Executive summary of a review into the death of a 10 month old baby who was the subject of a child in need plan, from a non-accidental head injury. The mother's boyfriend was convicted of manslaughter. The mother was 16 and living in a hostel. Considers issues around supporting young mothers and assessing the needs of the mother and the baby; disguised compliance, neglect; parenting capacity; assessing unknown men in the family; optimistic thinking; failure to take up support services offered; adolescent behaviour; substance misuse; capacity to challenge families and professional colleagues. Makes interagency and various single agency recommendations covering children's social care, housing, early childhood services; GPs and NHS Trusts and the police.
      
 Title:  Executive summary of the serious case review relating to Child G LSCB: West Sussex Local Safeguarding Children Board Author: Fiona Johnson Date of publication: 2013  This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC.  This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above.                          1         West Sussex Local Safeguarding Children Board  Executive Summary of  The SERIOUS CASE REVIEW relating to Child G 2  1 INTRODUCTION 1.1 Background to the review  The review was held because, whilst in the sole care of her mother’s partner, Child G sustained a catastrophic head injury caused by the use of significant force. Police investigation of the events resulted in mother’s partner being arrested and charged with murder; he was convicted of manslaughter for which he was sentenced to 8 years in prison.    1.2 The specific Terms of Reference for the case were  • The key relevant points/opportunities for assessment and decision making in this case in relation to the child and family? Do assessments and decisions appear to have been reached in an informed and professional way? Specifically:  o Were the decisions made at the CP Conference reasonable o In light of the Conference recommendation was the full extent of the role and responsibilities of mother’s partner in Child G’s life, and his ability to care for the child assessed appropriately? o Were there any indications of potential risk at any point during the period of review, and if so were they shared or acted upon appropriately and in a timely manner?  • The actions taken following assessments and decisions and whether appropriate services were offered/provided or relevant enquiries made, in the light of assessments?  Specifically:   o Did the Children in Need plans and services provided effectively meet the child’s needs?   • The degree to which the child’s needs were taken into account when making decisions about the provision of children’s services, and whether this was accurately recorded? • The sensitivity of practice to the racial, cultural, linguistic and religious identity of the family and any issues of disability or other diversity issue relating to the child and family, and whether this was explored and recorded? • Was there sufficient management accountability for decision making and the involvement of managers at key points in the case?  • The adequacy of training and supervision of staff to carry out their role? • The consistency of work with each organisation’s and the Local Safeguarding Children Board’s policy and procedures for safeguarding and promoting the welfare of children, and with wider professional standards?  • Any organisational difficulties being experienced within or between agencies and whether there was a lack of capacity or resources in one or more organisations? • Any examples of good practice or lessons to be learned about single and multi-agency working? • Any recommendations you would make to the West Sussex Local Safeguarding Children Board regarding training, practice or procedures? 3  Later information was provided by the police that became available via their criminal investigation. This information indicated that Child G was exposed to drugs over a period of time. As a result all agencies were asked to provide an addendum report indicating to what extent did they consider substance misuse by any adults involved with Child G to be a factor.  1.3 The serious case review panel membership was as follows: • Jane Browne, Surrey and Sussex Probation Trust: Chair  • Designated Nurse • Manager, Early Childhood West Sussex County Council • LSCB Business Manager  • Sussex Police • Managers, Children Social Care West Sussex County Council  Additionally Fiona Johnson, the Independent Overview Writer attended review Panel Meetings.  1.4 Reports were received from the following sources: • West Sussex County Council Children Social Care  (including the Child Protection Unit),  • West Sussex County Council Early Childhood (Children and Family Centre and outreach)  • Sussex Police,  • A Residential Hostel,  • Sussex Community NHS Trust  (Health Visiting),  • NHS Sussex Cluster (West Sussex)   (GP)  • Western Sussex Hospitals Trust  (A&E, Midwifery and Child Development Centre) • Health Overview Report  1.5 Additionally reports were received from a number of agencies who had limited contact with the family during the relevant period but who had information that would assist the review. Reports were received from: -  • A London Hospital • South East Coast Ambulance NHS Trust  • Borough Council Housing Department • A domestic violence victims advisory service  Checks were also undertaken with Connexions and the Youth Service with regard to any involvement that they may have had.   1.6 Consideration was given to involving the parents in the review process however this was not immediately possible because of on-going criminal investigations. When the criminal trial was completed contact was made with mother and maternal grandmother and maternal grandfather. The independent overview author met with 4  mother and maternal grandmother and their views are included later in the report. Numerous unsuccessful attempts were made to arrange a meeting with maternal grandfather however this was not achieved. The father was offered to see a copy of the report prior to full publication.  2 THE FACTS 2.1 The Family background Name1  Relationship  Age Ethnicity  Child G  Subject baby White British Carly G Mother 17 years White British Russell S Father  19 years White British Chris B Mother’s Partner 26 years Dual heritage white British/black Caribbean Maureen G Maternal Grandmother Unknown White British Mark G Maternal Grandfather Unknown White British Pam B Chris B’s mother 44 years White British   2.1.1 Child G’s parents are white British and their first language is English; religious affiliations are unknown. Chris B is dual heritage, white British/black Caribbean, his first language is English and his religious affiliation is unknown. Child G was the first child of Carly and Russell and their relationship ended soon after Child G’s birth. Carly started her relationship with Chris B when Child G was very young. Child G and Carly were living in a hostel as a result of Carly becoming homeless during her pregnancy, following a disagreement with her mother. Prior to being pregnant Carly worked as a hairdresser; however, for the period of the review she was in receipt of benefits. Chris B had a criminal record for minor drugs offences. Russell S was known to the police and he had been involved in incidents of domestic abuse but had no criminal convictions. Carly had some support from her father and was also supported by Chris B’s mother.   2.2 Agency Involvement with family 2.2.1 The first significant agency involvement with Carly was when she booked for her confinement early in her pregnancy. She was identified as a potentially vulnerable mother by virtue of her youth and received an enhanced service from the midwife with whom she developed a positive relationship. At this stage Carly was in a relationship with Child G’s father although they were not living together.  2.2.2 Early in the pregnancy Carly had to leave her mother’s home and was provided accommodation in a hostel for vulnerable young mothers. The hostel offered Carly                                                            1 Grace, Carly, Chris B  etc are the names given by West Sussex LSCB to provide anonymity 5  a range of services aimed at improving practical skills such as cookery and money management. Child G was born after a difficult labour where Carly experienced an eclamptic fit; but was a healthy baby of normal weight.  2.2.3 Soon after Child G’s birth there was an incident of domestic abuse between Carly and Child G’s father which resulted in their relationship ending. Carly received support at this time from all agencies via a Multi-agency Risk Assessment Conference (MARAC2) domestic violence support plan. At this point Carly was being supported mainly via the health visitor but an assistant care manager (ACM) from Children’s Social Care was also involved. Carly started a relationship with Chris B two months later.  2.2.4 Carly’s care of Child G was initially supervised by the midwife and then health visitor and during the first three months the care was deemed ‘good enough’ although there were some concerns that Child G was left unsupervised in the room in the hostel. Soon after Carly started her relationship with Chris B the health visitor received a referral from a person who reported that Carly was not coping, was feeling low and had no milk for Child G. The health visitor found Carly with ‘made-up’ feeds that were not refrigerated and no further formula; she also said she had few clothes for Child G that fitted. Carly seemed low but said that she had more formula at her boyfriend’s flat which she visited regularly. Child G was seen and seemed well and had gained a little weight. The health visitor was concerned about the poor management of money and the lack appropriate care regarding Child G’s formula and reported these concerns to the ACM.  2.2.5 The ACM discussed these concerns with her manager and following this a visit was undertaken by the ACM and a Senior Practitioner. This visit took place at Chris B’s flat as Carly was staying there. This visit raised further concerns regarding the care being provided to Child G as the conditions within the shared house were poor. There was evidence of cannabis use in the bedroom and it became apparent that Child G had spent the night in a bouncy chair as there was no travel cot despite Carly having previously told the ACM that this was where Child G slept when they stayed over at the house.  2.2.6 Following further discussion with the manager and a strategy discussion with the police it was agreed that an appropriate way forward was to convene a child protection conference. At this stage the police considered that there was no need for a joint section 47 investigation. The evidence of need for a child protection conference was limited being based on the two visits by the health visitor and ACM; the concerns that were raised were that Child G was at risk of chronic neglect, Carly failing to prioritise Child G’s needs and Carly associating with people involved in drug-use.  2.2.7 The decision of the conference was that there would not be a child protection plan but that Carly and Child G would be supported via a child in need plan. The                                                            2 Multi-Agency Risk Assessment Conferences (MARACs) are meetings where information on high risk domestic abuse victims is shared between local public agencies. By bringing all agencies together to share information, a coordinated safety plan can be put together to support the victim. Around 250 MARACs operate across England, Wales and Northern Ireland. http://www.caada.org.uk/marac/MARAC.htm 6  recommendations from the conference included that the core assessment should be updated and an assessment of Chris B undertaken; that Carly should attend all appointments and engage in support offered by the Children and Family Centre including a parenting course and independent life skills course; that Carly should be supported regarding housing difficulties and any recurring difficulties regarding domestic abuse from Russell; that a family group conference be considered; and finally that a contract of expectations should be drawn up which would specify the need to have a further child protection conference if Carly did not co-operate with services provided. The child protection conference was not attended by the hostel who sent a report or by the GP who was not invited.  2.2.8 Soon after the conference; and following a review of the police file by a supervising officer, Sussex Police determined that there should be an unannounced visit to Chris B’s accommodation to check regarding possible substance misuse. Sussex Police made contact with the student social worker to arrange a joint unannounced visit. This was delayed for over four weeks as Chris B had moved address and there were difficulties in getting the new address from Carly. Eventually there was a joint visit but it was not unannounced due to miscommunication between the police officers and the student social worker. When the visit was undertaken the flat was seen to be clean and tidy and was newly decorated, there was no evidence of drug-use and the officer visiting considered that Chris B appeared to be making an effort to provide a suitable home environment for Carly and Child G.   2.2.9 Immediately after the conference all agencies found it hard to make contact with Carly who was also spending significant periods away from the hostel. She continued this behaviour for the next six to eight weeks having an increasingly contentious relationship with staff at the hostel as she was unhappy that other residents were rehoused before she was. During this time Carly spent significant periods away from the hostel and was also in rent arrears.  2.2.10 At this time the student social worker was attempting to work in partnership with Carly and had drawn up a contract of expectations and had an outline child in need plan. Neither of these documents were shared with other agencies; and although there were planning meetings held, these were disorganised, and minutes of the meetings were rarely circulated. Carly was unwilling to attend the children and family centre but did undertake some direct work with the student social worker.  2.2.11 After the student social worker had been working with Carly for approximately four months she appeared to become more co-operative and started to spend greater time at the hostel. At this time she also paid off her rent arrears possibly with assistance from her father. As a result of the progress the hostel indicated that Carly would be able to move into permanent accommodation in the near future and the student social worker thought that sufficient progress had been made for the child in need plan to be downgraded to a CAF plan co-ordinated by the children and family centre staff or health visitor.  2.2.12 The day before Child G sustained the life threatening injury, the child was seen by the health visitor and student social worker who both visited, separately, but on the same day. The student social worker visited in the morning and considered that all was well with Carly and Child G. Carly told the social worker that Child G had fallen 7  onto the headboard of the bed the previous week and mentioned a bruise to the head. The student social worker could not see any sign of an injury. The health visitor called later in the afternoon and was not told by Carly of the fall. The health visitor examined the child who was seen to be ‘babbling, smiling, sitting, crawling, weight-bearing and exploring [the] environment’; ... height and weight were normal and no problems were identified’.  2.2.13 Later that day Carly took Child G to stay overnight with Chris B; she left Child G in Chris B’s care and returned alone to the hostel. It had been agreed that he would care for Child G to enable Carly to sleep as she was very tired. At some point that night Child G experienced a life-threatening injury that eventually lead to the child’s death.  3 VIEWS OF FAMILY MEMBERS 3.1 Carly was clear that in her view there was nothing that could have been done to prevent Child G dying, as no-one knew that Chris B would harm Child G; and, since the death nothing further had been identified that would have indicated that he posed a threat to the child’s safety. 3.2 Carly was also very clear that she had never seen Chris B taking drugs apart from occasionally smoking cannabis which he always did outside, away from Child G. Carly said that she never took any drugs, even cannabis, and would not have remained with Chris B if she knew that he was taking other drugs.  3.3 Carly was asked about the support that was provided to her, before and after Child G’s birth. She indicated that prior to the birth she was assisted by the midwife, although she was surprised that the input was an enhanced service. After the birth she felt everything was acceptable until a person contacted the health visitor and made untrue allegations about her care of Child G. Carly said that the child protection conference held after this was a difficult meeting; and did not enable her to express her point of view, or to tell people the truth. Particular inaccuracies were that Child G had not slept overnight in a bouncy chair, but in a carry-seat that was part of the push-chair and was meant to be used as a travel cot for babies. Also there were plenty of toys and clothes available. 3.4 Carly agreed that after the conference she was not very co-operative with professionals as she was angry that they had not listened to her. She was also unhappy that other girls had been re-housed from the hostel ahead of her. Carly said that she did not like it at the hostel as there were mouse droppings in her room and on her bed. Carly said that this was the reason that she did not pay her rent rather than because she did not have money. Although she also said that Chris B was often short of money and that she used to feed him. Carly paid off her rent arrears independently without any assistance from her father and said that the staff at the hostel did not offer any support in enabling her to learn to manage her money. 3.5 Carly confirmed that she were unaware that there was a child in need plan and had not signed any written agreement and felt that while the social worker was visiting she received  very little support but had to go to a lot of meetings which was sometimes unhelpful. 8  3.6 The maternal grandmother was able to offer little in addition to Carly’s views. She said that she had never met Chris B and had no contact with Carly for the period of the review. Maternal grandmother’s major concerns were about the effect that publication of the case review would have upon Carly who was emotionally vulnerable. 4 KEY THEMES IDENTIFIED BY THE REVIEW PROCESS  4.1 Skills in engaging families 4.1.1 A significant issue identified in this review was the extent to which any professional was able to engage and build a positive working relationship with Carly. With the possible exception of the midwife it does not appear that any professional found it easy to engage Carly and there is some evidence that she avoided contact and could be deceptive in her responses.  4.1.2 This ambivalence and unwillingness to engage was however not clearly understood by the agency system as Carly was also very adept at diverting professional attention by being critical of other professionals. This is most overt in her relations with staff at the hostel but could also be seen in some of her responses to the student social worker and health visitor. For instance there were a number of occasions when the student social worker contacted the health visitor on Carly’s behalf rather than encouraging her to take responsibility for resolving matters with the health visitor directly. Carly was also very adept at appearing to be positive about future involvement in support services which she then failed to attend. This behaviour was apparent with regard to attendance at the parenting groups and involvement with the sessions offered by the hostel.  4.1.3 Adolescents are often difficult to engage and a pattern of partial co-operation is not unusual from teenager mothers. There were aspects however of Carly’s behaviour, particularly after she became involved with Chris B, that were more representative of a pattern of behaviour observed in other serious case reviews where families show disguised compliance. This is described in research as being ‘where parents defused professionals’ attempts to take a more authoritative stance by making pre-emptive shows of cooperation… The family’s compliance was only temporary but it was sufficient to persuade workers of their apparent willingness to be more open and therefore kept them at bay.’ 3 Ostensibly the family seemed to co-operate with the professionals but in fact this was illusory and the pattern of engagement included ‘deliberate deception, disguised compliance and “telling workers what they want to hear”, selective engagement and sporadic, passive or desultory compliance.’4   4.1.4 Whilst there was significant involvement by agencies with Carly and Child G and much time was invested in helping her improve their circumstances; it was clear from the IMRs that very little was known about their day-to-day life. In particular it was very unclear to what degree Chris B was involved in direct care for Child G and whether it was intended that when Carly moved into independent living that Chris B would be living with her.                                                             3 Reder et al (1993), 4 P 76 Understanding Serious Case Reviews and their Impact – Brandon, Bailey, Belderson, Gardner, Sidebotham, Dodsworth, Warren and Black, DCSF 2009 9  4.1.5 As a result of meeting with Carly and receiving her contribution to the review process the overview author considered that Carly’s lack of compliance was mainly a product of her youth. It was clear that no professional was able to engage her however this was not because she was deliberately manipulative but was a feature of her inexperience. It is possible that a greater understanding of her adolescent ambivalence by professionals might have enabled better partnership working.  4.2 Quality of supervision 4.2.1 It is clear that all staff were receiving regular supervision; however, there is some concern as to the quality of the supervision provided; in particular whether it sufficiently challenged professionals in their attitudinal perspectives. Reder and Duncan argue that front-line staff need to develop ‘a dialectic mind-set’ in which there is a constant balancing of opposing arguments, alternative hypotheses or conflicting versions of events. 5 Similarly in ‘Working together to safeguard children’ it is suggested that professionals ask themselves:  • Would I react differently if these reports had come from a different source? • What were my assumptions about this family and what, if any, is the hard evidence supporting them?6  4.2.2 The absence of clear analysis of the major risk factors in the core assessment initially undertaken by the ACM would argue that the supervision and oversight provided to her work did not provide her with sufficient challenge and scrutiny. Similarly the supervision provided to the student social worker was practically oriented and there was little evidence that it questioned the developing optimism about the apparent change that was being achieved. The role of the supervisor should be to provide independent and objective challenge and if that had been available it seems unlikely that the drift in child care planning and failure to effectively engage with Carly would have remained hidden. Despite discussion in supervision about agreeing a contract of expectations there was apparently no consideration of actions that should be taken if the contract was breached.  4.2.3 There was some evidence of challenge provided in the police oversight however the delay in arranging the follow-up visit and the move to a pre-arranged appointment would indicate that this was not sufficiently robust.  4.2.4 The health visitor was clearly receiving regular supervision and there was a child centred approach as indicated by the decision to maintain health visitor continuity when the GP changed. The supervision seemed however to be led by the health visitor and there was no evidence that the supervisor queried whether there was sufficient improvement or enabled the health visitor to challenge the student social worker perspective about the effectiveness of the child in need plan.  4.2.5 Overall the extent to which the supervision provided to professionals provided the opportunity for critical reflection is dubious given the failure                                                            5 Reder & Duncan Lost Innocents 1999, p98 6 Department of Health, Home Office, Department for Education and  Employment, 2006: p113 10  by any agency to critically analyse the purpose and functioning of the child in need planning process. The exception to this would be the police supervision of the initial section 47 investigation; unfortunately the follow-up to this intervention was less effective and the delay in action influenced the outcome.  4.3 Significance of substance misuse  4.3.1 Substance misuse was never identified as a key issue in the assessment of this family despite there being some evidence that Chris B used drugs and at one time lived in a house where it was suspected that there was drug-dealing. The significance of this issue was not recognised at the initial strategy discussion as it should have resulted in a joint section 47 investigation. This error was however identified during supervising police officer review of the work and rectified.  4.3.2 It is clear that the state of Chris B’s first flat was a significant factor in the ACM’s perspective that an initial child protection conference should be held. This issue however then became absorbed into a general concern about Carly’s neglect of Child G rather than focussing on what could have been the reason for the neglect. No professional linked the neglectful parenting with possible substance misuse.  4.3.3 One reason for this may well have been that there was very little evidence that Carly was involved in drug-use. She was never seen to be intoxicated by professionals and there was only one referral alleging alcohol abuse which was received after Child G’s death. The evidence of drug use may have been hidden as professionals had very limited access to Chris B’s accommodation and it is probable that he was the source of any drugs.   4.3.4 Since Child G’s death there have been two allegations by family members that the child was given alcohol by adults however there is no other evidence to support these assertions. Neither of these alleged incidents were known about by professionals prior to Child G’s death.  5 LESSONS LEARNED FROM THE REVIEW 5.1  The importance of effective engagement of families and the need for assertive and inquiring interventions that include all adults, particularly men in the assessment process. Alongside this the review identified the difficulty of working with teenager mothers; and the problems of distinguishing between ‘usual’ adolescent behaviour, and more problematic, ‘passive resistance’. A key factor for professionals working with families is their capacity to challenge and confront when outcomes are not achieved; regardless of the underlying causes.  5.2   The need for challenging and empowering supervision that enables professionals to review their work effectively. This needs to engender sceptical review and the capacity to re-evaluate existing presumptions. The challenge for supervisors is to be sufficiently aware of progress in work with families whilst still maintaining a degree of independence and scrutiny. It is crucial that supervisors do not solely rely on the supervisee to raise issues.  5.3  The need for improved child in need planning processes. These systems need to have multi-agency involvement and ownership and must ensure that there is 11  sufficient capacity and capability to review the effectiveness of the child in need plan. This evaluation needs to include an on-going consideration of the assessment process which allows for re-assessment as time progresses and enables an evidence–based approach to casework planning.  5.4 The importance of greater awareness and consideration of substance misuse and the ways in which it may influence and affect parents and carers’ abilities to provide safe and consistent care for children particularly the more vulnerable babies. This understanding requires that professionals move beyond outward signs such as direct use of drugs and alcohol and consider other factors such as money management and availability as other indicators of possible substance misuse.  5.5 The importance of ensuring that all appropriate persons are invited to conferences and receive minutes within reasonable time frames.   6 CONCLUSIONS 6.1 Even with the benefit of hindsight there has been no evidence identified that Chris B presented a risk of physical harm to Child G. It must be acknowledged however that very little was known about him or about the level and nature of care that he was providing to Child G. If the work undertaken with agencies had been significantly different there would be no guarantee that Child G’s death could have been avoided. The reality is that there was limited information held by any agency to indicate that Chris B posed a risk to Child G and the review has not been able to identify any information that could have been accessed that would have shown that he was unsuitable to be caring for the child. 6.2 With hindsight it is clear that Child G was exposed to drugs. The issue of substance misuse was not fully addressed in any professional assessment of Child G and the mother. It is possible that if there had been a more thorough investigation of this issue when it was first raised then the risks to Child G might have been identified. 6.3 It is possible that if an effective assessment had been undertaken investigating the concerns regarding substance misuse that this would have identified further information about Chris B but it is equally possible that this would not have provided any additional knowledge.  It is therefore not clear how this death could have been prevented.  7 RECOMMENDATIONS  LSCB  7.1 That the West Sussex LSCB ensures that the learning is shared with all relevant staff.  7.2 That the West Sussex LSCB ensures that the recommendations in all of the completed IMRs are implemented by regular review of individual action plans.  7.3 That the LSCB ensures that all relevant member agencies are engaged with and fully understand the child in need planning processes including the use of ‘contracts of expectation’.  12  7.4 That all relevant agencies should satisfy the West Sussex LSCB that assessment processes include due consideration of the involvement of fathers  and/or partners in the child's life. Where possible this should include their effective involvement in the process.  7.5 That the LSCB request all agencies examine their supervision of professionals who work with children in need. Agencies to report on whether supervision arrangements are sufficiently robust and capable of challenging and sceptical review.  7.6 That the LSCB undertake a review of multi-agency working with families where substance misuse is considered; following the launch of the ‘Think Family’ protocols  7.7 That the LSCB requests the Children’s Safeguarding Unit to review the processes regarding invitations to and distribution of minutes from child protection conferences.  WSCC CHILDREN’S SOCIAL CARE 7.8 To ensure agency checks are completed and recorded on Framework I within all Section 47 enquiries (7.5.9)  7.9 A review of the quality of Child in Need Plans arising from an Initial Child Protection Conference (7.5.4)  7.10 Improve the quality of assessment in relation to the following;  • children alleged to be suffering from neglect. (7.2), • parenting capacity of teenage parents (7.1) • the role and impact of new partners in relation to the child (7.5.2) • ensure all CIN plans include a contract of expectations (7.5.4).  7.11 Improve the quality of student supervision in relation to casework practice, analysis and planning, allocation of cases and understanding of working in a multi-professional context.   7.12 Raise awareness of the value of Family Group Conferences or family meetings in Children in Need plans.  (7.5.7)  SUSSEX POLICE 7.13 That any changes to the existing Police processes for the way information is shared and recorded are subject of post implementation audit and review.   WSCC EARLY CHILDHOOD  7.14 Establish a single strategic oversight for Safeguarding and Family Support activities within ECS - (reference paragraph 10.1 in Section 10 ‘Learning Points’.)   7.15 The implementation of a case file structure for Family Outreach Worker Service – to ensure consistent practice across the service - (reference paragraph 10.2 in Section 10 ‘Learning Points’).  7.16 Ensure consistent practice for casework supervision with related record keeping – (reference paragraph 10.3 in Section 10 ‘Learning Points’.) 13   7.17 Family Outreach Service to have clear and consistent care planning requirements which ensure focus on children’s needs and related improved outcomes  - reference paragraph 10.4,  10.5 and 10.6 in Section 10 ‘Learning Points’.  7.18 To ensure that diversity issues are routinely considered in all contacts with children and their families – (reference paragraph 10.7 in Section 10 ‘Learning Points’.)  HOSTEL,  7.19 Improve record keeping.  7.20 Align Hostel ISP and CIN Plan reviews and Safeguarding processes.  7.21 Review Visitor Time procedures to ensure robust risk assessment of visitors to vulnerable tenants.  7.22 Revise Hostel Safeguarding policy and procedures to make more comprehensive.  7.23 Revise Confidentiality and Data Protection policies.  7.24 Develop Trustees understanding of Safeguarding.  7.25 Improve management and sharing of key information.  7.26 Increase manager involvement in Safeguarding cases.  7.27 Review all Safeguarding cases.  SUSSEX COMMUNITY NHS TRUST (HEALTH VISITING), 7.28 Sussex community Trust to ensure that HV assessments meet the required Core Service Standard.  7.29 Sussex Community Trust to ensure that practitioners who attend child protection conferences are fully conversant with the process.  7.30 Sussex Community NHS Trust Child Protection and Safeguarding Children Procedures to include clear guidance on the roles and responsibilities of health professionals within integrated working on a CIN plan.  WESTERN SUSSEX HOSPITALS TRUST  7.31 Where there are vulnerabilities recognized at clinic consultations, letters should be copied to relevant parties such as the health visitor, with the consent of the individual  7.32 Although the A & E visit of 1st September 2010 appears to imply a minor illness, it is unclear that there was any regard taken of her social situation. This should be reviewed using the new paediatric A&E flow chart to trigger the assessment of vulnerabilities.  14  7.33 Although safeguarding training and the hospital procedures provide clarity on how the safeguarding team can be accessed to support staff and help with progressing safeguarding concerns, this should be strengthened.  7.34 There are not any copies of the PICU retrieval documentation in the notes; this should be remedied by the provision of an HDU/PICU retrieval pathway, or copies of PICU documentation should be added to the medical notes.  NHS SUSSEX CLUSTER (WEST SUSSEX) (GP) 7.35 That NHS Sussex Cluster (West Sussex) advise all GPs in West Sussex that when the GP hears of a child protection conference being scheduled, they ensure that they have been invited and if they are unable to attend they send a report and also advise GPs that the GP contacts the social worker if they do not receive a report after the conference.  7.36 That the NHS Sussex Cluster (West Sussex) advises GP surgeries in West Sussex to ensure that their practice nurses document which adult attends with a child for vaccinations and whether they have parental responsibility and they document why a vaccination has been given later than advised if this has happened.  7.37 NHS Sussex Cluster (West Sussex) requests that the Acute Trusts that are commissioned by them ensure that their Accident and Emergency Discharge Summaries are legible so that GPs and Health Visitors and others are able to identify any concerns from the records.  7.38 NHS Sussex Cluster (West Sussex) commission future midwifery services to include a requirement for midwives to document antenatal and postnatal consultations within the GP medical notes.  7.39 Recommendation that NHS Sussex Cluster (West Sussex) carry out an audit of all West Sussex GP Surgeries to discover which GP surgeries hold a regular multi-disciplinary child safeguarding meeting (to include GPs, practice staff, health visitors (HV), school nurses (SN) etc) and to encourage those surgeries that do not hold such meetings to introduce them.  SUSSEX COMMUNITY NHS TRUST & WESTERN SUSSEX HOSPITALS NHS TRUST 7.40 Sussex Community NHS Trust and Western Sussex Hospitals NHS Trust to review the system for receiving and processing Child Protection Conference invites and documentation, to ensure there is a clear audit trail of receipt of information and that non receipt of expected documentation is followed up appropriately.     Fiona Johnson January 2013 