all of them.  6.29. With regard to F’s occupation and beliefs, it is recorded that he was a spiritual healer but what this meant in practice was not ascertained. Health visiting paper records for S1 indicate that both parents occupation was recorded as ‘Spiritual Teacher’.  F was recorded as being retired but previously working as a gambler and a spiritual leader within M’s pregnancy booking records. What this may have meant in terms of family functioning and family culture/norms is not known.   6.30. F had lung disease and as such was seen frequently by health professionals. F requested the Emergency Ambulance on a frequent 25  NCSCB Submission Copy  basis for his medical condition, however, not enough to trigger action as an EMAS High Volume Service User (HVSU). Although F did not meet the criteria of HVSU, it has been suggested that calling 999 for an emergency response on numerous occasions to be treated on scene and decline hospital attendance indicated that he was potentially not managing his symptoms at home. The fact that F declined admission may have been linked to the emotional support provided to and required by M, although there is also evidence of him declining other home based support services.   6.31. There is no evidence of concern with regard to F’s mental health.   6.32. Information from the hospital indicates that assessments of F were primarily focused on his role as a patient with chronic ill health that was dependent on his wife for care. There was awareness of the pregnancy and subsequently (after the birth of CHILD H) that he had a young child but there was little focus upon him as a father.   6.33. From discussions with practitioners present at the practitioner panel, it was established that professionals would not have routinely asked a patient of F’s age about having dependent children as it is unusual in this patient group.   6.34. The health visitor described F as articulate and bright, interested in discussions and appeared involved in family decisions. She observed him to play with CHILD H.   6.35. With regard to the family: • Evidence of domestic stress relating to parenting, health or finances • Opportunities for early intervention, in particular during March 2013 • Quality of assessments, decision making, referral and communication • Responses to events on the weekend of Child H’s death  6.36. There was some evidence of domestic stress within this case, although not to the extent that a safeguarding response was felt to be required. At no stage did there appear to be concern regarding the parenting of the children. As stated previously, there was a lack of assessment of the impact of parental physical and mental health upon the parenting of the children, although the outward signs appeared to be positive. S1’s period of poor school attendance was viewed in the context of M having just had a baby and being unable to get S1 to school. Although there is some mention of financial difficulties, these were not raised as any area requiring support. It is evident that the family were isolated, and that M did not have a wide support network.  26  NCSCB Submission Copy   6.37. It has been established that there were opportunities for early intervention in March 2013, following the contact made with NHS Direct, and subsequently by the GP and health visitor, and then again, following M’s admission to hospital where it became apparent that she was under stress and had sole care of two small children. A CAF would have been a way forward to share information and coordinate support. A referral for a carer’s assessment would have been appropriate at several stages within the chronology but the professionals who had contact with the family were not aware of the process. At the practitioner panel, acute medical staff shared that they did not pick up on the vulnerabilities within the family; and felt that this was due to a lack of familiarity in dealing with social issues.   6.38. No assessments were completed of the family. With regard to referrals, NHS Direct made an appropriate referral to Children’s Social Care in March 2013. Although the screening and duty worker spoke with the health visitor and school, they did not speak with the GP or the family, although it would have been pertinent to do so. As stated within the children’s social care agency report, from the information provided the decision that no further action was required by children’s social care was an appropriate decision. However given the number of services involved and the concerns surrounding the family an assessment under the Common Assessment Framework would have been appropriate at this stage. There was no discussion of this with the health visitor.   6.39. The outcome letter sent to agencies informing them of action to be taken following their contact/referral was only sent to NHS Direct following their referral in March 2013. A copy should also have been sent to School, the Health Visitor, the GP and parents.   6.40. With regard to the referrals to children’s social care on 31st August 2013, there is no record of a referral from EMAS. Decision making in respect of the events of that day were made in conjunction with the police. The children’s social care agency report has highlighted that there was an absence of analysis recorded in relation to decisions made and highlighted that as events took place at the weekend the Emergency Duty Team and the Police would have been unable to liaise with School, the GP or the Health Visitor to ascertain their views. The Emergency Duty Team undertook Carefirst (social care database) checks for current and historical records and found two records from January 2013 (regarding potential need for a carer for F when M gave birth) and March 2013. No concerns had been raised with Children’s Social Care in the six months subsequent to the referral in March 2013.  6.41. With regard to communication, there is evidence within the chronology of communication between agencies such as between NHS Direct and social care, police and EMAS. There was robust communication between the two police forces involved on 31st August 2013.   27  NCSCB Submission Copy  6.42. However communication between the health visitor and the GP did not occur. This would have been a good opportunity to share information especially in light of the ongoing prescriptions of lorazepam to M.   6.43. Practitioners reflected upon the barriers to communication with GPs and felt that there was a physical barrier in that they are often busy in surgeries and that from this a perception has developed whereby it is  hard to talk to a GP, so professionals cease trying. Although practitioners were generalising, given the knowledge that GPs have, and information to which they have access, this is an area of learning that requires further exploration.  6.44. The responses to events on the weekend of CHILD H’s death are recorded within the chronology. It is evident that the two police forces committed significant resources to ensuring that M and CHILD H returned to Nottingham safely. This was not due to concern regarding M’s mental health rather a concern that they had been reported as a high risk missing case and needed to return to Nottingham without delay as S1 was at the police station. At the practitioner panel it was discussed whether the police would have taken a different course of action had they been in possession of all of the information known about the family. The outcome of the discussion was that this was not realistic as no one agency held all of the information, compounded by the challenges of information sharing between agencies at weekends. In addition, this is a deliberation with the benefit of hindsight and knowledge of the final outcome. What is evident from the chronology is that agencies were not overly concerned regarding the family and it therefore follows that even had all the information been known to the police, the decisions made between themselves and EDT were highly likely to have remained the same.   6.45. With regard to the capacity of EDT to undertake visits to families out of hours, visits will be undertaken where there are child protection concerns. Given that EDT is operated by two workers there is no capacity to undertaken support visits. It is unhelpful to speculate in what a home visit may or may not have achieved that evening. It is clear however that requests and arrangements for visits to families out of hours, including those undertaken by the police, need to be clearly recorded, explicit and purposeful. This is an area that will require further development.   6.46. With regard to the drop in S1’s school attendance, the school decided to adopt a supportive rather than punitive approach given the family circumstances. S1 was offered pastoral care within school, including positive reinforcement. The school engaged S1 in an arts project at the local art gallery and submitted her work to competitions.  6.47. With regard to agency involvement in the case: 28  NCSCB Submission Copy  • How sensitive were practitioners to the needs of Child H and how equipped were practitioners to work effectively with the family? • Was practice sensitive to the racial, cultural, linguistic and religious identity and any issues of disability within the family? • What was in place to ensure management accountability for decision making and management oversight of the case? Was this effective? • Was work consistent with the agency and the LSCB’s policy and procedures? Were professional standards met? • Were staff involved trained to the appropriate level in safeguarding?  • Were there any contextual issues that impacted upon work in the case i.e. staffing, capacity, sickness, organisational change, resources? • Is there evidence of positive practice?  6.48. This SCR has established that there was a lack of thought given to the impact of M and F’s functioning upon the parenting that CHILD H and S1 were receiving. There were no reported concerns regarding CHILD H, who presented as a well-cared for and thriving baby. This gave professionals the impression that even in times of stress; M was able to meet the needs of the child.   6.49. The focus of the discussions between agencies in relation to CHILD H tended to be focused on the mental health needs of M and the physical health needs of F and in the main did not include an assessment or analysis of the impact of the adult issues on parenting capacity and the experiences of the children. Within this case, the large number of different professionals, particularly with the midwives caring for M and the heath professionals caring for F; may have contributed to the lack of exploration of support needs or early intervention.  6.50. With regard to whether practitioners were equipped to work effectively with the family, this SCR has prompted discussion regarding recognition of symptoms of emerging mental health issues. Student health visitors receive training on postnatal depression within their degree course, however once in practice, training in relation to the detection and management mental health issues is not included within the core training competencies for clinical staff working within the health visiting service.  The health visitor in this case had not undertaken any mental health training since qualifying. Mental health training is now being rolled out to health visitors with Nottingham City Care Partnership, using the Parental Mental Health package developed by the Institute of Health Visiting.   29  NCSCB Submission Copy  6.51. There was opportunity for more robust monitoring of M by her GP but this did not occur, even when it would seem probable that her mental health was a continued concern or indeed deteriorating.   6.52. With regard to whether practice was sensitive to the racial and cultural identity of the family, it would appear that M’s nationality was not given a great deal of attention. As stated in the agency report for the CCG, her fluent English and white ethnic group may have led practitioners to minimise her non-British cultural background and whether this impacted upon her willingness to disclose any previous mental health problems. It would appear that practitioners were influenced by the positive presentations of the family, including material presentation such as the home conditions within which the family lived.   6.53. With regard to management accountability, it has been established that the health visitor did not escalate her concerns to her supervisor. The NHS Direct Nurse Advisor did seek guidance from a senior clinician; however despite being advised to open a separate record for M she did not do so. The initial contact completed by the children’s social care screening and duty team worker was not signed off by a team manager, as was the requirement although this was unlikely to have made any material difference. Relevant senior officers from the two police forces were involved in the decision making on 31st August, although the children’s social care EDT worker did not raise the case with an on call manager, probably due to the fact that action was not taken by EDT and there was no need to provide alternative accommodation for S1 given M’s return to Nottingham.   6.54. The SCR has not indicated that there was a failure to comply with policy and procedure and professionals involved were all trained to the appropriate level of safeguarding.  6.55. The SCR has not indicated that agencies, apart from the health visitor, were impacted upon by any contextual issues such as staffing, capacity, sickness or organisational change. The health visitor however was managing 200 cases yet working only 2 days a week. This meant that she spent 1.5 days on her caseload as 0.5 was spent in clinic. In interview the Health Visitor spoke of being very busy and that although her team were supportive she had minimal contact with them given her working hours.   6.56. With regard to examples of positive practice, the efforts of the two police forces on 31st August 2013 are to be commended. The decision to transport M and CHILD H to Nottingham would have had a significant resource implication. In addition, the NHS Direct Nurse Advisor made great efforts to seek support for M.   6.57. With regard to the multiagency system: 30  NCSCB Submission Copy  • Whether the issues identified above have resonance with other similar cases • What the case tells us about any underlying patterns that either support good practice or create conditions in which problematic practice is more likely 6.58. There have been a number of cases where the understanding and use of the Common Assessment Framework has been an issue of concern. This has been taken forward as part of the refresh of the Family Support Pathway. Practitioner understanding of early help needs to be improved, and the re-launch of the Family Support Pathway is the ideal opportunity to achieve this. Within this case, the practitioners shared that the barriers to undertaking a CAF included a lack of peer support from colleagues in other involved agencies and that the CAF was not perceived to add value. This is important learning to be taken forward. It has also been raised that there is a lack of a coherent CAF training programme within agencies which no doubt impacts upon professional confidence in completing a CAF.   6.59. In addition, a lack of understanding of carer’s assessments has featured in SILPs and a Domestic Homicide Review undertaken locally. Despite there being a carer’s strategy within Nottingham City, practitioner understanding of this would appear to be extremely limited.  6.60. Within this case, the practitioners identified that they were not aware that carer’s assessments existed, what they were or how they could access one, the exception being at the Acute Hospital who deal with mainly elderly patients who have elderly spouses or partners. Even in the knowledge of carer’s assessments, these practitioners still wondered if they would have considered a referral in the case of M as she was young and fit in outward presentation. The definition of a carer plus understanding of additional responsibilities, especially those of caring for dependent children, is learning that needs to be taken forward.   6.61. With regard to underlying patterns that create conditions in which problematic practice is more likely, this SCR has explored the barriers to a whole family approach. It was felt by practitioners involved in the case that the focus upon their primary client group had the greatest impact. For example, community adult services will hold information on file about others living in the household but this information is not used to ask wider contextual questions given that their role is very task focused and has a narrow remit. However, acute services working with adults could not see any major blocks to asking about the family context in routine paperwork, including any dependants or triggers for additional need.  7. The experience of the child 31  NCSCB Submission Copy  7.1. There has been considerable discussion regarding the experiences of the children, especially during the weekend of CHILD H’s death. Although CHILD H appeared well cared for and content in her mother’s care, the circumstances within which she arrived in London were unusual. Professionals focused upon the presenting situation, rather than the context within which events were occurring and the perspective of the child within that.   7.2. The SCR panel has deliberated whether contact with emergency health professionals in London might have been an appropriate consideration although it is noted that given M’s presentation at that time, this would have been unlikely to alter the sequence of events. A discussion involving health rather than one held just between social care and the police would have been a sensible approach however, and potentially might have brought a greater focus upon the experience of the child and allowed opportunity to gather information in order to better understand the antecedents that led to the situation within which Child H and M found themselves.     8. Expert Opinion  8.1. Dr Margaret Oates, Consultant Perinatal Psychiatrist, has considered all of the agency information provided to the SCR and submitted her written comments. These comments have helpfully enabled the SCR panels to fully consider the issue of M’s mental health and whether professionals involved should have been more alert to concerns. Dr Oates has identified key events where a mental health assessment would have been a pertinent consideration, such as following admission to the Stroke Unit and when arriving in London with CHILD H. It is recognised however that M did not present to non medical professionals as mentally unwell. With regard to the interventions of the GP, Dr Oates’ view is that the fact that M appeared to be fluctuating and free from evidence of symptoms when seen, was taken to be evidence that she was not seriously mentally ill.  Indeed, Dr Oates found that all the professionals involved appeared to make their judgements upon the cross-sectional evaluation of M’s current presentation and functioning.    8.2. On the basis of the written information made available to Dr Oates, her expert opinion is that is very unlikely that M was suffering from a postpartum onset depressive illness often referred to as postnatal depression.  Her view is that it is more likely that M had a more longstanding serious mental illness, possibly a chronic psychotic state which she was able to contain by her unusual lifestyle, which might have merely seemed eccentric to others, except at moments of great stress.  Dr Oates has suggested that this would explain her fluctuating presentation and the fact that on occasion of contact with professionals she appeared to have none of the symptoms that a non-32  NCSCB Submission Copy  specialist would regard as indicative of a psychosis i.e. she did not appear to have hallucinations or thought disorder.  Any evidence of delusional thinking or unreasonable beliefs would only have been evident if the reasons had been explored and then probably only by an experienced mental health practitioner.  Dr Oates’ expert opinion is that it is probable that M was psychotic at the time that CHILD H died and probable that she had been for some time.    8.3. The author has had sight of the psychiatric assessment of Dr M di Lustro, Consultant Forensic Psychiatrist, completed in respect of M during the criminal proceedings. The assessment details that M was guarded in the information that she would provide and was adept at containing her symptoms, having done so when she was mentally unwell and seeing professionals including her own GP after the birth of CHILD H and with police officers who escorted her back to Nottingham from London and were in her home just a few hours before she killed CHILD H, believing her fit to care alone for her children.  8.4. It was outlined that M has previously sought to avoid acquiring a label of having mental health problems and chosen not to report her previous history to community services.   8.5. The psychiatric assessment has described a diagnosis of: a) Schizoaffective disorder, for which M had avoided treatment through her lifestyle choices and the use of alternative coping strategies, such as meditation and mindfulness skills. b) Personality disorder c) Mental and behavioural disorders due to use of alcohol-dependence syndrome. M has denied excessive alcohol use in recent years, although she was described to be intoxicated following CHILD H’s death. 8.6. It is the expert opinion of Dr di Lustro that M was suffering from symptoms of this mental illness and personality disorder at the time of CHILD H’s death.   9. Changes in Practice and Actions Already Taken  How is the wider multi-agency system operating now? 9.1. The following bullet points outline the many changes in practice that have now occurred.  9.2. Within NUH: • Recommendation with regards to staff making enquiries with regards admission documentation incorporating a question on Carer responsibilities.  Responsibility for this action has been allocated to the NUH Documentation Group and will become part of the admission documentation (timescales to be confirmed). Safeguarding Champions within NUH have been informed of the 33  NCSCB Submission Copy  importance of asking this question and the Champions will disseminate to ward areas  • The letter from Midwives to GPs following an  antenatal booking includes all relevant history and safeguarding information • Paediatric Liaison Health Visitors have attended Safeguarding Champion Meeting April 2014 to Staff on role their and function within NUH.   9.3. Within Social Care:  • As of October 2013 all Initial Contacts must be authorised by a Team Manager. Before the Manager will authorise the form they will need to see that checks have been undertaken with the appropriate health agency (GP, Health Visitor, School Nurse, and Mental Health Midwife), School, probation and housing services. The Manager will want to know when the child was last seen, whether the parents have been spoken to and that all concerns raised within the contact have been followed up and that it includes information on previous contacts, referrals and interventions by Children’s Social Care.   • A step by step guide has been developed for Screening and Duty practitioners outlining information that needs to be obtained and from whom when managing a contact/referral. Furthermore each screener has a prompt guide outlining the things that they need to take into account. This includes how many referrals there has been in the last twelve months, previous Child Protection Plans and concerns, family support, mental health, learning disability, domestic abuse, alcohol and or drug misuse, whether there is a CAF in place and views of other professionals.     • A system has been established that when a contact/referral has been made and contact has not been possible with either a parent (as there are no telephone details) or an agency (due to school holidays) a note will be placed in the diary as a prompt to contact the parent and school when they reopen. Furthermore a letter will be sent to the parent requesting that they contact Children’s Social Care.  This system is currently a paper diary system the possibility of this becoming an electronic system is being explored.    • In January 2013 the Local Authority began rolling out a workforce training programme on Signs of Safety; alongside the training programme changes are being made to processes and documentation to support the roll out. The framework of Signs of Safety supports practitioners and referring agencies to analyse complex information focusing them to be clear about; what they are worried about (danger/risks) what’s going well (safety and strengths) what needs to happen and how safe is the child on a scale of 0 - 10, with 0 being no signs of safety immediate action required by Children’s Social Care and 10 being high levels of 34  NCSCB Submission Copy  safety no further action needed. Referrers and workers are required to provide a rationale for their concerns.   • In December 2013 the Contact and Referral Form, Initial and Core Assessments and CAF forms (used by Family Community Teams) were revised to include the Signs of Safety framework, which focuses the referral concerns to be about the impact to the child. The new single assessment documentation implemented on 1st April 2014 also reflects these changes. Supervision case discussion records have also been revised to include Signs of Safety, thus allowing practitioners and Team Managers to monitor if change is happening and whether or not safety is increasing. These changes keep the voice of the child at the heart of practice.  • In November 2013 the new service Children and Families Direct was launched.  All new calls relating to children and families go to this service, which directs callers to the most appropriate service for their query/need. In relation to cases involving safeguarding concerns, these are referred straight onto the Screening and Duty Team. It is anticipated that the volume of calls to Duty and Screening will reduce as a result of this new service.  9.4.  Within Nottingham CityCare Partnership:   • Nottingham CityCare have invested in improving both the number of CAF’s initiated and practitioner knowledge regarding its use.  In addition to the development of a CAF policy, guidance and training, the CityCare safeguarding team have performance management systems in place with regard to CAF.   • A two day training course is being delivered to all band 6 and 7 health visiting staff. To date, 3 sessions have been delivered resulting in 25 staff attending. The programme is delivered by a small team who have been trained to use the Parental Mental Health package developed by the Institute of Health visiting. CityCare are using the Edinburgh Postnatal Depression Scale tool, along with the Wooley questions as a precursor if required.  • A pathway for strategy discussions between Health, Police and Social Care which is concordant with Working Together to Safeguard Children 2013 has been developed.  • A Serious Incident Review group has been developed within CityCare, chaired by the Named Nurse for safeguarding, whose primary task is to embed the learning from Serious Case Reviews and Serious Incident Learning Processes and ensure that recommendations and action plans progress in a timely manner. In light of the learning from this review, all services are required to 35  NCSCB Submission Copy  implement routine questioning regarding caring responsibilities and a pathway for the referral for Carer’s assessment.  • CityCare have introduced a new model of strengths based working with families (based around the ‘Signs of Safety’ model)  which will facilitate discussions with children, parents and carers in a child focused way by the usage of a number of tools that are developed to capture the child’s thoughts and feelings.  All Health Visitors and School Health Nurses are to receive this training in line with the implementation plan.  • CityCare has reviewed and transformed the Safeguarding supervision model within the organisation.  At the beginning of the safeguarding supervision, the Universal Partnership Plus caseload is reviewed to ensure that all families within the caseload have a CAF in place and where there is not a CAF, a rationale is documented.  9.5. Within NHS Nottingham City:   • The review has not been able to provide an explanation or understanding of the clinical rationale for the decisions made in relation to the prescribing of Lorazepam for M during March – July 2013.  As this matter has not been resolved, a referral has been made to the Medical Directorate of the Derbyshire and Nottinghamshire Area Team of NHS England in order that it can be addressed.  10. Conclusions: 10.1. It is evident that this was a family who experienced periods of stress and M in particular, had considerable demands placed upon her. The impact of this family environment upon the children was unassessed and as such there is little sense of the child’s experience. Outward signs were that there were no concerns regarding CHILD H and only minor concerns regarding S1 which were being addressed by school.   10.2. It has been suggested that the nature of M’s mental illness; with such a seemingly rapid recovery on two occasions (March and August 2013) served to mislead professionals regarding its severity. The expert psychiatric opinion has indicated that M was suffering from a long standing psychotic illness and had become adept at concealing her symptoms.   10.3. There were opportunities to provide early intervention and support to this family. This would of course have been reliant upon their cooperation and there is evidence of the family declining support and not acting upon advice given. There was also opportunity for closer monitoring of M by her GP.   36  NCSCB Submission Copy  10.4. Even with the benefit of hindsight, and in the knowledge of all of the agency information, it is unlikely that this case would have reached the threshold for safeguarding activity during CHILD H’s short life. However key learning has been established that is relevant to families, such as the barriers to completing a CAF, the lack of understanding of carer’s assessments and the perceived barriers to engaging effectively with GPs. In addition, the interface between the police and the Social Care emergency duty team has highlighted the need for greater clarity regarding requests for visits undertaken by both agencies out of hours.   10.5. This learning will be taken forward as part of the recommendations arising from this SCR.   11. Recommendations 11.1. Each agency that has completed an agency report has developed recommendations for their agency. These are attached as Appendix 2. The implementation of these recommendations is monitored through the NCSCB.  11.2. The following recommendations have been made for Nottingham City as a result of learning from this Serious Case Review. They reflect the analysis and learning points, taking into account progress already made. A Strategic Action Plan has been agreed to implement these actions and ensure that services are developed as a result of the learning from this case. This is attached at Appendix 3. This action plan will be monitored through the SCR Standing Panel, with further assessment of the evidence and impact on practice being undertaken by the NCSCB Quality Assurance Group.   Recommendation 1: The revisions to the Family Support Pathway need to address:   • the barriers to providing early help including specific guidance on how to initiate early help  • guidance to adult services in contact with families •  the role of GPs in the context of family support and safeguarding  •  whether early help processes are robust enough to encompass a whole family perspective • specific reference to the impact of parental health factors upon the parenting provided to dependent children.    Recommendation 2: The Nottingham City Carer’s strategy needs to be meaningful to practitioners working with families and as such, awareness needs to be greatly improved. A referral pathway for carers assessment should be cascaded amongst agencies.   Recommendation 3: NCSCB need to be assured by agencies that practitioners are equipped, in accordance with the nature of their role, to work 37  NCSCB Submission Copy  confidently with cases where there are a number of issues of concern. The Excellence in Safeguarding tool developed by the NCSCB is an ideal mechanism to ensure this.   Recommendation 4: Heath visiting services should ensure that any concerns regarding a parent’s mental health are routinely shared with the GP.   Recommendation 5: NCSCB need to be assured by the relevant agencies that arrangements and requests for information exchange and visits to family out of hours are robust, clearly recorded, explicit and purposeful.   Recommendation 6: Practitioners working with families need to recognise that the presentation of families can influence judgement and present an overly optimistic or positive picture. Practitioners require skills to be able to unpick what may lie behind the presentation and focus upon the child’s experience. A culture of professional curiosity needs to be embedded.                      Glossary of Terms  Term Definition  LSCB Local Safeguarding Children Board NCSCB Nottingham City Safeguarding children Board SCR Serious Case Review DASH RIC  Domestic Abuse, Stalking and Honour based Violence risk identification checklist  EDT Emergency Duty Team NUH Nottingham University Hospitals NHS Trust  38  NCSCB Submission Copy  COPD chronic obstructive pulmonary disease EMAS East Midlands Ambulance Service                          Appendix 2: single agency recommendations   Nottingham CityCare Partnership   1. Health Visitors should write a clear summary on SystmOne of any concerns relating to a child or a carer/parent before they temporarily leave or transfer to another caseload.  The HV should record on SystmOne that they have given a formal handover to the new HV.  2. Regular review of caseloads within children’s services,  by the caseload holder, should occur to ensure that children, young people and families are receiving the right level of intervention according to their needs. 39  NCSCB Submission Copy   3. Mental health awareness training should be included within the core training competencies for clinical staff working in health visiting teams.  4. All health assessments undertaken within Nottingham CityCare Partnership should enquire about caring responsibilities and potential issues relating to this role, as standard.  5. The role of carers and a carer’s assessment requires strengthening across Nottingham CityCare Partnership.  All staff should be aware of when to offer carers assessment and how to achieve this.  A Nottingham CityCare Partnership strategy for carers should be developed.  6. All clinical staff working with individuals living with long term conditions should be confident and competent in assessing the impact of the long term conditions on  emotional wellbeing.  Enquiry regarding the emotional wellbeing should be included in assessments as standard.   EMAS No recommendations were made  Metropolitan Police No recommendations were made  NHS Direct The recommendations relate to the individual Nurse Advisor who has subsequently left the organisation. No wider learning or action has been identified.   Nottingham University Hospitals NHS Trust  1. Staff should explore wider family issues, obtaining and documenting a clear history, considering the impact of this information on the welfare of the family including any children or other dependents and taking actions as appropriate.  NHS Nottingham City  1. Information and a reminder to be issued to all GP practices in relation to the use of Benzodiazepines for managing anxiety  2. An audit to be undertaken in Primary Care of postpartum woman, up to one year post delivery, when anxiety /depression medication are being prescribed to assess compliance with guidelines for managing anxiety and depression.   40  NCSCB Submission Copy  3. To include “Think Family” strategies within GP training sessions. The effectiveness of the input will be monitored within the GP leads meetings on a quarterly basis by exploring case histories and discussing solutions to use in practice.   Nottingham City Council Children’s Social Care 1. Where a Contact or Referral results in there being no further action required by Children’s Social Care and it is felt that a CAF is needed this option box is ticked in the outcome letter sent to key agencies not just the referring agency    2. Parents and agencies must be contacted when gathering information for a Contact or Referral.  3. The protocol for the Children’s Assessment needs to outline practice expectations in responding to Initial Contacts and Referrals.  4. Children’s Social Care records need to include the rationale for decision making including planned follow up actions. For  EDT  this should include the rationale for safe and well checks not being conducted by EDT  5. This recommendation is for the consideration of the Overview Report Author. Given that there might have been a number of adult health services involved with F, it would be helpful if there was consideration for a strategic recommendation that those providing adult services should consider the needs of children, including whether parenting is impacted in situations where additional support has been required. Ideally this would include guidance on factors that may increase domestic stress or vulnerability.  Nottinghamshire Police 1. If there is any doubt or concerns around the mental health of an individual then an expert medical assessment should be sought in all cases particularly where there are safeguarding concerns around the capability to care for a child. 2. Improved safeguarding and vulnerability training for front line staff. In August 2013, Nottinghamshire Police commenced a new one day training delivery to all frontline police officers and police staff (Response and Neighbourhood Policing Teams).  The subject matter is ‘Vulnerability’ and aimed to support a holistic frontline approach to safeguarding and vulnerability, taking full consideration of mental health, substance misuse and domestic violence in both adults and children. This training has commenced and is on going. The training covers safeguarding adults and is the main focus of the training – it 41  NCSCB Submission Copy  details what vulnerability looks like and includes the vulnerability triangle and the referral process in both the County and the City.                        42  NCSCB Submission Copy  DRAFT Appendix 3:  DRAFT - NCSCB Strategic Action Plan  Recommendations Each agency that has completed an agency report has developed recommendations for their agency. The implementation of these recommendations is monitored through the NCSCB.  The following recommendations have been made for Nottingham City as a result of learning from this Serious Case Review. They reflect the analysis and learning points, taking into account progress already made. A Strategic Action Plan has been agreed to implement these actions this is attached below. This action plan will be monitored through the SCR Standing Panel, with further assessment of the evidence and impact on practice being undertaken by the NCSCB Quality Assurance Group.   • The revisions to the Family Support Pathway need to address the: o Barriers to providing early help including specific guidance on how to initiate early help o Guidance to adult services in contact with families o The role of GPs in the context of family support and safeguarding.  o Whether early help processes are robust enough to encompass a whole family perspective o Specific reference to the impact of parental health factors upon the parenting provided to dependent children.   • The Nottingham City Carer’s strategy needs to be meaningful to practitioners working with families and as such, awareness needs to be greatly improved. A referral pathway for carer’s assessment should be cascaded amongst agencies.   • NCSCB need to be assured by agencies that practitioners are equipped, in accordance with the nature of their role, to work confidently with cases where there are a number of issues of concern. The Excellence in Safeguarding tool developed by the NCSCB is an ideal mechanism to ensure this.   • Heath visiting services should ensure that any concerns regarding a parent’s mental health are routinely shared with the GP.   • NCSCB need to be assured by the relevant agencies that arrangements and requests for information exchange and visits to family out of hours are robust, clearly recorded, explicit and purposeful.   • Practitioners working with families need to recognise that the presentation of families can influence judgement and present an overly optimistic or positive picture. Practitioners require skills to be able to unpick what may lie behind the presentation and focus upon the child’s experience. A culture of professional curiosity needs to be embedded.   43  NCSCB Submission Copy   Outcome Recommendation Action By Whom Timescale (to be determined by SCRSP)  Evidence  1 Barriers to families receiving early help will be removed   Adult services and family GPs will have a clear reference point within the Family Support Pathway as to their role in family support and safeguarding.  Parental health factors and the impact of these on dependant children will be effectively identified, considered and acted upon.    The revisions to the Family Support Pathway need to address the: • Barriers to providing early help including specific guidance on how to initiate early help • Guidance to adult services in contact with families • The role of GPs in the context of family support and safeguarding.  • Whether early help processes are robust enough to encompass a whole family perspective • Specific reference to the impact of parental health factors upon the parenting provided to dependent children.  Revised Family Support Pathway to be completed CPB/NCSCB  Impact evaluation of Family Support Pathway  Quality assurance of CAF   2 Carer’s will be provided with appropriate support  The Nottingham City Carer’s strategy needs to be meaningful to practitioners working with Review of dissemination and implementation of Carer’s strategy NCC Adult Assessment   The number requests for carer’s assessments will 44  NCSCB Submission Copy   Outcome Recommendation Action By Whom Timescale (to be determined by SCRSP)  Evidence  families and as such, awareness needs to be greatly improved. A referral pathway for carer’s assessment should be cascaded amongst agencies.    Referral pathway available to practitioners including on line increase.  Source of referrals for carer’s assessments will be reflective of the wider workforce. 3 Families will be in receipt of assessments that are holistic and inclusive of all of their identified needs  NCSCB need to be assured by agencies that practitioners are equipped, in accordance with the nature of their role, to work confidently with cases where there are a number of issues of concern. The Excellence in Safeguarding tool developed by the NCSCB is an ideal mechanism to ensure this.  Review of the implementation and usage of the Excellence in Safeguarding tool NCSCB   All workers will apply the practice principles within the excellence in safeguarding tool in case management. 4 Parental mental Health needs are being appropriately identified and addressed within primary health  Heath visiting services should ensure that any concerns regarding a parent’s mental health are routinely shared with the GP.   Guidance is issued to health visitors and GPs reinforcing the need for communication  City Care Partnership  Early identification of parental mental health issues in evident within early help assessments  45  NCSCB Submission Copy   Outcome Recommendation Action By Whom Timescale (to be determined by SCRSP)  Evidence  5 Families in crisis are responded to effectively outside of office hours NCSCB need to be assured by the relevant agencies that arrangements and requests for information exchange and visits to family out of hours are robust, clearly recorded, explicit and purposeful.  An information sharing protocol between the key agencies out of hours is established  A protocol for safe and well visits is established Ratified by NCSCB   Protocols established and embedded 6 Workers will look beyond the presentation of families in order to avoid making judgments that could unduly influence their assessment   Practitioners working with families need to recognise that the presentation of families can influence judgement and present an overly optimistic or positive picture. Practitioners require skills to be able to unpick what may lie behind the presentation and focus upon the child’s experience. A culture of professional curiosity needs to be embedded.  Partner agencies to ensure that relevant assessment skills training encompasses the learning from this SCR and explores the barriers to effective assessment of the parent NCSCB partner agencies   Assessment skills training materials are quality assured by NCSCB     46  NCSCB Submission Copy   