Death of a 4-month-old baby boy from a serious head injury in December 2011. Both parents had been looked after as children, had experienced childhood abuse and were chronic substance users. Father had two older children who had been removed from his care and had been living with adoptive parents for a number of years. History of prolific paternal offending including convictions for actual bodily harm, harassment and threatening behaviour. Identifies themes for learning including: establishing a professional lead in multi-agency processes; need for acquiring comprehensive social histories from parents; understanding the needs of children not yet born or too young to express emotions or feelings; recognising unemployment and poverty as risk factors; recognising disguised compliance and maintaining a sufficient level of professional scepticism; impact of coercive relationships on vulnerable women; and engaging men and fathers. Sets out key findings using a systems based typology developed by SCIE and raises issues for consideration in regards to the identified themes for learning. Includes Lancashire Safeguarding Children Board's response to findings.
      
 Title:  A serious case review: 'Baby E': the overview report LSCB: Lancashire Safeguarding Children Board Author: Peter Maddocks 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.                          overview report baby E publication version Page 1 of 90        Lancashire  Safeguarding Children Board       A Serious Case Review  ‘Baby E’  The Overview Report      October 2012     overview report baby E publication version Page 2 of 90 Index  1 Introduction and context of the review ..................................................... 4 1.1 Rationale for conducting a serious case review .................................... 4 1.2 The methodology of the serious case review ....................................... 4 1.3 Reasons for the review and terms of reference .................................... 6 1.4 The scope of the serious case review .................................................. 7 1.5 The terms of reference in national guidance ........................................ 9 1.6 Particular issues identified by the SCR panel for further investigation by the individual management reviews: ............................................................... 10 1.7 Membership of the case review panel and access to expert advice ........ 11 1.8 Independent author of the overview report and independent chair of the serious case review panel ......................................................................... 12 1.9 Parental and family contribution to the serious case review ................. 13 1.10 Time scale for completing the serious case review .............................. 13 1.11 Status and ownership of the overview report ..................................... 14 1.12 Previous serious case reviews ......................................................... 15 1.13 Inspections of services for children in Lancashire and Calderdale ........... 15 1.14 Summary conclusion of the review panel .......................................... 16 1.15 The family and other significant people ............................................ 22 1.16 Cultural, ethnic, linguistic and religious identity of the family ................ 23 2 Synopsis of agency involvement ............................................................. 25 3 The critical reflection and analysis from the individual management reviews. . 30 3.1 Summary .................................................................................... 30 3.2 Significant themes for learning that emerge from examining the IMRs ... 30 3.3 Good practice identified through the review ...................................... 31 4 Analysis of key themes for learning from the case and recommendations ...... 69 4.1 Learning from previous serious case reviews ..................................... 70 4.2 Innate human biases (cognitive and emotional) .................................. 70 4.3 Responses to incidents or information .............................................. 76 4.4 Longer term work ......................................................................... 77 4.5 Tools .......................................................................................... 79 4.6 Management systems ................................................................... 82 4.7 Issues for national policy ................................................................ 84 5 APPENDICES ....................................................................................... 87 Appendix 1 - Procedures and guidance relevant to this serious case review ....... 87 Legislation ............................................................................................. 87 The Children Act 1989 .......................................................................... 87 The Children Act 2004 .......................................................................... 87 Safeguarding Procedures ......................................................................... 88 The local safeguarding children procedures .............................................. 88 Other local procedures relevant to this serious case review ........................ 88 Multi-Agency Pregnancy Liaison and Assessment Group (MAPLAG) .............. 88 National guidance ................................................................................... 89 Working Together to Safeguard Children (2010) ........................................ 89   overview report baby E publication version Page 3 of 90 Framework for the Assessment of Children in Need and their Families 2001 .. 89 Common Assessment Framework (CAF)................................................... 90    1 Preface: 11 July 2013  This report was completed in late 2012 but could not be shared with family members or published until after the conclusion of associated criminal proceedings. Since the report was completed, MO and FI both pleaded guilty to child neglect and received custodial sentences. The final report has been shared with MO and she did not wish to add anything to the content of the report.   Following the conclusion of this review in late 2012 the Department for education has published revised guidance for the completion of serious case reviews. This review was completed using the statutory guidance in place during 2012.   overview report baby E publication version Page 4 of 90 Introduction and context of the review  1. In December 2011 Baby E, aged four months was admitted to hospital in Lancashire in the early hours of the morning with serious head injuries, said by his parents to have been caused by a heavy object having fallen onto him. He was transferred to a specialist children’s hospital outside of the county, where he died the following day. MO and FI were both present when the incident had occurred and had called the ambulance.  2. The circumstances of the death are still subject of an ongoing investigation by the police and a coroner’s enquiry.  3. Baby E was the only child of MO.  She had moved back to the county from Calderdale soon after the birth of Baby E in the summer of 2011.   4. FI was born in West Yorkshire. He has two older children who had been removed from his care and placed for adoption more than ten years previously while he was living in West Yorkshire.   5. The decision to commission a serious case review was not taken until the results of toxicology tests of the parents and other evidence identified that the circumstances of Baby E’s death was suspicious. As soon as this information became available it was referred back to the child death panel and a serious case review panel was commissioned. Further information is provided in section 1.3.  1.1 Rationale for conducting a serious case review  6. Regulation 5 of the Local Safeguarding Children Board Regulations 2006 requires a Local Safeguarding Children Board (LSCB) to undertake a review of a serious case in accordance with procedures set out in chapter 8 of Working Together to Safeguard Children (2010).   7. The LSCB should always undertake a serious case review when a child dies and abuse or neglect is either known or is suspected to be a factor in their death.   1.2 The methodology of the serious case review  8. A serious case review panel was convened of senior and specialist agency representatives to oversee the conduct and outcomes of the review. The panel was chaired by an independent and suitably experienced person.   9. Work began on compiling a chronology in May 2012, which coincided with the appointment of the independent chair of the serious case review panel and of the independent author of this overview report. Neither the chair nor   overview report baby E publication version Page 5 of 90 the overview author has worked for any of the services contributing to this serious case review. Further information about their relevant experience and knowledge is provided in section 1.8.  10. This serious case review was completed using the methodology and requirements set out in current government national guidance that applied at the time of the review being commissioned and completed. That guidance is being extensively revised following the publication of the Munro Review’s final report and recommendations in 2011.   11. The government has indicated that it supports changes recommended by Professor Eileen Munro that future serious case reviews should be conducted using systems based learning methodology; details about what that methodology and framework will be had yet to be finalised when this review was completed.   12. The LSCB in Lancashire are already working on how future serious case reviews in the county can be developed in order to provide a more productive window into the local systems for safeguarding and protecting children1 and have participated in regional and national pilot work on using system learning within serious case reviews developed by SCIE (Social Care Institute for Excellence).  13. In the meantime this review and the overview report have complied with current requirements. The analysis in the final chapter of this report uses some of the framework developed by SCIE to present key learning within the context of local systems. This also takes account of recent work that suggests that an approach of developing over prescriptive and SMART recommendations have limited impact and value in complex work such as safeguarding children2. The final chapter of the review for example explores the influence of family and professional interactions, the responses to incidents and the tools that are used by professionals to help inform their judgments and decisions.                                            1 Analysis of clinical incidents; providing a window on the system not a search for root causes. CA Vincent; Quality and Safety in Health Care, 2004;  The article argues that incident reports by themselves tell comparatively little about causes and prevention, a fact which has long been understood in aviation for example and is the basis of developing a systems learning approach to serious case reviews in England.  2 A study of recommendations arising from serious case reviews 2009-2010, Brandon, M et al, Department of Education, September 2011 The study calls for a curbing of ‘self perpetuating and proliferation’ of recommendations. Current debate about how the learning from serious case reviews can be most effectively achieved is encouraging a lighter touch on making recommendations for implementation through over complex action plans   overview report baby E publication version Page 6 of 90 14. It is important to state that this is not a SCIE review that has used systems methodology to collect and analyse information from the people directly involved with the family. The panel have worked to place the evidence that has been analysed into a framework that begins to explore how the local systems both promote and in some circumstances inhibit professional practice and decision making.   15. The panel agreed case specific terms of reference that provided the key lines of enquiry for the review and were additional to the terms of reference described in national guidance. The panel established the identity of services in contact with the family during the time frame agreed for the review. For services that had significant involvement they were required to provide an independent management review (and are listed in section1.4). These reports were completed by senior people who had no direct involvement or responsibility for the services provided to the children and their parents.   16. An overview of the health agencies was provided in a health overview report. This was provided jointly by Calderdale and Lancashire health services and was co-ordinated by the designated nurses for safeguarding in NHS Calderdale PCT and  the PCT for this area of Lancashire.  1.3 Reasons for the review and terms of reference  17. The reason for undertaking this review is that Baby E may have died as a result of negligence. The death was reported to the Lancashire Safeguarding Children Board (LSCB) on 19th December 2011 and considered by the serious case review (SCR) panel on 9th January 2012. At that point there was insufficient information to enable a decision to be made as to whether the circumstances of Baby E’s death met the national criteria for undertaking a serious case review, as it was unclear at that time whether this was more than a tragic accident.   18. The matter was considered again by the SCR panel on 5th March 2012, when more information was available. However, the police investigation was ongoing and it was not yet clear whether anyone might be held responsible for the death.   19. On 13th April 2012 both adults were charged with child neglect and MO was also charged with gross negligent manslaughter. The SCR Panel met on 1st May 2012 and decided, in the light of information that had become available, that the criteria for a serious case review were met. The review was commissioned by Nigel Burke, the independent chair of the Lancashire Local Safeguarding Children Board (LSCB) on the 1st May 2012. A serious case review panel was convened and was chaired by Annie Dodd who is independent of all the services involved.     overview report baby E publication version Page 7 of 90 20. The serious case review panel at their first meeting on the 30th May 2012 confirmed the scope and terms of reference. The scope and terms of reference of the review was routinely discussed and updated at subsequent panel meetings to take account of any new or emerging information and reflection.   21. The purpose of the review is to establish what lessons are learned from the case through a detailed examination of events, decision-making and action. In identifying what those lessons are, to improve inter-agency working and better safeguard and promote the welfare of children in Lancashire and Calderdale.  1.4 The scope of the serious case review  22. The time period covers the lifetime of Baby E, including the time his mother was pregnant with him. The time of conception was late 2010 and Baby E died in December 2011.   23. All information known to a service providing an IMR was reviewed. Any information regarding involvement prior to the period of the detailed chronology and analysis was summarised in the IMR and the health overview report.  24. The SCR also sought to establish if there was anything in the parental history, or the history of either parent, that could and should have led to different actions and decisions being made in respect of Baby E. Therefore all agencies were asked to check their records for mother and father and to include anything of note in their IMRs.  25. All agency chronologies included detailed information about when the child was seen or observations were made about him.   26. Agencies that identified significant background histories on family members pre-dating the scope of the review provided a brief summary account of that significant history.   27. Reviews of all records and materials were considered including;   Electronic records   Paper records and files  Patient or family held records.  28. Individual management reviews were completed using the template provided by the Lancashire Local Safeguarding Children Board (LSCB), and were quality assured and approved by the most senior officer of the reviewing agency.    overview report baby E publication version Page 8 of 90 29. The following agencies have provided an individual management review that was to be completed in accordance with Working Together to Safeguard Children (2010), Chapter 8 and the associated LSCB guidance and relevant procedures.   Health services in Lancashire that include:  o A Lancashire Hospital NHS Trust (provided post natal and paediatric services after MO moved to Lancashire and provided hospital treatment) o Lancashire NHS Care Foundation Trust o Lancashire NHS General Practitioner   Inspire (the specialist substance misuse service in Lancashire that worked with MO but not FI)  Lancashire County Council Children’s Social Care (received a faxed referral from Calderdale CSC after Baby E and MO had moved to Lancashire)  Lancashire Sure Start Early Years (had accepted a referral but had not formally begun involvement prior to Baby E’s death)  Calderdale Children’s Social Care (aware of the family from May 2011 through duty service but never an allocated case)  West Yorkshire Police Service  South West Yorkshire Partnership NHS Foundation Trust (provided specialist substance misuse services who worked with MO and FI)  Calderdale and Huddersfield NHS Foundation Trust (provided the midwifery service)3  Calderdale Community Health Services (GP)  Calico (housing provider in Lancashire)4  30. Information was sought from other services although these agencies were not required to provide an IMR.    Bradford and District Care Trust (FI known to the drug dependency service historically over several years)                                          3 MO was involved with Calderdale Substance Misuse Service (CSMS), and was therefore under the care of the Eden team specialist midwife service which links into MAPLAG (multi agency pregnancy liaison and assessment group); further information is provided about the protocol in later sections of the report. FI was known to have mental health problems and was also receiving a service from CSMS and was on a Methadone programme. As a consequence of her substance misuse and Methadone programme, MO was managed throughout the antenatal period by a multi-agency perinatal service hosted by Calderdale Substance Misuse Service (CSMS) managed by South West Yorkshire Partnership Foundation Trust (SWYPFT). Included in this service was the Eden team substance misuse midwives (CHFT). Running concurrently alongside this service was the MAPLAG assessment process and a safeguarding integrated care pathway (ICP)   4 Calico was not commissioned to provide an IMR until after the first meeting of the panel in June 2012.    overview report baby E publication version Page 9 of 90  Central Manchester University Hospital NHS Foundation Trust (Baby E was admitted by ambulance following the head injury and is where he died)  North West Ambulance Service (responded to the initial emergency call after Baby E was injured and transferred him to Central Manchester)  NHS Direct  Consultant paediatrician’s report for the panel in regard to whether injuries identified after death could have been identified by any of the professionals in contact with or visiting Baby E and his family; the report confirmed that although Baby E would have exhibited symptoms of distress at the time the injury was incurred it would not have been obvious to professionals visiting after the incident  Yorkshire Ambulance Service  31. Because of the involvement of services from two other local authority areas, those LSCBs were invited to participate in the serious case review. Calderdale had been involved during the timeline established for the review and provided IMRs from the CSC and health trusts included in the list of agencies in paragraph 24. Bradford’s involvement had been more historic and therefore information reports were provided on behalf of CSC and health services. Reference is made to this information later in the report.   1.5 The terms of reference in national guidance a) Keep under consideration if further information becomes available as work is undertaken that indicates other agencies should carry out individual management reviews.  b) To establish a factual chronology of the action taken by each agency;  c) Assess whether decisions and action taken in the case comply with the policy and procedures of the Lancashire Safeguarding Children Board;  d) To determine whether appropriate services were provided in relation to the decisions and actions in the case;  e) To recommend appropriate inter-agency action in light of the findings;  f) To assess whether other action is needed in any agency;  g) To examine inter-agency working and service provision for the children;  h) To establish whether interagency and single agency policies adequately supported the management of this case;  i) Consider how and what contribution is sought from the family members;     overview report baby E publication version Page 10 of 90 j) To develop a clear multi agency action plan from the overview report.  1.6 Particular issues identified by the SCR panel for further investigation by the individual management reviews5: 32. In addition to analysing individual and organisational practice, the individual management reviews should focus on:  a) Examine whether all agencies and professionals gave due and proper consideration to all diversity issues, including ethnicity, religion, language, disability, culture, social background and integration.  b) Examine whether all agencies kept the child and his experiences at the centre of their assessments of and interventions with the family.  c) Examine whether information sharing and communication systems within and between agencies and across boundaries were effective in safeguarding Baby E.  d) Examine whether historical information was given appropriate emphasis within assessments and interventions. This relates to mother and father's histories, extending to others where this is relevant to the period under review and thus the care of Baby E. This should include any assessments of the mother’s entitlement to support in relation to her care history, drugs, alcohol and domestic violence and any pre-birth assessments of the needs of Baby E. It should also include any relevant information about the father’s older children. Any relevant historical information prior to the timescale for the Review should therefore be summarised and included in IMRs. e) Examine whether agencies fully understood any issues about parental substance misuse and mental ill health and the impact this had on Baby E and took appropriate actions. f) Examine whether agencies dealt with any domestic violence issues appropriately and considered the risks to Baby E from those issues? g) Examine whether any safeguarding and child protection issues were identified and dealt with appropriately by agencies. Consider whether agency responses were correct and timely and whether safeguarding procedures were followed appropriately. Consider whether professionals relied for information on the self reporting of parents, and how far this influenced the safeguarding and protection of Baby E. Consider whether there were any barriers or difficulties in the child receiving services.                                          5 These are the detailed issues that are analysed by the IMRs and in the detailed analysis in chapter fours and five of this report.    overview report baby E publication version Page 11 of 90 h) Consider whether agencies had the necessary resources and capacity. Consider also whether professionals working with the family were suitably skilled and adequately supervised and whether there is evidence of management accountability and support. Consider whether any organisational changes impacted on work with this family. i) Consider whether there are any common themes from previous serious case reviews or critical incident reviews and the effectiveness of your agency’s actions in relation to these.  1.7 Membership of the case review panel and access to expert advice  33. An independent person was appointed to chair the case review panel from the outset. Section 1.8 includes information about her experience and knowledge.   34. The case review panel that oversaw this review comprised the following people and organisations;   Position Organisation Annie Dodd Independent Chair Directorate Safeguarding Manager Children’s Safeguarding Services LCC Early Years Lead Quality and Continuous Improvement Service, LCC Temporary Deputy Head of Children's Social Care Children’s Social Care Services LCC Strategic Safeguarding Lead Nurse  Lancashire Care Foundation Trust Detective Chief Inspector Lancashire Police Service Acting Service Manager Safeguarding and Quality Assurance Service Calderdale Commissioning and Partnership Care Senior Young Peoples Substance Misuse Co-ordinator  Lancashire Drug and Alcohol Action Team Designated Nurse for Safeguarding Children NHS Calderdale  Designated Doctor NHS Lancashire Designated Nurse NHS Lancashire Named Nurse Safeguarding Children South West Yorkshire Partnership NHS Foundation Trust (SWYPFT) Detective Inspector West Yorkshire Police Service Associate Director for Safeguarding Calderdale and Huddersfield NHS Foundation Trust Safeguarding Lead Adults A Lancashire Hospitals NHS Trust   overview report baby E publication version Page 12 of 90 Floating Support Service Manager Calico Enterprise Panel Observers/Support Peter Maddocks Independent Author Business Manager Lancashire Safeguarding Children Board (LSCB) Business Manager Calderdale Safeguarding Children Board (CSCB) Business Manager Bradford Safeguarding Children Board (BSCB)   35. The independent author of the overview report attended every meeting of the panel.  36. The panel had access to legal advice from a solicitor in the council’s legal service.  37. Written minutes of the panel meeting discussions and decisions were recorded by a member of the LSCB staff team in Lancashire.  1.8 Independent author of the overview report and independent chair of the serious case review panel  38. The independent chair of the serious case review panel was Annie Dodd. Ms Dodd was previously employed as an assistant director with a local authority children’s social care service and has over 30 years experience as a qualified social worker. Ms Dodd is now self employed as a consultant. She has previously chaired a serious case review for Lancashire SCB but has no other connection with Lancashire Safeguarding Children Board and has not been involved in any aspect of the management of the case.  39. Peter Maddocks was commissioned in May 2012 as the independent author for this overview report. He has over thirty-five years experience of social care services the majority of which has been concerned with services for children and families. He has experience of working as a practitioner and senior manager in local and national government services and the voluntary sector. He has a professional social work qualification and MA and is registered with the General Social Care Council (superseded from August 2012 by the Health and Care Professionals Council (HCPC). He undertakes work throughout the United Kingdom as an independent consultant and trainer and has led or contributed to several service reviews and inspections in relation to safeguarding children. He has undertaken agency reviews and provided overview reports to several LSCBs in England and Wales as well as work on domestic homicide reviews. He has undertaken work as an overview author on a previous serious case review in Lancashire. Apart from this, he has not worked for any of the services contributing to this serious case review.    overview report baby E publication version Page 13 of 90 1.9 Parental and family contribution to the serious case review  40. The parents were made aware of this serious case review when it was commissioned. Both have been charged with criminal offences relating to Baby E's death, and contact with them has to be managed very carefully with assistance from the police to ensure their involvement does not impact on the criminal processes. The arrangements are subject of national guidance that has been agreed between chief constables (ACPO), the chairs of LSCBs and the Crown Prosecution Service (CPS) in England.  41. The parents were sent a letter giving them information about the SCR via their solicitor. There has been no response from either MO or FI or from their solicitors.   42. The maternal great grandparents were sent a letter. There was no response. The chair of the panel made contact with them both by telephone to explain the process of the SCR and to establish if either of them wished to make a contribution to the information examined by the SCR panel. Both have confirmed that they did not want to meet the chair of the panel. The maternal great grandfather said that when they saw their great grandson he was fine and therefore he had nothing further to say. The maternal great grandmother expressed her view that parents who are using alcohol or drugs should receive more visits; the review has confirmed that there were additional levels of contact by the health visitor and midwife. Both maternal great grandparents indicated that they felt certain no other member of the family would want to speak with the chair of the panel.  43. The maternal great aunt was contacted by letter initially and no response was received. A follow up telephone call was made by the chair of the panel although was unable to get a reply.  44. The maternal uncle and aunt were contacted by letter and no reply was received. The chair of the panel made contact by telephone and spoke with the maternal aunt who said that she had no issues to report in regard to the services who were in contact with MO. She felt that it was for the family to have noticed if something was wrong and if services were not given any concerns it was not the fault of the professionals. She did not want to provide any further information.   45. Another maternal aunt was also contacted by letter and by telephone although no reply was achieved.     1.10 Time scale for completing the serious case review    overview report baby E publication version Page 14 of 90 46. The case review panel met on six occasions between May 2012 and October 2012. The initial chronology of services involvement was completed by June 2012.  The first draft agency reviews were completed in June 2012. The first draft of the health overview report was completed in September 2012. This overview report was presented to an extraordinary meeting of the participating LSCBs in October 2012.  1.11 Status and ownership of the overview report 47. The overview report is the property of the Lancashire Safeguarding Children Board (LSCB) as the commissioning Board and Calderdale LSCB who provided IMRs and Bradford LSCB that has provided background information. Both Bradford and Calderdale LSCBs had representation at the SCR panel. The overview report and executive summary has been provided to all three LSCBs.  48. Since June 2010, all overview reports provided to LSCBs in England have to be published in full. This overview report provides the detailed account of the key events and the analysis of professional involvement and decision making in relation to Baby E and his family.   49. The report has to balance maintaining the confidentiality of the family and other parties who are involved whilst providing sufficient information to support the best possible level of learning.   50. In reading this report, it is important to remain clear about the purpose of the overall review and of this overview report in particular. The review examines with the benefit of hindsight, if it possible to identify whether alternative judgments and decisions could or should have been taken, and whether different outcomes might have been achieved for Baby H. The review does not investigate the circumstances of Baby H’s death. That is a matter for the Coroner and for the police.  51. The review aims to be very challenging of all services for the purpose of building on the considerable knowledge and expertise that has developed in relation to the safeguarding of children in the UK. In doing this work, the panel are mindful about how complex or unclear some of the information and events may have looked to practitioners at the time of events.  52. An executive summary was provided at the conclusion of the review. This provides a brief summary of events and the most significant points of learning identified as a result of the review. The LSCB will determine how and what further information is provided to the family at the conclusion of the   overview report baby E publication version Page 15 of 90 review and following the submission of the overview report and executive summary to the Department of Education6.    1.12 Previous serious case reviews  53. The LSCB in Lancashire had undertaken nine previous serious case reviews between 2007 and 20107. Calderdale has published three executive summaries of serious case reviews between December 2008 and December 2009. Bradford has published four serious case reviews between 2006 and 2010.   54. Reference is made by several IMR authors to some of these and other previous serious case reviews completed in other parts of the country and is also referenced where relevant in this overview report. The purpose of this is to highlight where similar issues or themes have been identified in previous reviews. This ensures that action already recommended is not unnecessarily repeated.   55. Chapters four and five of this review describe in greater detail the specific lessons to emerge from a detailed analysis of this serious case review and include comments on how learning from previous reviews has been used.  1.13 Inspections of services for children in Lancashire and Calderdale  56. All children’s services in England are subject to inspections. Lancashire was subject to a Comprehensive Annual Assessment (CAA)8. In December 2011 the CAA annual rating given to children’s services in Lancashire was performing well9. This means that services were above minimum national standards.   57. The CAA letter highlights that although many aspects of contact, referral and assessment arrangements for children in need and children who may be in need of protection are satisfactory a number of areas required attention.                                          6 In England, Ofsted have the responsibility for evaluating the thoroughness of the serious case review. The executive summary includes a statement about that evaluation.  7 The coalition government’s notice issued on the 10th June 2010 under section 16(2) of the Children Act 2004 which amended the previous national guidance in Working Together to Safeguard Children requires that both the executive summary and the overview report with suitable redaction to provide confidentiality are published. The coalition government ended the formal evaluation of SCRs from the 5th July 2012.  8 The coalition government announced the abolition of the CAA from 2010. 9 This profile includes findings from across Ofsted’s inspection and regulation of services and settings for which the council has strategic or operational responsibilities, either alone or in partnership with others, together with data from the relevant Every Child Matters indicators in the new National Indicator Set (NIS).   overview report baby E publication version Page 16 of 90 These included the uneven distribution of experienced and newly qualified staff within social work teams and the under-developed use of the common assessment framework across the partnership. However, focused action is being taken by the local authority and plans are in place to address immediate deficiencies. These factors are identified as being contributory factors in how aspects of this case were managed.  58. In early 2012 there was a statutory inspection of safeguarding and looked after arrangements in Lancashire10. This evaluated safeguarding arrangements as good in Lancashire with a well managed child protection service; Baby E was not subject of any child protection plan. The inspectors commented that the local authority contact, referral and assessment arrangements had been comprehensively redesigned. This had already had a positive impact. The quality of referrals made by partner agencies seen was good. Child protection enquiries were prioritised and responded to effectively to ensure children are safe. The CART (children’s referral and assessment team) had already led to improvements in the management of contacts and referrals but there were a small number of examples where referrers had not been satisfied with the CART and not all aspects of the service were subject to rigorous audit.  59. The last annual assessment of children’s services in Calderdale found children’s services to be performing poorly. A full inspection of safeguarding and services for looked after children undertaken in January 2011 had assessed services to be inadequate. The inspectors had found serious weaknesses in services to safeguard children and young people and it continues to be the major area of development for Calderdale. The local authority still needed to improve the inconsistent application of thresholds for access to children’s social care. In front-line services improvements needed include: the quality of referrals from partner agencies; aspects of management in the First Response service; inconsistency of recording, including recording management decisions on the electronic recording system; the timeliness of completing assessments and the frequency of staff supervision. Aspects of these issues are reflected in the case that is subject of this serious case review.  1.14 Summary conclusion of the review panel  60. The purpose of conducting a serious case review is to undertake a detailed examination of the events within the context of understanding how the                                          10 The inspection was carried out under section 138 of the Education and Inspections Act 2006. It contributes to Ofsted’s annual review of the performance of the authority’s children’s services, for which Ofsted will award a rating later in the year, subject to any changes that the coalition government may introduce. The inspections are part of a national programme of enhanced inspection of children’s services introduced in 2009 following the death of Peter Connolly (Baby P) and the two subsequent serious case reviews in Haringey.   overview report baby E publication version Page 17 of 90 judgements, decisions and actions were taken by the various professionals involved with Baby E and his family for the purpose of drawing out learning to inform future policy, service development and individual practice.   61. The Munro Review commissioned by the coalition government in 2010 has emphasised the importance for learning and improving services and practice by looking at information within the context of people’s professional and organisational arrangements and the information they knew at the time of events. Hindsight can distort and mislead and cause the focus to fall on how individuals behave and act rather than understanding how they are influenced by a range of contributory factors.   62. The influences on practitioners doing their work effectively include the stability of the organisation they work in, their personal workload and more generally of their services, the quality of their training and knowledge, the clarity of working arrangements in matters such as recording and sharing essential information as well as their cognitive functioning (how they are processing and analysing information). These were all important in understanding this case.  63. When MO became pregnant with Baby E it was recognised as being a pregnancy that required additional support. The Calderdale MAPLAG (multi agency pregnancy liaison assessment group) procedures11 were invoked and were the principal framework for co-ordinating information about MO’s lifestyle and circumstances which were never defined as a significant risk to the safety of her baby. This was because professionals in Calderdale and then in Lancashire initially believed that MO had separated from FI and had no intention of sharing the care of Baby E.   64. Although the MAPLAG involved relevant professionals from different services there was a lack of shared clarity about the purpose of the framework and what was expected from the different participants. There was also insufficient clarity about the leadership and coordination of any action plan. This contributed to a pattern of contact with the family that was characterised by people working within their agency ‘silos’. When information such as MO acknowledging she used drugs shortly before the birth or the faltering growth before and after birth was observed it was largely dealt with as a separate episode along with inconsistencies regarding the status of the relationship. When information was provided to CSC it was subjected to a ‘start again’ approach. These are all familiar patterns identified in other reviews at a regional and national level.                                            11 The appendix provides a fuller explanation of the protocol which is used in Calderdale but not in Lancashire.    overview report baby E publication version Page 18 of 90 65. The HOR comments about how the MAPLAG provided an appropriate sharing of information at the outset but this did not lead on to a more robust assessment of risks or referrals and enquiries using the safeguarding protocols. The fact that CSC attended the MAPLAG may have encouraged other participants to believe that this removed any responsibility to consider whether a referral was required. The parents’ history of substance misuse, domestic violence and mental ill health were known to some extent from the outset (but detailed information was not collated) and should have been recognised as potential and significant sources of risk before and after birth.   66. Information about FI having had two previous children removed from his care was also partially known. The HOR comments about how extensive and significant information was known about both parents that were not accessed at the time. More could have been done to access historical information although the review identifies the difficulties faced by individual professionals knowing who and where to get information from.  67. The HOR comments about the problems that arise in complex service arrangements where there is contact with a family by several professionals who then record their information within their individual patient records. Both HOR authors experienced some difficulty in developing a clear narrative about this case and for busy professionals with limited time for contact and follow up this is a significant issue.    68. The parents’ history of drug and alcohol misuse was known about and there was also knowledge about the domestic abuse that characterised previous and the current relationship; professionals were persuaded that the relationship between the parents had ended before the birth and that MO was intent on establishing an independent household near her family in Lancashire. This provided false reassurance that persisted for several weeks that also reflected insufficient sceptism and understanding about the difficulties facing a pregnant woman leaving a relationship at the point of her first baby being born and the fact that FI was unlikely to relinquish contact with MO or his baby.   69. MO was also expressing intent about tackling her addictions and other problems and professionals were genuinely motivated and wanted to help her. This was a significant influence on how some services approached the provision of help and support and remained an important influence up until a few days before Baby E became injured. They did not feel that they were working with a reluctant or resistant parent and they were led to believe that she was not in a relationship with FI; this involved some deliberate misdirection on the part of both parents. The manner in which professionals especially in the CSMS in Calderdale dealt with the information about the ‘blips’ of drug use reflected a minimisation of concerns and probably provided encouragement to MO and FI that they could influence and misdirect attention.   overview report baby E publication version Page 19 of 90  70. Another important influence was the organisational capacity of some key services at the time. For example, CSC in Calderdale had been inspected by Ofsted and this had found safeguarding services to be inadequate. This had immediate repercussions in terms of the senior leadership and overall staffing of the service. Some senior people left or were moved and it also became difficult to recruit or to retain staff. There was a high reliance on temporary staff some of whom were not very experienced. People who should have been providing supervision and guidance had to become involved in direct case work and this further exacerbated the problems of capacity in providing the correct degree of critical challenge and reflection.   71. This had consequences for how the case was handled and the priority that was given to it. Insufficient information was sought about FI as well as MO. Assessments were not adequately conducted. Insufficient notice was given to Lancashire when MO was discharged from hospital and moved to Lancashire.  72. The reliance on MAPLAG whilst the case was managed in Calderdale inhibited the capacity of professionals to identify the underlying patterns and to be misdirected by the apparent openness and engagement of MO. For example, MO missed several midwife appointments before giving birth to Baby E and was also missing appointments with the substance misuse service. Matters were further compromised by insufficient attention to recording and sharing information; for example MO was tested positive for drugs as well being negative for methadone (which signified not taking it over several days which should have raised queries as to how she was managing her drug dependency). Two toxicology tests were not shared outside of the CSMS. The HOR has made recommendations to deal with this significant shortcoming.  73. Although there was an apparently good exchange of medical information that was known to midwifery services and community health (but did not include significant historical information or knowledge about a pattern of drug use) at the point of transfer, there was no pre-discharge meeting in Calderdale; this was a requirement of the MAPLAG.  A contributory factor appears to be the uncertainty about where MO was going to be living and the fact that she took her discharge early from hospital. The belief that MO was not going to be living with FI misdirected attention and concern away from the other factors relating to MO’s own history and circumstances which were incompletely known about.   74. For example, the fact that both FI and MO had experienced troubled childhoods that had involved abuse and that they had been looked after in public care was not apparently understood at the time. This comment is not to suggest that adults who have been looked after are not good parents. It is however important for professionals working with a first time mother in particular to understand the potential impact of a history of abuse and   overview report baby E publication version Page 20 of 90 attachment difficulties for example and the implications for appropriate emotional as well as physical care of a baby.   75. In this case, the impact of a coercive relationship and substance misuse were additional factors contributing to a potentially toxic interplay and axis of risk and impaired care. MO had begun using drugs during her adolescence including cannabis. There is research evidence about the impact of long term drug use that begins in adolescence exacerbating and influencing the cognitive functioning in adults; this has implications for memory, learning new skills, behaviour control and interpersonal functioning; all attributes that are relevant for the transition to parenthood.  76. The information in regard to social and family circumstances was not complete largely because basic enquiries had not been undertaken at the outset or in subsequent referral and other key moments; this was not initially known and understood in Lancashire in regard to the gaps in the information that existed in Calderdale and therefore persisted in Lancashire; when it was recognised there were further delays in being able to take appropriate action and making enquiries.   77. In particular the history of FI and the fact that he never showed any intention of accepting that the relationship with MO was over was never recognised until he was identified as being in the house in November. The notification to CSC in Lancashire did not highlight any safeguarding concerns. There was a delay in the information being looked at and then further delay in following up historical information particularly about FI. MO had been known to CSC and had in fact been looked after by the local authority for some years; this information was largely overlooked.   78. When Baby E died he and his family were receiving universal and additional support from the community health visiting team (Child and Family Integrated Team CFIT). The mother received regular support from CFIT services however there were regular no access visits and it is now known that she had withheld information from the named heath visitor (HV1) about her relationship with Baby E’s father. Due to the history of vulnerabilities and concerns about the father the family were known to social care and were due to start an assessment at the time of Baby E’s death. The family were seen on two occasions by the specialist safeguarding health practitioner who was co-located with CSC.   79. The family received additional targeted support due to the vulnerability factors within the family. The CFIT service uses a weighting tool which highlights children and families with additional needs to inform the level of help. This family were weighted ‘amber’ (proactive support to maintain and improve family and environmental factors) from 26th August 2011 and changed to ‘red’ (instability with family and environmental factors impacting upon parenting capacity & substance misuse affecting health or impacting   overview report baby E publication version Page 21 of 90 upon parenting capacity) on 21st September 2011. This weighting reflected the escalating nature of the needs of the family. It did not at that stage lead to a CAF being raised.   80. The decision to escalate the weighting followed concerns about inappropriate feeding practices; MO was believed to be diluting the formula milk and there were concerns about faltering weight gain. A referral by the specialist midwife for a paediatric opinion resulted in the paediatrician requesting that further information was sought regarding the family’s social circumstances.   81. A telephone discussion took place between the midwife and CSC in Lancashire; this revealed no concerns because at that stage Lancashire CSC were still largely working with information sent from Calderdale and there was a shared belief that FI was not in the household and that he was the primary source of concern.    82. In This part of Lancashire the CAF is routinely used and there is an expectation that a social risk assessment is completed and shared by midwives for all births in this part of Lancashire; this was not completed for Baby E as he had been born in Calderdale. This provides an example of how the application of a national framework such as CAF differs between local areas.   83. Both parents had experienced abuse and violence as children and both had been using drugs and alcohol for which they were receiving help and treatment. Although some of the history of the parents was known there were significant gaps in what professionals knew until well after Baby E was born. This meant that relevant historical information was not considered in terms of assessing risk or providing a more informed assessment about the type of support that MO needed encouragement to take up.  84. Although there was recognition that Baby E was a higher risk pregnancy, and interagency discussions were convened, these were not followed up with enough thoroughness and speed. An important factor was the impaired functioning of the referral and assessment services due to staffing and workload difficulties in both Calderdale and Lancashire. In Calderdale these difficulties were more longstanding whilst in Lancashire some of the issues that had an impact on the handling of this case reflected the fact that more staff had been recruited but were inexperienced and required training.  85. Although professionals were empathetic to MO as a vulnerable young woman, they relied too much on MO’s assertions that the violent relationship with FI was ended. The barriers that MO faced as an abused and coerced woman and the implications of her history of substance misuse were not sufficiently understood within a framework of research informed knowledge and respectful sceptical enquiry and challenge.   overview report baby E publication version Page 22 of 90  86. The impact of longstanding problems such as addiction, depression, violence and poverty are significant on parents and families where these are factors. The impact on those trying to help should not be underestimated. Baby E lived in some of the most deprived communities in north England.  87. In the last few days before Baby E sustained the injury that caused him to be admitted to hospital professionals had begun to realise that there was a deteriorating set of circumstances; MO was using drugs and the recognition that the relationship with FI was not over had led to a decision to begin a detailed assessment. Baby E died before this work was started.  88. Although the panel believe that action could have been more urgently undertaken it remains unlikely that Baby E would have been removed from his mother’s care at the time he was injured.  The expert paediatric report provided to the panel confirmed that evidence of injuries was only evident to professionals after the post mortem; no injuries had been observed prior to his death.   89. If information had been better shared and managed from before his birth it is highly probable he would have been the subject of either a child in need plan or rather more likely given the range of risks and the disguised parental non compliance, a child protection plan would have been in place.   90. The difference this would have made is that all the services would have been working to a common plan; there would have been a more comprehensive level of enquiry and assessment that gave more adequate attention to historical and current information and there would have been an explicit focus on the risks associated with both parents. This would either have achieved a better informed level of cooperation or would have provided the basis of further escalated action that might have involved taking the matter to court. This would probably have not been completed in the timescale before Baby E was tragically injured even if the work had started prior to his birth.  1.15 The family and other significant people  91. MO was aged 24 years old when Baby E died and FI was 41 years old.  92. MO was looked after by the local authority in Lancashire from 1994 and was subsequently supported by the leaving care service until 2008. MO has a history of using drugs and alcohol. By the time she became pregnant she was on a methadone support programme.  MO had experienced domestic abuse over many years.  93. FI had also been looked after in local authority care in Yorkshire from the age of 12 years old. His two older children born to a previous partner when he   overview report baby E publication version Page 23 of 90 was not living in Lancashire were the subject of child protection plans because of neglect and have lived with their adoptive parents for several years.  94. MO and FI are both long term users of drugs that have included heroin and cocaine. Both have received support from a range of services that have included substance misuse agencies; for MO in Yorkshire and Lancashire although FI was not in contact with services in Lancashire and therefore kept himself invisible to professionals in Lancashire until November 2011. FI has also had support from mental health services although had withdrawn from this help in late 2010.   1.16 Cultural, ethnic, linguistic and religious identity of the family  95. Baby E’s maternal and paternal families are white British. MO identified herself as being white British, Catholic and unemployed. MO identified FI as being white British, non religious and was also unemployed. MO’s first language is recorded as English and there is no recorded physical or learning disability. There is no record of the social background history or partner history in regard to Baby E. Baby E was living with his parents in rented accommodation at the time of his death.   96. Lancashire has a population of 1.16 million, which is projected to grow by almost eight per cent to 1.23 million by 2028. The county comprises a mixture of urban, rural and coastal communities and covers twelve district councils four of which (Burnley, Hyndburn, Pendle and Preston) rank in the top 30 most deprived districts in the country (Index of Multiple Deprivation 2007).   97. Five per cent of the population are from minority ethnic backgrounds, predominantly Pakistani and Indian, clustered mainly in parts of  this area of the county and in one other area. More recently, small but growing numbers of people from Eastern Europe have begun to settle across the county, with concentrations in Lancaster and Preston.   98. A total of 20 per cent of children across the county are income deprived according to the Index of Multiple Deprivation 2007. Six areas (three in Burnley, two in Preston and one in West Lancashire) are ranked in the two per cent of the most deprived in England for child poverty and 9.5 per cent of children in Lancashire live in super output areas ranked among the 10 per cent worst nationally for income deprivation.   99. The area where MO and Baby E were living in Lancashire is within the top one per cent of socially deprived areas as identified by the Index of Social Deprivation- Department of Communities and Neighbourhoods-2010. This in effect means that many families are presenting with extremely high needs such as poverty, ill health, domestic violence, substance and alcohol misuse,   overview report baby E publication version Page 24 of 90 infant low birth weight, teenage mothers, isolated single parents and homelessness. The children’s centre has between 2,500 and 3,000 service users registered at any one time and by definition a significant proportion of families and children is vulnerable and requiring substantial help and support.     100. Calderdale has a relatively static population and is relatively prosperous when compared to other metropolitan boroughs but still has significant areas of deprivation. Calderdale is ranked in the lowest third of authorities in the indices of deprivation. Parts of the area where FI and MO lived in Calderdale are considered to be amongst the most deprived areas in the country. These areas are characterised by incomes below the national average, low levels of employment, and below average education attainment and skills levels. The proportion of children currently living in over-crowded conditions substantially exceeds the national average, as does the number living in households without central heating.    overview report baby E publication version Page 25 of 90 2 Synopsis of agency involvement   101. This narrative summary of professional contact with Baby E provides an account of the most significant events and decisions from the different services involved with Baby E during the timeframe established for the review.   102. For example there are more contacts and visits with primary health care workers than are referred to in this synopsis. There is historical information that is referred to by IMR authors but is not described in detail. For example FI had contact with CSC in respect of his older children who were placed for adoption; he has had extensive contact with specialist substance misuse services and mental health support.   103. The police have also had extensive contact with FI since the early 1980’s in connection with offences that have been primarily in relation to theft although there had been convictions for ABH and threatening behaviour. The police had dealt with an incident of domestic violence in August 2009 that involved FI assaulting MO until another male intervened; this summary includes details of the incidents that the police dealt with between November 2010 and December 2011.  104. This summary, and indeed the whole overview report, has to strike a balance between protecting the confidentiality of the children, their family and the various people who were in contact with them whilst providing a sufficiently detailed account of events in order to draw out the points for learning and development in the later chapters.  105. MO had originally moved to Calderdale in 2008 because of violence that she was subjected to by a relative. It is not clear when MO and FI began their relationship although in late 2010 she returned to Lancashire to live in a refuge because of domestic violence.   106. FI has a long history being a prolific offender with twenty six convictions for forty nine offences since 1983 for predominantly theft offences. One conviction was for actual bodily harm in 1993, with convictions for threatening behaviour in 1989 and 2000 and a conviction for harassment in 1998.   107. FI first came to the notice of mental health services in Calderdale in 2008; he had previous contact with services in Bradford.  FI withdrew from the mental health support services in late 2010. Both parents were supported by specialist drug services. FI was reluctant to allow any information about his involvement with mental health services or drug services to be shared with professionals working with MO.    overview report baby E publication version Page 26 of 90 108. In early 2011 FI had made contact with MO following a chance meeting; his efforts to persuade MO to resume their relationship was initially rejected although by early February 2011 MO had become pregnant with his child.   109. It was noted by the specialist drug services that FI appeared to be displaying controlling behaviour towards MO. MO confirmed the coercive nature of the relationship in separate discussions and described FI as being possessive, paranoid and controlling.  110. MO was referred to MAPLAG (Multi-Agency Pregnancy Liaison Group) on 26th February 2011; this is an arrangement that operates in Calderdale but not in Lancashire. The Calderdale MAPLAG was established in response to a recommendation from a previous SCR. The MAPLAG protocol is designed to co-ordinate support for women who are identified as using drugs and/or misusing alcohol.  MO’s pregnancy was discussed for the first time at MAPLAG at 20 - 24 weeks of gestation in May 2011.  111. MO was described as ‘engaging very well, having only missed a few appointments’; she missed seven appointments with the CSMS and contact was by text on five other occasions during her pregnancy. No concerns were expressed in relation to MO; however concerns were expressed in relation to FI’s mental health. It is recorded in the minutes that FI’s last clinical record was dated January 2011 with a diagnosis of ‘displaced psychotic episodes, mental health has been stable for 12 months’; FI was reported to not think he had issues with regard to his mental health (that included a specific diagnosis). An action from this meeting was for the SWYPFT representative to do further checks on FI’s mental health history. It is recorded that FI was well known to the police and had two children who live with their adoptive parents; however it was noted that FI was unwilling to share any further information regarding them.  112. There is no evidence that the incident of domestic violence between MO and FI in early December 2010 and MO’s return to Lancashire to go into a refuge was disclosed or discussed at the MAPLAG meeting. Reference to domestic violence is made in the minutes of the meeting held on 6th May; however this appears to be in relation to MO’s move to Calderdale following domestic violence from her relative and in respect of FI and his previous partner.   113. MO continued to be managed throughout her pregnancy by the staff at SWYPFT - CSMS in addition to the Substance Misuse Midwife from the CHFT Eden Team and the prescribing GP’s, employed by SWYPFT. CSMS, who oversaw the prescribing of substitute medication for MO during the course of her pregnancy. MO failed to attend appointments with CSMS on seven occasions, on five of these occasions it is recorded that contact with the service was made by text message with a request that her prescription was   overview report baby E publication version Page 27 of 90 either forwarded to the nominated pharmacy or given to FI. FI was informed after one of these missed appointments when he collected a prescription that MO would not issue any further prescriptions without being seen in person.  114. MO underwent urine drug testing on three occasions. The test in May 2011 was positive for methadone only but the two subsequent tests in July were both positive for cocaine with one positive for cannabis. These results were not reviewed and shared by the specialist drug services and therefore collectively analysed by health professionals in the context of the effect these drugs, in particular cocaine, would have on Baby E either before or following his birth.   115. The GP providing the methadone prescription did not review the toxicology results and recording in regard to MO referred to her being ‘abstinent for illicit drugs’. The same information was reported to the MAPLAG. The MAPLAG never made a formal referral to CSC in Calderdale. Although the MAPLAG meeting in July discussed the possibility that FI had previous children removed this was not confirmed and a plan to arrange a follow up MAPLAG was not followed through.   116. By the summer and before the birth of Baby E, MO was indicating her intention to move back to Lancashire and that she intended to separate from FI. The belief that MO was drug free and that FI was the significant source of risk meant that risks to Baby E were regarded as being low although health care professionals continued to recognise the need to provide support through enhanced visiting by health visitors for example. This was formalised through the caseload weighting given to the case.  117. Although CSC in Calderdale attended the MAPLAG meeting this was not regarded as a reason for direct involvement by CSC. When Baby E was born a week prematurely (35 weeks) a referral was made to CSC. CSC contacted Bradford and established that he had two previous children removed and placed for adoption although the precise circumstances were not established during the telephone conversation.   118. CSC made the decision that an assessment would take place if MO remained in Calderdale but if she moved to another area then a referral would be made to that authority. Discussion at MAPLAG in August 2011 had established that FI did not recognise his mental health needs and it was confirmed that previous children had been removed although the circumstances had still not been clarified.  119. The referral to CSC did not lead to a fuller assessment. The fact that Baby E was in hospital and that MO intended to leave Calderdale led the CSC in Calderdale to adopt a wait and see approach as to where MO moved. This decision meant that no detailed information was secured in respect of history   overview report baby E publication version Page 28 of 90 or the circumstances of Baby E’s parents. The fact that MO was regarded as being positive about contact and support from other services also reduced any degree of further curiosity.  120. MO discharged herself and Baby E from hospital against medical advice. No discharge meeting had been arranged to plan discharge arrangements; this was a requirement of the MAPLAG procedure. Information was sent from services in Calderdale to their counterparts in Lancashire. The transfer of information between health services involved telephone discussion in contrast to CSC who only sent information by fax.   121. None of the services identified any risk of significant harm to Baby E and all described MO as having separated from FI. Although health visiting services were prioritised to reflect the support that MO required the belief persisted that MO was separated from FI.   122. The referral that was made to CSC in Lancashire after MO had moved to the county continued to describe the main source of concern to be FI’s mental health and his history of having previous children removed. The referral repeated the information that MO and FI were not living together.   123. Two days after the referral had been opened a team manager reviewed the information. This manager identified that there was insufficient information in the referral or the information that had been sent from Calderdale. There had already been delays in processing the information before the team manager reviewed the information.  124. A core assessment was completed in September 2011. This concluded that because there was no evidence that MO and FI were in a relationship and that MO continued to be supported by health services there was no role for CSC. The assessment was not completed by a qualified social worker.  125. By late summer health professionals had begun recognising that there was reluctance for MO to be involved with services. Referrals were made for floating support although this was not taken up by MO. An effort to encourage MO to participate in activities at the children’s centre was also rejected.   126. In October 2011 MO attendance with the specialist drug services was erratic. By November the health visitor and specialist drug worker were concerned about the lack of contact they were managing to achieve with MO.  There were also concerns that MO appeared to be involved with old acquaintances that were using drugs. She had again tested positive for heroin and cocaine. This information was shared with CSC in Lancashire.  127. In late November 2011 information was provided through a third party that FI was living with MO. During a visit to the property on an earlier   overview report baby E publication version Page 29 of 90 occasion by CSC it appeared that FI was seen but had been introduced as a friend. This was a deliberate misdirection.   128. A referral was made to CSC in the last week of November 2011. A visit was not made for another week and this was undertaken by a specialist health practitioner who was co-located with CSC.   129. The practitioner saw FI who identified himself. After leaving the house she consulted the team manager and agreed that urgent action was required. Although a section 47 inquiry was considered it was decided to proceed with a core assessment instead. A contributory factor was that the team were involved with training. The significance of not managing it as a section 47 enquiry was that work did not commence immediately.   130. Following the visit the practitioner spoke with the team manager who agreed that the case required urgent action. A section 47 investigation was considered although decided to proceed with a core assessment to be completed the following week on the basis that the risks at that stage were not clear. The Inspire worker who had originally made the referral on the 23rd November 2011 had continued to pursue information about what response was being made.   131. The Inspire worker spoke with CSC on the day that the specialist nurse had visited; the worker was concerned that MO had missed doses of methadone. CSC had tried to visit on four occasions without success.  132. During an appointment with Inspire at the beginning of December 2011 MO expressed her upset at CSC visiting and her anxiety that Baby E would be removed. She said that nobody had explained why FI should not have contact with Baby E. She acknowledged during the discussion that she was using heroin, cocaine and was drinking alcohol although presented the information as not being a daily occurrence.   133. Four days later Baby E sustained very serious head injuries. The parents’ account was that the TV fell on Baby E when they were changing a scart lead. The parents were arrested. Baby E died from his injuries the following day. Post mortem examination revealed that Baby E had sustained other injuries on previous occasions. The paediatric report provided to the panel confirmed that there was no evidence that a professional had missed signs of injury that would have been difficult to detect unless the incident causing the injury had been observed.     overview report baby E publication version Page 30 of 90 3 The critical reflection and analysis from the individual management reviews.  3.1 Summary  134. All of the individual management reviews were completed using Working Together to Safeguard Children (2010) which was also supported with additional local guidance provided on behalf of the LSCB. The IMRs include action plans for implementing recommendations. All the IMRs are countersigned by the senior manager for the individual commissioning agency.   135. Many of the services have already taken action or initiated action in response to improvements or areas of development identified through their individual review.   136. For some of the authors, they were simultaneously working on other IMRs for other serious case reviews. All of the authors were also undertaking their usual range of professional roles and responsibilities.   3.2 Significant themes for learning that emerge from examining the IMRs  137. The agency reviews identify themes that have implications for policy development and staff training that applies to all services working with children. In the summary of the review’s finding provided in chapter one there is acknowledgement that some of the issues to come out of this review are reflected in the finding of national evaluation and research. Important messages for learning from this review include:  a) The importance of establishing clarity in regard to who is the lead professional in multi agency processes such as MAPLAG, CAF or TAC (team around the child); b) Clarity about distinct processes such as MAPLAG, ICP (integrated care pathway), CAF and statutory assessment and why and when they are used and their purpose; c) The need for clarity about how assessments are planned and coordinated and quality assured (especially significant with the impending withdrawal of national frameworks); d) Understanding the needs of children not yet born or too young to express or display emotions or feelings by exploring with parents the significance of the child to them; e) The importance of ascertaining sufficient history about parents and their family to inform assessments of need and risk; f) The need for all professionals to have the confidence to ask questions and to maintain a sceptical curiosity; more than one professional commented on feeling overwhelmed or intimidated by the number of people sometimes in the in the house or the presence of FI;   overview report baby E publication version Page 31 of 90 g) The threat to effective practice when organisations become stressed or feel overwhelmed by the level and nature of need being presented; h) Understanding the nature of domestic violence and implications for assessment at the point of pregnancy and following birth; in particular understanding the coercive nature of such relationships and the extent of vulnerability it engenders on the part of the victim; i) Understanding the nature of addiction and substance dependency and its significance for assessing and supporting parenting capacity;  j) Confirmation of the need to ensure timescales and the attainment of key performance indicators do not perversely impact upon professional practice and the quality of child and family interventions. This will be a key feature of the directorate's response to the recommendation of Professor Eileen Munro's report.  However, this must be balanced with the need to ensure a timely response to safeguarding issues. k) Effective assessment requires appropriate knowledge and tools to help make sense of opaque and contradictory information; it cannot just rely on observation; l) Clarity of role and function of "embedded" multi-agency professionals as the momentum for co-located teams’ increases and to ensure the significant benefits of collaborative approaches are fully achieved. m) Develop the skills of front-line practitioners in working with adult males and fathers and making them more visible; n) Ensuring clarity regarding information sharing and requests to other authorities for historical information; a persistence in following up information;   o) The value of a chronology of previous involvement and where previous significant historical involvement has taken place with other authorities; p) The pitfalls within assessments of cognitive and confirmation bias and over reliance on self reporting.  The value of training and development opportunities to introduce and develop a more assertive, objective professional response; q) The importance for those working directly with a family having access to appropriate and reflective supervision; managers who have a dual practitioner status should not take responsibility for endorsing their own allocated cases.      138. It is important that constructive feedback and reflection is provided to all the practitioners involved in this case. In particular, it will be important to support practitioners who are at a relatively early stage of their career to give them the appropriate positive encouragement for their continued professional development and retention in the workforce.   139. The remainder of this chapter summarises key evidence relating to the terms of reference established for the IMRs.  3.3 Good practice identified through the review    overview report baby E publication version Page 32 of 90 140. To support the learning from the review the panel looked for examples of good practice. To constitute good practice, the panel looked for action or decision making that went beyond compliance with local and national policy, procedures and guidance.   141. Examples of good practice identified by the review include;  a) The MAPLAG provided an opportunity for early discussion about a higher risk pregnancy and sharing of information across relevant services; b) The midwife in Lancashire identified that Baby E’s weight had become static and made a referral for paediatric advice that was provided the same day; c) The paediatric assessment secured relevant social information including MO’s acknowledgment about using street drugs; d) The ambulance that responded to the emergency call after Baby E sustained his head injury was on the scene within four minutes having been diverted from another call; this is well within the national response target for ‘code red’ calls and indicated that the seriousness of the injury was recognised by the call dispatcher and good management of response teams;  e)  The ambulance crew ‘scooped and ran’ with Baby E and rendezvoused with a paramedic en-route to ensure that Baby E was receiving medical support in transit to the hospital;  f) The ECC call takers provided support to the crew liaising with the police and pre-alerted the hospital. This is an example of good practice where parts of the NWAS system worked efficiently to communicate with external agencies to pass on crucial information;  142. The remaining sections of this chapter summarise the most significant learning from the IMRs against each of the case specific terms of reference.  Examine whether all agencies and professionals gave due and proper consideration to all diversity issues, including ethnicity, religion, language, disability, culture, social background and integration.   143. It is striking how little information was collated about the background of MO or FI and insufficient inference given to their social and economic exclusion that was evidenced by their lifestyle and circumstances. The HOR comments on the specific factors that deserved further enquiry such as the childhood histories of being looked after as well as the difficulties and needs they both had.   144. The substance misuse service IMR acknowledges that little information was sought about MO’s sources of support although it was known that she had been in public care for a considerable time as a child. The serious case review panel has had considerable levels of information that could have been   overview report baby E publication version Page 33 of 90 available to services but was not accessed effectively at the time. This is explored further in later analysis in regard to the complex systems of information storage that confronts practitioners.   145. The CSC records in Calderdale did not collate information about the social background and culture of the family that included significant levels of abuse in both parents’ histories as well as concerns about domestic violence and substance misuse. This reflected the generally passive approach of managing the case as for ‘information only’ in the absence of a more active role of enquiry and assessment in response to MO’s stated intention to move from Calderdale and to leave FI.  It is possible that there was a degree of misplaced reassurance taken from the fact that the MAPLAG was discussing the case.   146. Similar problems persisted in Lancashire where the extensive previous involvement with MO did not feature in any of the assessments and not enough information was collated about FI’s extensive historical involvement with different services outside Lancashire in terms of his own history of childhood abuse and being in care as a child, his subsequent history of mental illness and substance misuse; most significant of all was the lack of information sought about the circumstances of his two previous children being placed for adoption.  147. In contrast, fuller information was collected in the midwifery records although the IMR author highlights significant gaps some of which reflect the design and layout of forms. MO completed her personal information section in the ICP and   identified herself as being white British, Catholic and unemployed. MO identified FI as being White British, no religion and also unemployed. MO’s first language is recorded as English; there is no place in the record that raises or allows a record to be made about the question of learning disability for either parent. There is no place in the ICP to record any social background history or partner history; this is a curious omission given the roles and function of the ICP. This case illustrates the significance of such information; MO acknowledged more than once the extent to which she ‘was in the dark’ about FI and his history.   148. The health visiting records included the birth notification as a faxed document that included coding for ethnic group but did not provide an explanation of the individual codes. The IMR comments that it is presumed that people using this information regularly would understand the codes without having to make reference to a guide. However the IMR comments that as records are now more frequently accessed by families and in some cases the court, it would be advisable to ensure that ethnicity and religion feature more clearly in the initial health assessment documentation and that where codes are used they are clearly explained.   149. The other problem with relying on codes is that a tick box mentality prevails rather than seeking and exploring the significance of information. The   overview report baby E publication version Page 34 of 90 cultural isolation and erosion of usual mainstream norms and values of families living at the periphery have significance for professionals undertaking child care assessments.    150. The IMR from CHFT comments on how little evidence there was generally in the health service that records how diversity in its widest sense was considered during antenatal and postnatal periods. The authors comment that given the complexity of concerns regarding this family, an understanding of diversity and its influence on engagement and outcomes would have assisted the care planning and in particular raised safeguarding concerns around the discharge of MO and baby.   151. There was no record of the extended family or support networks that would be in place in Lancashire for MO (or information about potential sources of risk given the family history and the fact that other family members were also dealing with their own addictions and problems. Learning that has already come from the SCR is that greater attention needs to be given to acquiring an adequate social history especially from vulnerable parents who are subject of an integrated care plan (ICP).   152. An assumption was made throughout the contact with MO that her level of understanding and comprehension of advice was adequate. The question of her level of cognition, educational attainment and whether she had a recognised learning disability such as dyslexia was never explored. This is curious given her known history of substance misuse that may have had an impact on some of her cognitive and other functioning12. The IMR author for CHFT refers to the strong evidence base that looked after children and care leavers have poorer learning outcomes than their peers; MO’s history of being in care was not known by health professionals and therefore was not considered when planning the support provided.  153. Very little was known about MO’s extended family and her support network; the plan for her to move to her own accommodation in Lancashire did not include an assessment of who would be there to support MO as a first time single parent. There is mention in the postnatal records of sporadic visiting from grandparents, but there is no information of whether they would be in a position to visit MO and provide support to her, or, whether their input would be appropriate, given that she had been in care herself. This is an area of learning together with the other issues that are being                                          12 For example research finds that persistent cannabis use during adolescence can cause lasting harm to a person's intelligence, attention and memory.  Researchers from the Medical Research Council (MRC) Social Genetic and Development Psychiatry Centre at King's College London's Institute of Psychiatry (IoP) collaborated with scientists from Duke University in the USA and the University of Otago in New Zealand on the study published on the 28th August 2012 Proceedings of the National Academy of Sciences Journal   overview report baby E publication version Page 35 of 90 implemented as part of learning from the review in terms of screening queries and tools with women early in their pregnancy.   154. Poor social integration and family background were significant factors in the way in which MO worked with agencies aiming to support her and Baby E. MO told HV1 that she had moved back to the area after the birth of Baby E to be nearer her family and end her relationship with FI. HV1 was sympathetic to MO's background and wanted to understand and support her parenting needs. HV1 felt that MO had good family contacts and spent a great deal of time with her sibling, who appeared to be supportive and responsive to MO's and Baby E's needs.   155. Initially the return to Lancashire had appeared to be a positive move for the family and MO was reported, despite some housing problems, to be settled and stable. However HV1 had no detailed discussions with the extended family about their thoughts on what services would best support MO and Baby E. It appears that the extended family were seen to be present and supportive but the extent of the support they actually offered was not known. For example, on a visit in late November 2011 MO had disclosed that when she had missed collecting her methadone prescription she used some of another person’s methadone.   156. This is evidence that some members of MO's extended family and social network, believed to be providing her and Baby E with support, were themselves dealing with significant personal issues which may have adversely affected their capacity to provide the level of support that MO needed to adequately parent Baby E. This may have resulted in MO being reluctant to ask for their support or for professionals having unrealistic expectations of the extended family or a combination of both which is more likely.   157. Despite having moved to be closer to her family MO still appeared to be isolated, and to some degree was self – isolating in her reluctance to access services at the children's centre or to engage with the one to one visits with NN2. The IMR explains that HV1 was one of the only people who managed to have regular contact with MO and Baby E.   158. This in itself is not unusual in single young women with babies, particularly those with a troubled and chaotic family and relationship history, as formal services represent the involvement of agencies that they most mistrust and, as in MO's case, are fearful of; she made clear her concerns about CSC removing Baby E in later conversations with another professional and this was a powerful motivation for keeping information secret and away from all professionals. There may have been other reasons for the self-isolation relating to MO’s experience of being abused as a child and adult.   159. The evidence from SCRs nationally and research evidence describes the range of behaviours that can be exhibited by families who do not want the   overview report baby E publication version Page 36 of 90 involvement of services that can be manifested in a variety of ways. Sometimes the rejection of help and contact is explicit and clear whilst for others it can be disguised and intended to make professionals less concerned and curious. It can be seen that in this case that there was a deliberate avoidance of service contact so as not to expose the resumption of MO's relationship with FI and her renewed use of illicit substances.   160. There was a reduced level of contact with HV1 and NN2 in the weeks leading up to the death of Baby E. The IMR author concludes that there is some evidence to suggest disguised compliance in this case and which is very difficult for professionals to identify and deal with13.  The panel felt that the lack of compliance was not so much disguised but rather not identified quickly enough by the different people involved with the family. This reflects the complexity of sharing information with several different services especially when nobody is in charge of the overall plan and leading it.   161. The ELHT author refers to the social and lifestyle factors that often complicate the delivery of care to drug dependant women. From Baby E’s perspective the inequalities began before his birth and had the potential to adversely impact on his health and development throughout life.   162. Drug dependant parents along with other marginalised groups are often subject to stigma and prejudice. This attitude within society often hinders social interaction and integration of this group of people.  The result of which is often frequent changes of address, lack of employment opportunities and a perceived chaotic lifestyle14.  Examine whether all agencies kept the child and his experiences at the centre of their assessments of and interventions with the family.  163. The invocation of the MAPLAG protocol in May 2011 was recognition that Baby E was a higher risk pregnancy requiring additional support. In spite of the significant although incomplete information about the circumstances of both parents the focus was predominantly on MO as a vulnerable and pregnant woman rather than achieving a far clearer interagency focus on the needs of a baby; no pre-birth assessment was completed. After his birth, Baby E was the subject of careful monitoring in aspects such as weight gain although the focus for overall case management generally was too frequently moved on to MO’s presenting needs and wishes.                                           13 ‘Disguised compliance’ involves a parent or carer giving the appearance of co-operating with child welfare agencies to avoid raising suspicions, to allay professional concerns and ultimately to diffuse professional intervention. The term is attributed to Peter Reder, Sylvia Duncan and Moira Gray who outlined this type of behaviour in their book Beyond blame: child abuse tragedies revisited : 14 The ELHT author refers to the UK drugs policy commission, Sinning and Sinned Against: the Stigmatisation of Problem Drug Users. (2010) UKDPC Publications.   overview report baby E publication version Page 37 of 90  164. There was not an explicit discussion in a multi agency setting about the use of drugs. The domestic abuse had implications for how MO could parents her baby. This was not discussed explicitly; in part this may have been a consequence of the misdirection that was achieved in regard to the professionals’ knowledge of FI and MO still being in a relationship.   165. CSC in Calderdale had made a decision to keep details about MO and the unborn Baby E as information only and appear to have based their decision making on the fact that unborn Baby E was at no risk whilst in hospital and that once born, as mother had advised that she would not stay in Calderdale but would move at the point of discharge from hospital to Lancashire, that there was no need to open the case or allocate to a named worker.    166. The plan appeared to be to only consider opening the case if mother had decided to remain in Calderdale following the birth of Baby E. If other services had disagreed with this course of action they could have escalated their concerns although it is borne in mind that at the time CSC was still dealing with the implications of a statutory inspection that had found services to be inadequate. The removal of senior managers and the impact on other parts of the service does not appear to have been recognised by external services.   167. The decision to treat the involvement in MAPLAG as being a discussion of information and not a basis for a referral or involvement of a social worker removed the opportunity for statutory assessment by a social worker. This meant that there was no initial or pre birth assessment which would have required a view about any possible risk from the birth father and given the required impetus to enquiries within Calderdale and other areas where MO and FI had previously lived.  This gap in collating information left Baby E vulnerable to any of the unknown or non assessed risks.  168. This was a collective failure to keep Baby E and the possible safeguarding risks at the centre of decision making and had an impact on subsequent case handling. The fact that CSC have statutory duties and responsibilities to lead enquiries (with the police when appropriate) and assessments when children are in need or at risk of significant harm does not remove or reduce the responsibility of other people and services to challenge and to escalate concerns if they believe the response from CSC is inappropriate. Effective safeguarding depends upon people identifying when systems and other individuals are not functioning adequately as much as doing the right things well.   169. The parents were in a relationship that was characterised by unemployment, poverty, domestic abuse and substance and alcohol misuse. MO was a young first time mother, with an untested parenting capacity; FI was considerably older than MO and was known to have two children from a   overview report baby E publication version Page 38 of 90 previous relationship who had been adopted. The circumstances for their removal and adoption were unknown to the practitioners involved; FI was known to have mental health issues and showed a reluctance to either acknowledge these or to allow information to be fully shared. Both were chronic substance users who were on methadone, MO originally presented to CSMS in relation to alcohol abuse and there is a record of hospital admission in 2009 for acute pancreatitis related to alcohol abuse. There is evidence that MO continued to drink and may have minimised both the quantity and frequency.  170. The midwives and health visitor in Lancashire visited MO and Baby E at a much higher rate than is routine and allocated a specialist midwife given the known history of substance misuse and paid close regard to issues such as monitoring Baby E’s weight15.   171. There was no clear evidence that professionals adequately recognised unemployment and poverty as risk factors for Baby E; this is a common theme in serious case reviews and represents another difficult area of practice for professionals especially when working in communities that have high levels of deprivation.   172. The family lived in areas of high deprivation in both Calderdale and Lancashire and from that perspective the family were not that unusual or different within their immediate social setting. The health visiting (LCFT) IMR includes information that MO feared being evicted from her flat in Calderdale for non payment of rent and that she was stressed out and reluctant to go out in case the locks were changed and she then became homeless. National guidance in Working Together that applied at the time of the serious case review refers to poverty and unemployment as the most prevalent risk when identifying children in families at risk having very poor outcomes.   173. There was evidence of domestic abuse in this relationship; the arguments between the couple were witnessed in Calderdale by health professionals and on more than one occasion MO had disclosed that FI’s controlling behaviour was an increasing concern for her; in one disclosure she stated that she sometimes didn’t leave the house for 2-3 weeks as it only caused problems; MO had also disclosed that FI kept all the household money. Although this information was recorded, there was little evidence of outcomes or actions from health professionals, or any understanding of the impact domestic abuse had on the unborn or potential harm after the birth of Baby E. The CHFT author refers to national research that establishes the negative impact of domestic violence on the ability of parents to look after                                          15 The ELHT author discusses the various factors that can contribute to low or inconsistent weight gain that include factors such as the mother’s life style in regard to issues such as the ingestion of substances such as alcohol, drugs and tobacco as well as the significance of social factors such as chaotic or inconsistent parenting practice and domestic violence.   overview report baby E publication version Page 39 of 90 their children and is exacerbated when it is combined with substance misuse and mental ill health.  174. The LCFT IMR comments that even where the parental issues were raised that could become overwhelming for professionals, Baby E remained the documented focus of many of the contacts or visits. This was best exemplified in the first visit with MO and Baby E by HV1 and DLM1 on 26th August 2011 (when Baby E’s static weight was noted and the dilution of formula feed). The difficulties in this visit were dealt with well and promptly by both of the professionals in attendance, resulting in Baby E being seen in hospital later that day. Despite this being an unintentional joint visit, both professionals worked well together to address the issues presented by MO whilst ensuring the needs of Baby E were assessed and managed appropriately.   175. As previously mentioned HV1 was sympathetic to MO's history of a very sad and troubled childhood. On 23rd November 2011 MO had explained to HV1 that she hadn't mentioned her contact with FI earlier because she was 'frightened of social services' and that they would remove Baby E from her care. Although it appeared to be an issue that HV1 had some sympathy with she was clear that CSC would need to be informed and made sure this done. These can be challenging and difficult conversations to have with parents but in this the issues were not avoided. This was good practice in difficult circumstances. HV1 did not feel that Baby E was at immediate risk of harm at this time but was aware that the situation had clearly deteriorated.  176. The Lancashire CSC IMR acknowledges that information about Baby E was limited by the low number of physical contacts (two) and on one of those visits Baby E had been asleep.   177. The difficulties that professionals such as social workers and primary health care workers face in considering the needs of babies and very young children beyond their immediate physical care and presentation is a recurring theme in serious case reviews and research. The fact that a baby cannot speak inevitably makes professionals more dependant on what they observe during their contact with families and what information is provided by parents or care givers.   178. Babies are very vulnerable to injury during the first 18 months; they are dependant upon the physical care and emotional empathy of their parent and are very susceptible to serious injury or inhibited development. It is for these reasons that having an adequate understanding about relevant history and taking account of known risks from factors such as substance misuse and violent behaviour have to be the foundation of work with a troubled family. Further comment and analysis is provided in the final chapter of this report.    overview report baby E publication version Page 40 of 90 Examine whether information sharing and communication systems within and between agencies and across boundaries were effective in safeguarding Baby E.   179. Good information sharing should be characterised by a clear understanding and a collective knowledge about the journey of a child as they progress through the various systems of help and support that they and their families encounter and that this improves the outcomes for the child. This is the aspiration that is described by Professor Eileen Munro16. Information sharing remains one of the most problematic aspects for multi-agency working.  180. The HOR reflects on the problems identified in health professionals not having any common systems of patient recording; this is a national problem. There was no sense of a common narrative that could identify patterns and inconsistencies. The HOR comments that the use of MAPLAG inadvertently contributed to some of the information problems; some of this might have reflected a belief that by simply meeting, the relevant individual professionals were getting sufficient information to make informed and balanced decisions and did not require further steps such as CAF or safeguarding referrals.   181. The IMR authors identify significant difficulties in how information was shared and the extent to which it impeded a quicker and more informed understanding about Baby E’s needs and circumstances. This is one of the major contributory factors in how this case developed. Some of the difficulties reflected the electronic systems and frameworks within which people had to record information; other factors reflected a lack of more appropriate urgency in following up emerging gaps in information.   182. The problems began at the outset when the MAPLAG first discussed the initial information and identified a number of factors about MO and FI. Although there was an acknowledgment that more information was required, this was not satisfactorily resolved. Some of the momentum appeared to be dissipated by the news that MO was separating from FI and that she was moving out of the area. Because MO presented as a cooperative and willing pregnant woman the risk factors in her own life took on less significance for professionals who had generally busy caseloads that included other families that had more apparent and pressing needs and problems.  183. FI was regarded as the source of the most dangerous risk and even though MO had made previous attempts to end the relationship, there was a belief that her move to Lancashire would allow separation to occur. This was an optimistic appraisal given the personal history of the case and the evidence about the difficulties that women face in leaving violent relationships. In this case it was always highly unlikely that FI would not want to be closely involved with Baby E.                                          16 The Munro Review of Child Protection Interim Report:  The Child’s Journey; Munro February 2011   overview report baby E publication version Page 41 of 90  184. The extent to which MO had sought to separate on previous occasions, the persistence that FI had shown in not allowing MO to leave the relationship, the concerns that MO had about his controlling behaviour and the fact that FI was clearly aware of where MO was moving to were all significant issues that were not adequately discussed or considered across the various people who became involved.   185. The management of information between CSC in Calderdale and Lancashire was not managed effectively. The information provided between other services assumed that FI would not be part of the household. The significance of MO and FI’s dependency on methadone was not adequately discussed outside the specialist substance services and in Calderdale the specialist drug workers displayed a lack of focus on the implications for a pregnant woman and her baby. The pattern of not engaging with services such as the children’s centre, the increasing disengagement from other services such as substance misuse was not adequately known and therefore underlying patterns were not seen.   186. For example, in November 2011 it became apparent after MO had undergone a routine test for drugs that she had begun using street drugs including crack and heroin. This information was not shared with the midwife for a week. The agency is introducing new induction arrangements for staff working with drug using parents to spend time with other services.   187. The CHFT author describes her experience of reviewing all of the records to compile the chronology and from completing ten staff interviews; the process presented her with a difficulty in having a clear understanding of where contacts with MO, FI and Baby E were recorded because of the multiple recording and documents and the different systems that were in place. These documents included hand held records, the ICP, MAPLAG and PAS (the electronic record).   188. As a result of this it was at times difficult for the IMR author to identify a holistic picture and to gain an understanding of the concerns around the case, how risk was being assessed or the clarity of risk factors that might escalate into actual risk, or understand what the care plan was and how it was derived.   189. This has significant implications for busy professionals working with families and explains why they often struggle to achieve a good enough overview of a case. Some hospital based midwives for example stated at interview their feeling that they did not have the whole story resulting in a fragmented understanding of the risks to MO and her unborn child.   190. This is an example of the type of systemic influences that have an impact on the quality of practice and decision making; what the author is describing   overview report baby E publication version Page 42 of 90 is a system that does not support effective front line contact with families who have complex histories and problems and maybe reluctant to openly share information. The CHFT author highlights changes already being made to systems. However systems only work effectively when people have the capacity to make the right judgments and decisions and follow them through and can recognise gaps in information that need further follow up.  191. The MAPLAG protocol requires a risk assessment and action plan to be formulated at between 20 and 24 weeks into the pregnancy. At 32 weeks a birth plan should have been completed. For pregnancies at a higher level of risk such as in this case (described as level four or five in the protocol) there is a requirement to convene a pre discharge meeting following the birth. Neither of these requirements was achieved adequately in this case.   192. The convening of the MAPLAG appeared to have limited effectiveness in improving the effective sharing of information; the discussion in general relied on partial knowledge about the current circumstances as well as relevant historical information. The purpose of such interagency arrangements is to both share exiting information, and identify where further knowledge is required.   193. The early information sharing about the concerns especially regarding FI seem to be good enough between MAPLAG and the local authority FRT (family resource team) to indicate sources of vulnerability and need and the potential sources of risk.  This does not provoke any formal referral, enquiry or assessment until August. There was no plan for any social worker to visit mother and Baby E on the ward prior to discharge.  194. The police IMR describe how information about the MAPLAG was not recorded on the police NICHE system (the police electronic recording system). The same IMR also comments that there was no direct communication from the West Yorkshire Police to their colleagues in Lancashire when MO moved into their area to alert them to the fact that MO had been a victim of domestic violence and that FI had been the perpetrator. Some of this probably reflected a belief that FI would not be in the household but the ongoing threat of violence given the previous history was sufficient to have passed the information over to Lancashire.  195. The IMR author comments that once aware that MO was pregnant and had been referred into the MAPLAG process, details of the meetings and copies of the minutes of the meetings should have been entered on the NICHE occurrence system. In the future this will be done to ensure that that all the information and tasks created on NICHE can by correctly implemented and monitored by supervision from within the police safeguarding units.   196. Had a NICHE occurrence been created, it would have been evident on this occasion, if West Yorkshire Police had notified Lancashire Police that MO was   overview report baby E publication version Page 43 of 90 now resident within their area. The author describes changes to processes and training and although no particular factors are identified for why information sharing was not more effective the author does refer to the significant volume of incidents of domestic violence.   197. The fact that the case was never allocated to a specific social worker in Calderdale prevented a more informed and formal transfer of the case to Lancashire which would have ensured that information was shared and passed over to the other local authority in a full and timely way.  198. Other turning points highlighted are the sharing of information between HV1 and MO's drug worker. Most of the information was obtained by HV1 from the drugs worker by request. However, the first contact between HV1 and the drugs worker on 9th November 2011 was initiated by the drugs worker to discuss concerns about MO's apparent low mood; HV1 updated the drugs worker with the plan for high level support from the CFIT. This should have stimulated regular contact between the services but it was not until HV1 contacted the drugs worker on 17th November 2011 with concerns that MO had disclosed that she had smoked heroin again that the drugs worker confirmed that MO had recently tested positively for heroin and crack.   199. There is no date for the drugs test documented in the records and it is possible that it had been a recent test, but as HV1 was the key worker for the child and family, the drugs worker it would have been good practice to have spoken with MO to discuss sharing this information with HV1. It further reflects a lack of understanding about the respective roles of different people and services; this is explored in later sections. For the CFIT another key issue regarding information sharing was the role of the specialist safeguarding health practitioners based in CSC who visited on two occasions and was used as a substitute social care worker.  This had implications for how for example the core assessment was recorded.   200. The transfer of information between the midwifery services in Calderdale and Lancashire was initially quick although important information for example about FI’s previous children, the fact that MO had taken her own discharge from hospital, and her recent use of street drugs was not shared clearly and was therefore not known to the midwives undertaking visits to MO and Baby E.   201. Once social care in Calderdale were informed that MO and Baby E were settled in Lancashire a fax was sent to the appropriate area office with a referral and copies of the referral information from CSMS.  There was however there was no person to person telephone call and appeared to indicate that it was being treated as being for information rather than requiring further action.  Although the IMR confirms that the practice supervisor is clear that no action would have been entered onto the child’s electronic file unless it was clear that there was confirmation that the fax was   overview report baby E publication version Page 44 of 90 received.  Good practice would have expected that with a new born child a telephone call may have been preferable followed up by a fax.  202. Once the case was opened to the Integrated Assessment & Support Team (AST) there were further delays that are attributed to the staffing and workload problems in that service. Although the gaps in information were recognised by the team manager, the deficits were not addressed quickly enough. Contact was made with Bradford and although this established that two previous children had been adopted, the circumstances were not inquired into; Bradford required a request in writing to release archived information and this was not done. The referral between Calderdale and Lancashire CSC was both delayed and incomplete. Neither of the services had secured adequate information from Bradford about FI’s previous children and both services were highly reliant on third party judgments about risk.   203. The decision to move immediately to a core assessment could have provided an opportunity for detailed contact and involvement with other sources of information; this did not happen due to workload. One visit to the home was undertaken by the social worker from the initial assessment team with the specialist health practitioner. This health practitioner then took on the task of completing the core assessment. This was inappropriate given she was not social work trained and qualified although was a very experienced and qualified health practitioner.   204. The home visit was not written up and recorded on the ISSIS electronic system (CSC electronic recording system). No discussion took place between the allocated social worker and the health practitioner. The allocated worker then closed the case.     205. The CSC IMR acknowledges that a discussion of the visit completed on the 25 August should have been essential social work practice.   This would have enabled two basic actions;   a discussion regarding the findings of the visit and the health practitioner’s judgment that the family circumstances required a full examination.    206. A significant contributory factor to the way the case was handled was the organisational stress arising from staffing and workload combining with a lack of information about the parents that had been factors in the handover of information from Calderdale. A high reliance was also given to MO’s assertion that her relationship with FI was over.  207. The CHFT author comments that at the point of transfer from Calderdale to Lancashire the transfer of information and records was very good, records were comprehensive and verbal communication was timely and appropriate, it was also well documented in the ICP. However the information did not indicate that FI and MO may still be in a relationship or the risk factors associated with FI in particular.    overview report baby E publication version Page 45 of 90  208. When Baby E sustained his head injury the ECC call taker provided support to the crew liaising with the police and pre-alerting the hospital. This was an example of good practice where parts of the NWAS system worked efficiently to communicate with external agencies to pass on crucial information.   209. The IMR highlights that the ambulance crew who provided a very prompt response to the emergency call and took all necessary action to get him treated and to hospital should have completed a safeguarding referral given that Baby E was alive but very poorly when they transferred him to hospital care and treatment. The information they observed about the parents being intoxicated and being unable to understand the seriousness of their son’s condition were all factors that deserved reporting.   Examine whether historical information was given appropriate emphasis within assessments and interventions. This relates to mother and father's histories, extending to others where this is relevant to the period under review and thus the care of Baby E. This should include any assessments of the mother’s entitlement to support in relation to her care history, drugs, alcohol and domestic violence and any pre-birth assessments of the needs of Baby E. It should also include any relevant information about the father’s older children. Any relevant historical information prior to the timescale for the review should be summarised and included in the IMRs.  210. The full extent of the parents’ previous involvement with services appeared to remain largely unknown for many of the professionals who came into contact with them in 2011. MO was a looked after child and a care leaver in Lancashire and FI had also been looked after in West Yorkshire and also had extensive involvement that had included the subsequent adoption of two of his children to a previous partner when he had lived in Bradford.   211. Both parents had experienced abusive childhoods; both had significant histories of domestic violence; MO as a victim and FI as a perpetrator; both had become dependent on drugs and alcohol; the mental health of both parents had required ongoing help; both parents had family networks that were not a source of positive help and support. In addition both parents were unemployed and socially isolated and this should have invited queries about the nature of dependence that each parent had of the other and the degree to which this was exacerbated when MO became unintentionally pregnant.   212. However, this extensive history did not feature within any of the assessments undertaken in Calderdale or in Lancashire; the term assessment is used generically to encompass the MAPLAG and ICP processes as well as the statutory assessments that should have been completed by CSC in Calderdale and was only partially undertaken by CSC in Lancashire.   Their IMR acknowledges that this significantly diminished the quality of the   overview report baby E publication version Page 46 of 90 assessment and decision making that relied on what MO primarily report during the brief contact with her.   213. The consequence is that there was insufficient understanding about the longstanding nature of the problems and the significance for example of chronic drug use on cognitive functioning for example. The HOR comments on how much of the information in regard to drugs, missed appointments for methadone and domestic violence are treated as episodic and separate occurrences and were ‘normalised’.   214. No pre-birth assessment was completed in Calderdale. The referral information from Calderdale was limited and no initial assessment had been undertaken and enquiries with other areas were not complete.  The handwritten recording by the worker in Calderdale on the initial referral received by that authority indicated that no action was to be taken until it became known whether mother was remaining in Calderdale. Consequently no immediate risk assessment was completed before birth and no adequate picture could be passed to Lancashire of the family circumstances.    215. The historical information in the case was significant and relevant. For example; it was largely unknown that MO had grown up in public care. She may not have wanted to have this information widely known but as the CHFT author discusses, this information was relevant within the context of what is known about the specific challenges and needs that MO might have and especially in regard to becoming a mother. There was a general lack of curiosity in previous history. Although this SCR has prompted a re-examination of how for example information is sought from especially first time pregnant women, inevitably there will always be a considerable reliance on what is reported or disclosed by the woman.   216. The CHFT author believes that the use of specialist staff such as the midwives might have encouraged an assumption to develop on the part of other people that these specialists were dealing with problematic issues such as the domestic violence; this combined with knowledge that MO planned to live separately to FI led to a misdirected belief that risk of violence was decreasing in spite of no formal assessment or analysis of what the risks were and how they should be managed.    217. This was an optimistic approach given the lack of information in the specific case and considering how common it is for the incidents of abuse to increase in violent relationships during and after pregnancy or when there is a threat of the woman ending the relationship. CSC in Calderdale relied on other services including CSMS to provide information and did not to carry out their own assessment. The lack of rigour exhibited in CSMS has already been commented upon.     overview report baby E publication version Page 47 of 90 218. The health visitor took a history from MO during a home visit on the 3rd September 2011 during which an additional history of drug and mental health issues emerged. MO had found her father dead at age 12 years, she was brought up by her maternal grandparents as her mother suffered from mental health problems and she remained a 'long term patient' in a mental health hospital. MO reported a history of depression herself, but had stopped taking anti-depressants when she became pregnant although she had reported feeling happy at the time of the visit.   219. Although the first meeting of the MAPLAG in May 2011 identified that father may have had previous children removed from his care there is an extended delay before contact is made with Bradford in August and even a that stage information about the circumstances for the children’s adoption are not clear. The first MAPLAG discussed father’s controlling behaviour and the plans that MO had for effectively ending the relationship; this had implications in terms of potential for violence given FI’s current behaviour and psychiatric conditions as well as the loss of social support for MO.   220. The Calderdale CSC author is clear that an initial assessment followed by a pre birth assessment should have been carried out and should have been triggered by the information shared about FI at the MAPLAG meetings.  Information that MO had lived previously in another area and had spent time in a refuge due to domestic violence should also have alerted social care to make further enquiries.  A further opportunity was missed when information was given to the CSC representative at the MAPLAG that FI may have other children who could have been placed for adoption probably in the West Yorkshire region.  One call was made in July 2011 by the practice supervisor to Leeds social care to ask if FI was known.  That response was negative. Contact was not made with Bradford who would have provided the information that was subsequently given to Lancashire.  221. CSC never made a visit to MO and Baby E at the hospital following the birth and was reliant on health professionals to ensure that all the arrangements were in place and identify any safeguarding risks to address prior to discharge.  A more appropriate plan if more information had been known to CSC could have been to hold a pre discharge meeting on the ward and to have invited a representative from Lancashire to attend given that at that point MO had a residential address in their area.    222. Enquiries to other areas were not made until 11th August 2011 in Lancashire and were not done until a further referral was received from the CSMS team.  A telephone call to Bradford confirmed that FI was known to them.  Two children had been placed for adoption.  The files had been securely archived due to the adoption of the children but requests could have been made for further information from the files which may have contained vital information about the background of FI and the reasons why those children were removed.  It was already known that FI was a user of illegal   overview report baby E publication version Page 48 of 90 drugs and had a diagnosed mental health condition.  This did not appear to be taken as an important indicator and a further reason why an initial assessment at least should have been undertaken and information urgently requested for that assessment especially from Bradford.  223. As no case was formally opened and details held as information only no one from children’s social care met with either MO or FI and social care had no first hand information.  The outcome was that no information current or historical was obtained by social care which would have been the basis of an informed risk assessment.  224. Although CSC in Lancashire had considerable previous involvement with MO over many years none of this information was apparently used to inform the later assessments in 2011. The IMR author explores the organisational circumstances that led to the two initial assessment and one core assessment being inadequate; the interplay of workload pressures, an inexperienced team, the development of short cuts to cope with back logs combining with training and industrial action were all contributory factors. These and other issues are explored further in later sections.  225. The NWAS IMR comments that they had no information about the history of domestic violence and were alerted to Baby E having been a premature baby by MO.   Examine whether agencies fully understood any issues about parental substance misuse and mental ill health and the impact this had on Baby E and took appropriate actions.  226. Although MO was assessed as having a low mood she has not been diagnosed with any additional mental health needs. The low mood is not unusual especially just after birth and given the additional stress that MO was facing before and after the birth of Baby E.   227. In contrast, FI did have diagnosed mental health needs although he was reluctant to acknowledge this and withdrew from mental health services.  228. Although there is involvement of several different and specialist services particularly with FI, it is not apparent that there was sufficient recognition of the potential risks that longstanding substance misuse and mental ill-health had for the baby. Some of this probably reflected the belief that FI was not going to share the care of Baby E. It also appears that some degree of misdirection was occurring as early as the initial MAPLAG meeting when comments such as MO being ‘pleasant’ and was ‘engaging’ with services were recorded.   229. The fact that she had a dependency arising from a history of drug use did not appear to be understood clearly enough. She was largely regarded as   overview report baby E publication version Page 49 of 90 having a historical substance problem which combined with her optimistic interaction with professionals contributed to a sense of optimism. This general optimism allowed the relapses to be treated as having less significance.  230. The extent to which adults can relapse especially during periods of crisis or stress was also not appreciated or the speed with which it can have an impact on the physical as well as emotional capability of a parent. It is notable that the specialist health practitioner noticed a significant change in MO’s physical presentation between the first contact in late August 2011 and when she saw her again in December 2011.   231. It is not clear that there was ever any structured discussion at any point about the implications for example of FI’s psychiatric condition (partly because an assumption was made that he was not in a relationship with MO) or the dependence that both parents had in regard to alcohol and drugs. MO’s desire to reduce her methadone was not apparently discussed and by implication was seen as a positive factor and therefore may have inadvertently led to a degree of optimism becoming an influence on how behaviour and information were subsequently viewed.   232. The HOR highlights serious non compliance with standards of required practice and procedure in regard to the conduct of toxicology testing in Calderdale. Information about two positive drug tests was not shared with other relevant professionals despite knowledge about the pregnancy. The consequence was that MO was not challenged and some professionals were not aware of the continuing risk of drug use for Baby E before and after birth. The HOR confirms that further investigation and action is taking place to ensure the problems are resolved.  233. MO’s lack of engagement with substance misuse services especially in the latter part of 2011 and her positive testing for street drugs in November 2011 was significant information and although there was communication between services it required more systematic enquiry than was achieved. The assessment that was planned to start in December was going to be an opportunity to do this.   234. The CHFT author points out that between them, MO and FI possessed four out of five of the highest ranking characteristics of parents found in the biennial analysis of child deaths and serious injury  through abuse and neglect17 (Brandon et al 2007) these were; mental health problems / personality disorder, domestic abuse, substance misuse and care history. The fifth characteristic is learning disability; whether either parent had learning                                          17 Analysing child deaths and serious injury through abuse and neglect: what can we learn? A biennial analysis of serious case  reviews 2003–2005: Brandon et al: DCSF 2007   overview report baby E publication version Page 50 of 90 disability was not known, but there was nothing to indicate that this was an issue.     235. The positive toxicology result during the antenatal period should in the IMR author’s opinion have been escalated across to social care services as a referral for a pre birth assessment. The Eden team midwife and the CSMS worker judged the positive toxicology to be a ‘blip’ warranting no further action, however, the combination of substances identified in the sample suggests that this was a planned and conscious decision by MO to misuse substances (rather than being impulsive and opportunistic). In the authors view there was a reluctance to see this episode for what it was, it was written off and minimised, was this because it did not fit with the originating assessment of risk in this case, which was that FI was the source of risk to Baby E.   236. It was an example of how professionals became misdirected at important moments. This is analysed further in the final chapter of this report within the context of national research and understanding about the influence of cognitive factors such as capacity to remain vigilant about the basis of judgements and a tendency to repeat patterns such as start again syndrome when confronted with opaque or difficult information.  237. In spite of the practice supervisor at the initial MAPLAG being informed about historic substance misuse of MO and alerted to the concerns of possible past involvement of social care with children of FI, no action was taken by that service; the practitioner did not participate in the following meeting and combined with poor recording undermined continuity from CSC.  It appears to the IMR author that CSC took reassurance that CSMS was taking the lead and was monitoring the situation with regard to substance misuse with MO. This was an inappropriate assumption.   238.  FI was known to have mental health difficulties although these were clearly regarded as historical although again there is no evidence about how that view was informed over and above what FI self reported.  It was stated in the minutes of the MAPLAG on 6th May that FI was then on Subutex, that he was coming to the end of his treatment and if discharged no one would be monitoring his health.  MO had already disclosed that FI was becoming controlling and more so since the pregnancy had started and she was indicating that she would want her own accommodation.  Appropriate actions were not taken by children’s social care as an initial assessment at least was indicated at this point given that the pregnancy was now said to be at approximately 22 weeks and past the mid way point. Procedures on indicators for initial assessment are clear according to the IMR.  239. The health visitor was provided with information about MO’s historical drug abuse during the history taking on the 3rd September 2011. MO stated that she had not taken drugs for four years but was on a reducing   overview report baby E publication version Page 51 of 90 programme of methadone (MO tested positive indicating she had ingested crack and heroin in November 2011); she was hoping to have reduced further but couldn't due to her pregnancy. It is not documented if the nature of MO's historical drug use was discussed in any detail. The impression of HV1 at the time was that MO appeared stable on her current methadone programme.   240. HV1 and the specialist health practitioner in their assessment of MO's apparent stability felt that the substance misuse would not necessarily impact negatively on her parenting capacity. The IMR author comments that this viewpoint, although common, is not supported by research on the impact of parental substance misuse on children. It reflects a tendency to accept a minimisation of risk primarily based on what MO wanted to disclose. This has implication for the cognitive understanding that is referred to elsewhere as well having implications for supervision and the tools that are used.   241. CSC in both Calderdale and Lancashire knew that MO had a history of using drugs and alcohol although believed that she was no longer doing so. MO had disclosed using street drugs in Calderdale just days before giving birth to Baby E. After she moved to Lancashire her compliance with the drug support service became increasingly chaotic and it was apparent that she was using street drugs by November 2011.   242. On MO’s return to Lancashire CSC were informed that she was not using street drugs, had engaged well with drug misuse services and had immediately registered with the local drugs team. However, this position had deteriorated by November 2011 and mother was reportedly using illegal drugs although did not lead quickly enough to a reappraisal of the implications for Baby E.    243. This would have been an essential area of the core assessment that planned to take place in December 2011 although the injury and death of Baby E occurred before the work had been undertaken.   The description by the specialist nurse following her visit on the 2nd December 2011 had outlined a picture of potentially quite extensive drug misuse.   Baby E was observed in his crib and the home conditions were described as "warm". This contributed to a judgement that the baby was not at immediate risk.   244. The ambulance crew identified that FI and MO appeared to be under the influence of alcohol and/ or drugs when they were called to attend after Baby E was injured. This is referenced in their statements and is recorded on the PRF. They had no prior knowledge of the family and the behaviour of both adults caused significant concern and possible delays in making haste to Hospital 1. The crew statements describe how they ‘hurried’ both adults to get on board the ambulance due to their lack of urgency and generally vague demeanour.    overview report baby E publication version Page 52 of 90 245. When the police had arrested FI on the 1st December 2010 to prevent a breach of the peace the custody sergeant was responsible for conducting a risk assessment with FI. This risk assessment included asking for information about his physical and mental health and about any risk of self harm. FI stated that he did not have any mental ill health; this was an example of his denial of his mental health needs. When he subsequently hallucinated a medical examination was arranged. The focus of the assessment and management of FI was on how police officers and staff should handle their contact with him; there was no sharing of information or referral to social care or other service. The IMR author refers to the training that has been undertaken with police officers to improve awareness of the police responsibility to share information about vulnerable adults as well children.   Examine whether agencies dealt with any domestic violence issues appropriately and considered the risks to Baby E from those issues?  246. That assumptions were made from a relatively early stage that FI was not going to be part of parenting Baby E was a significant contributory factor in how professionals worked with MO and therefore did not regard domestic violence as a threat unless and until FI and MO resumed their relationship. This reflected the generally optimistic approach and does not reflect a more informed and sceptical understanding about the nature of relationships that are characterised by domestic violence.   247. There was a degree of naivety in understanding how realistic it was that FI would be willing to have no contact with his baby and a lack of understanding that in violent relationships there is an increased risk of violence and injury during and after pregnancy and especially when the relationship being ended by the woman. It also reflected a lack of understanding about the barriers that women face in leaving violent relationships. Women want the violence to stop but also face emotional and psychological difficulties in ending a relationship; it is also exacerbated if they face the prospect of becoming homeless; this was a fear for MO who had described feeling trapped in her flat.   248. The Lancashire CSC IMR comments that MO described the relationship with FI as being ‘on and off’. Even if the information had been correct and MO had been able to separate from FI she had a history of previous relationships with violent men.   249. It was apparent before MO discharged herself from hospital after the birth of Baby E that FI was planning to continue his relationship with MO and knew where she was moving to. The history of both parents would have provided powerful motivation to keep any relationship secret.  250. By November 2011 it was clear that FI was playing a significant role within the family's life in Lancashire and was known to CSC and health and   overview report baby E publication version Page 53 of 90 substance misuse services. Following two referrals and MO eventually conceding that she was allowing contact with FI should have led to more urgent discussion and planning of enquiries.   The circumstances of the AST did not encourage a more active and urgent approach. Further analysis is provided in the final chapter.   251. The extensive history of FI that was beginning to become clearer, including being a historical perpetrator of domestic violence, should have led to an urgently convened strategy discussion and subsequent section 47 enquiries.  This did not occur partly because of the organisational problems that beset the AST at the time as well as perhaps because the original mindset that had been influenced by MO’s ‘pleasant’ determination to turn her life around had not yet adapted in response to the contradictory information that was becoming more evident. There was also probably a lack of understanding about how quickly MO was relapsing in terms of her use of alcohol and drugs.  252. The MAPLAG minutes of 6th May 2011 had recorded that MO had spent time in a refuge in Greater Manchester, where she used to live, due to domestic violence from a relative.  There are no further details and is an example of the gaps in information that have beset this case.   There is also information in the same minutes from MO that she was finding the behaviour of FI towards her more controlling.  As social care did not carry out any assessment there were no further details or evidence of this at this time.  There was no recorded contact with any social care services in Greater Manchester to see whether MO was also known to them and if there were further details about her spending time in a refuge.   253. There is a growing recognition that dealing with domestic violence effectively is a challenge for policy development and for professional intervention. There is a growing range of research that provides evidence about the impact of domestic violence on women and children in terms of the emotional damage and the barriers that face both professionals trying to help and the victims of the violence. A recurring theme is the difficulties that women in particular face in seeking and accepting help.   254. At present, systems tend to rely on evidence of violence in terms of visible injury and harm and the willingness of the victim to consent to some form of intervention. In this case there was no apparent recognition about the presence of domestic violence that should include an understanding about coercive relationships.   255. Evan Stark18 for example describes how domestic violence has to be understood more clearly as coercion in order to understand the impact on                                          18 Coercive Control: How men entrap women in personal life Evan Stark: Oxford University Press 2007    overview report baby E publication version Page 54 of 90 the women and to understand why these relationships endure, why abused women develop a profile of problems seen among no other group of assault victims. In this case mother was isolated from her family, apparently had no close friends or other sources of support and was unemployed and dependant on state benefits.  256. The SMS midwife who did the first antenatal contact recognised the escalation in domestic abuse; she worked on the premise that support and monitoring for MO around this issue was being given by the CSMS workers. The second SMS midwife acknowledged that she did not ask about domestic abuse at her first antenatal contact and in hindsight should have explored this with MO.  257. The CHFT IMR author’s analysis from this would be that there was an assumption that CSMS were addressing escalating domestic abuse as part of their remit, which would have been appropriate if in conjunction with the SMS midwives, however, there is no record of a conversation within the perinatal team that gives assurance that escalating domestic abuse was being risk assessed.   258. MO stated at every ante-natal contact that she planned to move away from FI because of his controlling behaviours and she reiterated this to several different people. This is documented in the ICP record; however, there is no recording of what this meant in respect of the care plan or of what the safeguarding implications for Baby E might be. On interviewing antenatal and post natal staff, the IMR author found that there was little recognition of domestic abuse as a feature in this case, the focus remained firmly on FI’s mental health as the primary safeguarding issue and the plan for MO to move away from Calderdale without FI was known by every member of staff interviewed. This plan was seen by all staff involved as the solution to any safeguarding concerns.   259. The West Yorkshire Police IMR is satisfied that officers dealt positively with the incidents of domestic abuse between MO and FI conducting the initial SPECCS risk assessments19 at the scene, and there was the appropriate intervention from the domestic violence coordinator from the police safeguarding unit. However, the domestic incident on 31st December 2010 was attended and although dealt with as a domestic incident, a Vivid report was not created by the attending officers, which was an omission on their part; established safeguarding and domestic abuse protocols are in place by West Yorkshire Police, including established recording processes of such incidents.                                           19 SPECCS is an anagram of six high risk factors (Separation, Pregnancy/new birth, Escalation, Cultural issues and sensitivity, Stalking and sexual assault) describing a risk assessment tool.   overview report baby E publication version Page 55 of 90 260. According to the police IMR, the quality of the information recorded on the police IT systems concerning all aspects of safeguarding have developed considerably due to an awareness of other high profile cases and the subsequent development of safeguarding training to both the front line and specialist safeguarding officers and staff throughout the police service area.    261. Since 2011, processes are now in place for the front line staff to complete the DASH risk assessment20 when dealing with incidents of domestic abuse. Initial risk identification must be undertaken and the level of risk should be identified to ascertain what level of intervention applies. If the case is classified as high risk, a more detailed risk assessment will be completed by a safeguarding officer and a referral to MARAC will be made. If such a referral is not appropriate the reasons why will be fully recorded on the NICHE occurrence system which replaced the previous Vivid database system.  262. The CSC author for Lancashire includes information about the pilot within the CART that replicated a MASH (multi-agency service hub) within the Preston district.   This has improved the gathering of specific multi-agency information regarding domestic violence incidents and linking this to a targeted and prioritised response to cases that have or are likely to result in significant harm to children and young people.  The IMR anticipates that this will be launched on a county basis.  263. In This area of Lancashire the CAF is well established with an expectation that a social risk assessment is completed and shared by midwives for all births in this part of Lancashire but this was not completed for Baby E as he had been born in Calderdale. The IMR author believes that practitioners could also benefit from a standardised assessment tool such as the child and family plan which is used in Blackburn with Darwen and has been developed in part to address lessons learned from SCRs. This framework allows routine discussions about key health and social factors at the primary visit and is reviewed at eight months and two years. It covers a range of questions relevant to this family including for example: some women tell me their partners are cruel. Have you ever been in a relationship past or present where you have been hurt physically, mentally or emotionally? Were you or your partner ever in care as a child or teenager?  264. Under the Lancashire Improving Futures Programme there will be a review of the CAF process with the aim of refreshing and implementing a new and                                          20 The introduction of the Domestic Abuse, Stalking and Honour Based Violence (DASH 2009) Risk Identification, Assessment and Management Model from March 2009 meant that for the first time all police services and a large number of partner agencies across the UK are using a common checklist for identifying and assessing risk with the aim of saving lives. ACPO (Association of Chief Police Officers) Council accredited the DASH (2009) model to be implemented across all police services in the UK from March 2009.   overview report baby E publication version Page 56 of 90 revised CAF across the county. This will incorporate an updated continuum of need (CON), thresholds documentation and lead professional development.   265. In Wales, there is a national pathway screening for domestic violence that encourages primary health worker such as health visitors and GPs to routinely inquire about a history or experience of domestic violence. No such arrangement operates across England and is unlikely to given the move to less central guidance and more emphasis on local practice. This difference is exemplified in the contrast between arrangements in Calderdale and the more proactive approach described in Lancashire. Reference is made in the final chapter to the national research being undertaken in regard to routine screening for domestic violence.  Examine whether any safeguarding and child protection issues were identified and dealt with appropriately by agencies. Consider whether agency responses were correct and timely and whether safeguarding procedures were followed appropriately. Consider whether professionals relied for information on the self reporting of parents, and how far this influenced the safeguarding and protection of Baby E. Consider whether there were any barriers or difficulties in the child receiving services.  266. The HOR is unequivocal in stating that the information that was known to the MAPLAG should have been sufficient to have generated a referral to CSC under the safeguarding procedures in Calderdale. There may have been a belief that by involving CSC in the MAPLAG discussion was sufficient to ensure that appropriate action was being taken. If that was the belief it was misplaced and a misunderstanding about the purpose of MAPLAG. The HOR concludes that the MAPLAG ‘debilitated’ the process of risk assessment.   267. The HOR comments that services were largely delivered in accordance with the systems that were developed by the providers rather than reflecting an accurate and well informed assessment of Baby E’s circumstances.   268. National research is providing compelling evidence that services have to be embedded in frameworks that understand the importance of child development21 and the extent to which questions about what a child means to a parent and what the parent means to that child in respect of their emotional care and security.  269. The safeguarding and child protection issues were not sufficiently identified and therefore not understood adequately at the outset. When safeguarding concerns were recognised at a later stage in Lancashire there were problems in identifying an appropriate person to undertake the required assessments;                                          21 Brandon, Sidebotham, Ellis, Bailey and Belderson. Child and family practitioners’ understanding of child development: Lessons learnt from a small sample of serious case reviews Department for Education May 2011   overview report baby E publication version Page 57 of 90 this in turn led to delays in escalating the level of enquiries and invoking joint agency safeguarding procedures.   270. Although this was identified as a high risk pregnancy the focus remained largely on how MO presented to the health professionals in particular. She was regarded as ‘pleasant’ and ready to ‘engage’ with the help and support being provided. This appeared to be a significant influence in her relationship with professionals who by and large felt that MO was taking adequate and appropriate action for herself and her baby.   271. Her plan to leave Calderdale and to end the abusive relationship with FI was regarded as positive on the basis that the main threat was from FI and his history of children being removed. Although this was a significant and relevant source of concern; attention was misdirected away from other factors associated with MO’s own history, lifestyle and sources of vulnerability. The declared intention to leave FI should also have been recognised as a source of increased danger and threat.   272. The requirement to have a discharge meeting after the birth of Baby E was substituted by an informal discussion between the midwife and MO. This mindset towards MO did not fundamentally change until December 2011 just days before Baby E died. When concerns were coalescing about the presence of FI in the house and MO’s withdrawal from professional support, the response still lacked a sufficient focus on the potential harm on Baby E’s well being.   273. The MAPLAG and ICP remained the principle framework for multi agency working. Although the MAPLAG is a protocol designed to coordinate help for pregnant women who (and/or their partners) are excessive users of alcohol or drugs implemented through the LSCB, there were some fundamental misunderstandings about the meeting. Some agencies such as CSC for example thought that the MAPLAG was a health meeting that they were just participating in for the purpose of sharing information with the health professionals managing the pregnancy. Although the protocol describes arrangements for completing risk assessments and action plans (which were not completed in sufficient detail) there is no explicit linkage to children’s safeguarding protocols such as s47 enquiries or completion of pre-birth risk assessments for the unborn child.   274. There was a marked deterioration in MO’s circumstances in the weeks after she moved to Lancashire that was being noticed in November. She increasingly withdrew from contact with services and her ingestion of street drugs was increasing in the weeks before Baby E died.   275. The delayed referral to CSC in August 2011 had cited the previous history of FI having children removed from him permanently as the risk factor for undertaking an assessment. Although this historical information was relevant   overview report baby E publication version Page 58 of 90 and should have been sought more quickly there were a range of other factors that deserved attention before the birth of Baby E. The fact of his premature birth did not add substantially to any further consideration of vulnerability over and above his immediate physical needs.   276. Issues had been identified during the early MAPLAG meetings kept on the system by social care as for information only and according to the IMR were perhaps only to be opened up as a referral if it was confirmed that MO was to stay in the Calderdale area once Baby E was born.  This is concerning as it reflects an organisational approach (it will not be our problem) to the information rather than a far more appropriate child focussed approach.   277. Ironically, there did not appear to be any thought given to the enhanced risk to a very young a premature child moving to a new area where the family apparently had no sources of support and the mother was trying to leave her relationship with the child’s father. No thought was given to how the father would react when he found out or understood the intention of MO to effectively limit his involvement with his child and especially given his loss of other children.   278. There was no consideration of the need to complete an Initial and a pre birth assessment where any safeguarding concerns could have been identified and the statement by MO to separate from FI challenged and confirmed.  Unfortunately due to a lack of pre birth assessments social care had collected none of their own information and relied totally on information from other agencies with CSMS acting as lead agency.    279. Once Calderdale CSC were made aware of the concerns of previous drug misuse of mother and particularly of the previous adoption of two children of FI had a statutory duty to assess and complete an initial assessment to indicate the way forward and what supports/interventions were needed.   This was not done.  There was no consideration of any barriers as CSC had no face to face contact with either parent or Baby E once born. The only barrier which may have been in place was capacity within the social care team as the team at that point was mainly made up of agency workers.  The practice supervisor told the IMR author that she had been making all the decisions about case management and information coming in to the FRT team rather than the team manager.  The IMR author believes that the team manager now shares those decisions.   280. When there was a positive toxicology result in the antenatal period, the decision jointly made by the Eden team midwife and CSMS worker was that this was a ‘blip’ and the analysis of this episode has been covered. Similarly, Mo’s disclosures of an escalation in FI’s controlling behaviours and the implications for practice have been explored.     overview report baby E publication version Page 59 of 90 281. MO’s declared intention to leave FI and move to her own accommodation was considered to be the best outcome for her and Baby E by all staff involved as it was a held belief that FI posed a safeguarding risk to Baby E and arguably distracted attention from the implications of the separation and the absence of support for MO.   282. Health professionals accepted MO’s self reporting of this wish without question. MO had continued to live with FI throughout the antenatal period, and when in the antenatal period, MO was admitted for monitoring of Baby E; FI visited, administered her Methadone and took all her belongings to Lancashire in readiness for the move. FI was present at the delivery of Baby E and he visited sporadically in the post natal period.   283. The CHFT IMR author is sceptical as to whether MO was being open and honest with health professionals as all of these episodes demonstrate a strong dependency or commitment on from the two partners to this relationship.  284. A CAF was completed by HV1 which identified other services which could offer MO support to her parenting and a clear action plan for a team around the child (TAC) meeting was considered. The role of the safeguarding specialist health practitioner is highlighted by the IMR for further consideration. The role is based in CSC and aims to enhance the multi-agency assessment process within the initial assessment team, providing a valuable health perspective to social care assessments. If the visit on 2nd December 2011, had been undertaken by a social worker then the outcome might have been different if the assessment had achieved a more comprehensive and holistic consideration of Baby E’s circumstances; the fact that the AST was experiencing problems of workload and capacity at the time would have been a significant factor for any practitioner.   285. This suggests the inappropriate use of a health practitioner. The specialist safeguarding health practitioner was not attending the address as a social worker but as a qualified health professional and as a result did not have the underpinning of the statutory framework within which local authorities and their representatives operate. This impacted on specialist safeguarding health practitioner as she was visiting alone and acting on behalf of social care. This clearly left her more vulnerable to maternal antagonism as she was seen by MO as a social worker and not a health representative. The CSC author in Lancashire acknowledges that it was inappropriate to have the core assessment led by a health professional. It was also not compliant with current national guidance or local protocols.  286. In this instance although in receipt of enhanced health visiting service and having identified additional needs it was the health visitor’s belief at that time that the support and services that were being provided to the family from the agencies and the extended family were meeting all those needs and   overview report baby E publication version Page 60 of 90 until the father was seen in the home HV1 had no reason to believe that Baby E could have been at possible risk of harm and that the mother was unable to meet his needs safely. HV1 acted appropriately and swiftly when she found the father was having contact with Baby E.       287. At this time of his death Baby E and his family were receiving universal and additional support from the CFIT in Lancashire. The mother had received regular support from CFIT services however there were regular no access visits and it is now known that she was withholding information from the named heath visitor (HV1) about her relationship with Baby E’s father. Due to the history of vulnerabilities and concerns about the father the family were known to social care and were due to start an assessment at the time of Baby E’s death. The family were seen on two occasions by the specialist safeguarding health practitioner who is not a qualified social worker and therefore was not in a position to complete a core assessment.   288. The last visit to the family home days before Baby E died resulted in a specialist safeguarding health practitioner leaving the house feeling intimidated and had been required to leave by the verbal and non verbal behaviour of the parents. Although there was a discussion later that day with managers in CSC they decided that although a core assessment needed to be completed they did not decide to have a further and urgent visit made to the house. A key influence was that the team would be away on training for two days (although there was cover from other social workers) and they still believed that MO was a sufficient protective influence counterbalancing the unknown risk about FI.  289. The specialist safeguarding health practitioner was not concerned about Baby E’s immediate safety; the intimidation had been directed at her. However, given the escalating pattern that is now much clearer with the collation of information from the review, the IMR author acknowledges that a strategy discussion involving other services could have made a significant difference to the decision about how quickly to visit.   290. Following the visit a discussion took place between the specialist health practitioner and the assistant and team manager.  Unfortunately this is not recorded as a case management decision as it is self reported by the three professionals.  A section 47 was explored but a decision is made to undertake a core assessment.     291. Two referrals had now been received outlining key issues of safeguarding concerns,  service users were now outlining their own concerns,  the specialist nurse had visited and  in effect both confirmed these and added direct evidence of a deteriorating situation,   significantly a male who on balance is probably FI,  and physical evidence of IV drug misuse.    overview report baby E publication version Page 61 of 90 292. A contributory factor to decision making was the organisational difficulties that were being managed at the time. These are described in further detail in the following relevant key line of enquiry.   293. The ambulance crew identified safeguarding concerns in relation to parenting capacity as both FI and MO appeared intoxicated. There was a disclosure by FI that MO used methadone (but no apparent reference to his own). The crew noted the positioning of Baby E’s changing mat directly underneath the heavy object which is alleged to have fallen onto him. This indicated a lack of care for the welfare of Baby E and failure to protect him from harm. As previously mentioned the crew did not submit a safeguarding child referral and this lack of recognition of the need to do this has been referred to the Trust Incident Learning Panel  Consider whether agencies had the necessary resources and capacity. Consider also whether professionals working with the family were suitably skilled and adequately supervised and whether there is evidence of management accountability and support. Consider whether any organisational changes impacted on work with this family.  294. The HOR does not identify any organisational issues that had an impact on how the case was managed in the health services in Calderdale and Lancashire.   295. In contrast, there were issues that had an impact on CSC services in Calderdale and Lancashire. Organisational capacity is an important aspect to understanding how aspects of this case were handled at the time and the contributory factors that determined how judgments, decisions and actions developed. For example, the social care services in Calderdale and Lancashire were both dealing with significant issues in regard to the staffing of frontline services.   296. In response to the issues identified within this review an independent review of professional practice and resources has been urgently commissioned by Lancashire CSC.   This review has also been tasked with developing tools to identify teams in acute stress and develop escalation measures to ensure early identification of teams experiencing similar difficulties and challenges.  297. In Calderdale there were historical issues relating to the quality of practice and recent inspections of services had generated significant pressures for improvement. The IMR describes how the FRT service was highly reliant on temporary agency social workers; nine of 13 posts were being covered. The workload was high and the practice supervisor was involved with a significant personal case load that had an impact on her capacity to provide the level of challenge, refection and oversight that was required.    overview report baby E publication version Page 62 of 90 298. In Lancashire there were challenges facing the service in recruiting and retaining practitioners and workloads were also high. Although there was active recruitment taking place this generated pressures to train staff as well as to reconfigure some aspects of service.   299. The team manager described the workload pressures in November 2011 as being significant and exaggerated by the acute staffing difficulties and that this case was one of many that presented with drug misuse and domestic violence.  The team manager is acutely aware on reflection that this case required a more rigorous, timely approach.  The IMR quotes her description about the pressures of "being bombarded day in day and that the decision making is influenced by volume, working capacity and thinking capacity. I am aware it affects judgment this type of pressure".    300. The initial assessment team within the area that Baby E lived was under considerable pressure due to a combination of vacancies, maternity leave, annual leave and inexperienced staff members.  In addition the team manager reported that the month of November was a period of extremely high referral rates and that she had 12 cases managed by the duty system. (These cases are not allocated to but responded to by whichever member of the team is on the duty rota).      301. This had impacted upon the team's ability to prioritise cases and to fulfil the statutory timescales for assessments.   The relative inexperience of key segments of the social work workforce was being addressed strategically by the undertaking of a three day district wide training event on "Undertaking Balanced Assessments."   This had a perverse impact in this specific case in that ultimately the event impacted upon the team's ability to deal with this referral in a timely manner.   This was further compounded by a day of industrial action within the same week as the training.    302. The IMR queries whether there are enough social workers to cope with the level of demand. The IMR describes how the team of five social workers appears low in comparison with other districts and that this needs to be further examined. The district manager in discussion outlined how he ideally would like to reconfigure this team and "front load" its function.  However, this is currently prohibited by the workload in the child protection team which has experienced a significant increase in safeguarding court work.  303. The significant issues for learning is the extent to which the organisational stress that was operating within services was recognised at the time and exploring how the action taken to ameliorate operational problems and pressures had unintended and negative consequences for professional practice. This is explored further in the final chapter.  304.  A superficial examination of the case will conclude that people in several organisations did not do their jobs well enough whilst acknowledging that   overview report baby E publication version Page 63 of 90 several were very conscientious. Although there are problems highlighted about how some aspects of professional work was undertaken, the review has to explore why people were not more effective at the time. It would be wrong to conclude that people did not care about this family or about Baby E. It would be wrong to conclude that nobody ever saw any risk in this case.  Professionals are expected to make sense of what are often chaotic lives where issues such as substance misuse and mental health create complexity and risk. Creating opportunities to provide effective help begin with trying to build a relationship with adults who are distrustful.   305. A serious case review offers opportunities to reflect on the options that were available to act differently and to understand the barriers that prevented opportunities either being seen or else followed through. In this case there are issues about the stability and capacity of the service as well as a need to reflect on how professionals make sense of the information being provided or observed.   306. There is an increasing range of research about the importance of organisational arrangements supporting good judgment and decision making. The stability of organisations in terms of their leadership, management and staffing is of course important. The ethos of the organisation and the extent to which it promotes appropriate thinking and action are important factors in analysing why people are able to make decisions or can act in compliance with good standards and policy expectations and can develop good outcomes for children.   307. Good safeguarding work depends on well trained professionals having the systems in place to promote clear communication and have appropriate knowledge and theory frameworks within which to gather and analyse information.   308. In this case it is evident that local protocols were being used when a high risk pregnancy was identified there were significant organisational factors that influenced how information was handled and the quality of decision making. It is important to understand why things happen rather than just what did happen.  309. The practice supervisor in Calderdale who was the point of contact for FRT children’s social care was an experienced senior member of the duty team whose role at the time of the receipt of the information and the referral was to screen and make decisions about the management of that information.  The role made decisions about whether information was progressed to a contact and then allocated.     310. The IMR author confirms that the practice supervisor acknowledges that in retrospect a wrong decision was made about how the information and decisions were handled and it should have been properly opened and   overview report baby E publication version Page 64 of 90 allocated to a social worker for completion of an initial assessment.   The practice supervisor explained that the team were under a considerable amount of stress at the time with most of her colleagues being agency workers who had not been there for very long.  At the same time, the whole organisation was also dealing with the implications of being judged a poor service by inspectors that had led to the departure of several senior people.   311. Since that time additional permanent employees have been recruited to assist with some of the admin functions, which allow social workers to be freed up to deal with casework.  Referral and Information co-ordinators are now in place that take the initial information and ensure it is entered on the system. The team is now mainly permanent staff and only one agency worker.  This has assisted with positive changes.  The case and information with regard to MO, FI and unborn Baby E would only have been discussed in supervision had the case been allocated to a worker.  It was not allocated.  312. Analysis of the CHFT concluded that the capacity, skill levels, supervision and management support were adequate to good in respect of MO and Baby E’s care throughout the antenatal and postnatal period. There has been a subsequent staffing increase on the postnatal ward and training around the embedding of the new safeguarding ICP and record keeping has been delivered.  313. West Yorkshire Police have recognised that there was a requirement to develop their response to safeguarding and on 2nd April 2012 new safeguarding arrangements were implemented within the organisation. This followed a safeguarding pilot in the Calderdale, commissioned in October 2010, to explore the benefits of combining Crime Division Child and Public Protection Units (CPPU) resources with divisional safeguarding functions. The new arrangements aim to improve service delivery by bringing together, at district level closely related areas of safeguarding business, ensuring that operational accountability, supervision and responsibility is delivered locally for all adult and children safeguarding concerns  314. Additionally police officers and police staff through training, accreditation and a general awareness of the LSCB child protection and adult safeguarding procedures, now have a better understanding of their responsibilities in their day to day dealings with all vulnerable adults and children.   315. The co-location of professionals is becoming an increasingly common practice. The specialist health practitioner within the IAS had extensive child and family experience.    316. The specialist nurse has extensive child and family experience within this case.  However, due to the statutory regulations she is unable to complete core or initial assessments.  Her extensive knowledge brought a different key dimension to the team.  This would have been complimented in November   overview report baby E publication version Page 65 of 90 (and addressed some of the staff safety issues via a joint visit with a social worker).  This was the accepted process within the team but the backlog led to the inability to prioritise this.    This would have brought the key social work safeguarding dimension to the visit.     The specialist nurse described her role as being asked to introduce the idea of an assessment to the parent. The team manager asked the nurse to go through the referral and ascertain the nature of the contact and it would be then subsequently allocated.   The IMR author comments that that appears in essence a holding exercise due to the staffing challenges.  Consider whether there are any common themes from previous serious case reviews or critical incident reviews and the effectiveness of your agency’s actions in relation to these.  317. The HOR comments on the extent to which information was accepted at face value by all the health practitioners. This contributed to serious misdirection especially in regard to the evidence that MO was continuing to use drugs despite her professed intention to remain abstinent. The degree to which everybody shared in a degree of optimism in their dealings with MO in particular contributed to a collective sense of being ‘swept along’. This in itself created the conditions within which the empathetic approach to MO was not tempered by an application of sceptical and research informed analysis. Empathy without reflection and challenge will create the conditions in which dangerous collusion can develop.   318. An executive summary on Child C from 2009 in Calderdale comments on the significant delays in social care services completing an assessment of the family and of the potential risks to the unborn child. Information was taken at face value, little attention paid to risk factors and lack of robust analysis of the overall situation.  Risks to the unborn child were underestimated.   Child C was under one year old as was Baby E.  In the same summary it is commented that care services (and health services) did not engage effectively with the father and knew very little about him.  These are issues similar to the current circumstances with this case.    319. After Child C the chair of the Calderdale Safeguarding Children Board was asked to issue a reminder to all agencies for the need to involve both parents in assessments.  This was done but Calderdale CSC was aware that a majority of the social workers in the FRT at the time of Baby E were from an agency and may not have had the opportunity for the identified learning.   320. The IMR author comments that it would appear that Calderdale CSC may still have been making the same errors at the time of Baby E and that it is not the absence of procedures but lack of clear decision making at the time information is received.    overview report baby E publication version Page 66 of 90 321. The Lancashire CSC author refers to the lessons learnt in a previous SCR regarding the qualification and experience of people responsible for co-ordinating assessments. This issue was highlighted in SCR A undertaken by St Helens LSCB, which Lancashire CSC contributed to.   322. Following this SCR guidance was issued to all District Teams regarding the requirement that assessments must be led by a qualified social worker. In light of the issues again raised within this IMR, an audit of District Teams has been undertaken to review practice in this area. This has confirmed that all other districts are compliant with this requirement. The issues in this district appear to have arisen due to team capacity.   323. This has been addressed and an instruction issued that safeguarding health practitioner's, whilst contributing to the health elements must not lead the assessment. This is the responsibility of a qualified social worker.   324. The same author also refers to the SCR relating to Child AB that identified the need for training for staff in the completion of assessments, including the importance of information gathering, historical information, risk analysis and evidence informed practice to inform decision making. In response to this a significant county wide training programme in balanced assessment was delivered to all District Children's Social Care Teams, Children with Disabilities Teams, Youth Offending Teams and Independent Reviewing Officer's, including front-line practitioners and managers during 2011/2012. The training focused on the assessment process, risk management and signs of safety.   325. The SCR relating to Baby E also highlights the importance of multi-agency assessments. The SCR relating to Child Z in (2008) required that core assessment planning meetings take place prior to the commencement of a Core Assessment. At that time the LSCB re-launched the safeguarding children procedures with an emphasis on multi-agency engagement within the Core Assessment process. In light of the learning in this review the use of core assessment planning meetings needs to be further embedded in practice.  326. The implementation of improvement action from previous SCRs will be monitored within the audit cycle framework and in particular the multi-agency Best Practice audit panels which operate under the auspices of the Lancashire Safeguarding Children Board.  These panels examine on a multi-agency basis a small number of cases to examine best practice and explore any learning points that can be applied across the professional network and further multi agency understanding of the interventions provided to families.     327. Ofsted’s evaluation of serious case reviews from 1 April 2009 to 31 March 2012 identify that nationally there are problems in how information is sought and shared. Both Calderdale and Lancashire IMRs refer to learning from   overview report baby E publication version Page 67 of 90 serious case reviews in regard to the importance of securing relevant historical information in order to inform current assessments. The Lancashire CSC IMR refers to training that has been commissioned to improve the use of chronologies to support improved practice in the future.   328. The ELHT author refers to the fact that Baby E was known to be vulnerable due to MO’s history of substance misuse placing him in the two or three per cent of children in England and Wales who have a parent with serious drug or alcohol problems. (Hidden Harm 2003).  329. The same author acknowledges that with the benefit of more information about MO’s relationship history, drug use history as well as the inevitable hindsight provided through a detailed serious case review there appears to have been overlapping parental stressors which together would increase the risk factors for Baby E.   Being a baby under the age of one year also placed Baby E into a vulnerable category22.   330. There also appears to be an ‘invisible father’ who was thought to be uninvolved with MO and Baby E but by the time Baby E sustained the fatal head injury MO’s partner was part of the family unit.  There has been a dearth of information about men in most serious case reviews, both nationally and locally. The failure to make an assessment of partner’s and fathers connected to the mother and children has been identified in national evaluations.  331. Three recent SCR's highlighted by the Lancashire CSC author (relating to Baby J and Child AB (undertaken by Lancashire LSCB) and Child L/Child K (completed by Trafford LSCB), which Lancashire CSC contributed to, had highlighted the importance of assessments including adult males within the family.   332. National evaluations of SCR's have also found that fathers or male partners have not been understood well and therefore the risks assessed inadequately. Given the important role that men often play in children's lives it is important that front line workers have the skills and confidence to engage with individuals who may be threatening and aggressive. This case highlights the importance of assessing relationships and going beyond self-reports in the interests of safeguarding children.                                           22 As evidenced by the IMR author in All babies count: prevention and protection for vulnerable babies: a review of the evidence Cuthbert, Chris, et al (2011).  Also noted in Ages of concern: learning lessons from serious case reviews A thematic report of Ofsted’s evaluation of serious case reviews from 1 April 2007 to 31 March 2011 October (2011).     overview report baby E publication version Page 68 of 90 333. Misinforming and possible manipulation of professionals often known as ‘disguised compliance’ is also referred to by more than one IMR author as may have been a factor in this case. From ELHT records it is unknown if MO was consistently having contact with Baby E’s father and also if her substance misuse was not stable on methadone alone and if MO frequently used ‘street drugs’.  Disguised compliance and manipulation of professionals has also been identified in ‘Baby Peter’ SCR Haringey LSCB) and ‘Child T’ (Surrey LSCB).   This is difficult to address but professionals need to feel able to challenge.    overview report baby E publication version Page 69 of 90 4 Analysis of key themes for learning from the case and recommendations  334. This report begins with an acknowledgment of the imminent changes that will take place over the forthcoming months in the conduct of serious case reviews throughout England. These changes are driven by the recognition that for any meaningful analysis of the complex human interactions and decision making processes that are involved in multiagency work with vulnerable families has to understand why things happen and the extent to which the local systems (people, processes, organisations) help or hinder effective work within ‘the tunnel’23.   335. In this chapter the panel set out key findings that are designed to offer challenge and reflection for the LSCB and partners. The emphasis is not on the more traditional articulation of SMART recommendations. The key findings are framed using a systems based typology developed by SCIE. Although this serious case review has not used systems learning to collate evidence there is value in using the following framework to identify some of the underlying patterns that appear to be significant for local practice in Lancashire and/or Calderdale whilst accepting there are some limitations and mismatch between how the evidence has been collated and this form of presenting the key findings.   a) Innate human biases (cognitive and emotional) b) Family-professional interaction c) Responses to incidents d) Longer term work e) Tools f) Management systems 336. The remainder of this report aims to use this particular case, and to reflect on what this reveals about gaps and inadequacies in the local child protection system and use it as a limited window into the local systems.   337. In providing the reflections and challenges to the LSCB there is an expectation that the Board will provide a response to each of the key findings as well as to the recommendations and action plans that are described in the IMRs. As far as the key finding described in the remainder of this chapter it is anticipated that the Board will take the following action.  LSCB response  a) Does the Board accept the finding?                                          23 View in the Tunnel is explained by Dekker (2002) as reconstructing how different professionals saw the case as it unfolded; understanding other people’s assessments and actions, the review team try to attain the perspective of the people who were there at the time, their decisions were based on what they saw on the inside of the tunnel; not on what happens to be known today through the benefit of hindsight.   overview report baby E publication version Page 70 of 90  b) How is the Board to take this forward? If not, please explain why.  c) Who is best placed to do this?  d) What are the timescales for response?  e) How and when will it be reported?  338. The LSCB will determine how this information is managed and communicated to relevant stakeholders. This report recommends that the LSCB discuss the key findings and make a formal response that is also published.   4.1 Learning from previous serious case reviews  339. The LSCB in Lancashire had undertaken nine previous serious case reviews between 2007 and 2010. Calderdale has published three executive summaries of serious case reviews between December 2008 and December 2009. Bradford has published four serious case reviews between 2006 and 2010.   340. Reference to the evidence from serious case reviews has been made throughout the IMRs, the health overview report (HOR) and this overview report.  4.2 Innate human biases (cognitive and emotional) Empathetic responses to support the efforts and intentions of a vulnerable woman trying to overcome long term addictions and coercive relationships misdirected professionals from maintaining a sufficiently informed level of sceptism focussed on the needs of the child and the inconsistent information.  341. The circumstances and reported history of MO provoked an empathetic response in the professionals working with her. The importance of making an emotional connection between the people needing help and the person providing support is a well understood foundation for developing the basis of effective intervention. The 'sad' history of MO evoked an understandably sympathetic response from several professionals who generally sought to take a strengths based approach to supporting MO and higher levels of contact24.                                            24 Strengths based or solution focused approaches enhance the capacities of individuals, groups, families and communities to deal with their own challenges. Empowerment results from being treated with respect and having strengths acknowledged and enhanced.   overview report baby E publication version Page 71 of 90 342. The use of such an approach is based upon respect and trust that the parent is able to exercise the appropriate judgments and care; if this is not achievable and there is risk to the child a more assertive approach has to be developed. In this case, the initial approach was unable to identify the inconsistencies and indicators of concern.  343. The decision to invoke the MAPLAG in Calderdale when MO’s pregnancy was confirmed was recognition that she would require an enhanced level of help and support. Although risk was discussed it related primarily to concerns about FI’s history rather than MO’s own history and lifestyle. Given the difficulty that MO had in separating from FI before she became pregnant it remains a source of some puzzlement why many people believed that she would achieve this after hr baby was born. FI made clear very early on that the pregnancy was very significant for him. He was always intending to be part of his baby’s life.   344. The MAPLAG is a protocol that describes arrangements for professionals to meet and share information; it does not require the direct participation of the pregnant woman or her partner. Discussions were therefore largely based on what agency representatives brought to the meeting. This required some action in both preparing for the meeting in terms of undertaking basic checks and then following up lines of enquiry identified during the meeting. This was not consistently achieved and therefore even higher reliance was given to what MO stated were her intentions.   345. There is an inherent dilemma in working with parents who have lifestyles and needs that they know will be a source of concern to health and social care professionals. They will have strong motivation to manage information and this was exhibited in this case. MO appeared to have a good understanding about what would cause professionals greatest concern in regard to her baby and sought to minimise, disguise and to misdirect attention.   346. Even at the point that CSC in Lancashire were making their decision to undertake a formal assessment in December just before Baby E died MO was apparently keen to be seen to cooperate with the process. Up until that point she had displayed a tolerance of contact with the various professionals although had rarely taken up opportunities for example to participate in activities at the children’s centre.   347. The difficult circumstances under which MO was living provoked a strong sense of empathy from professionals providing help and support. This sense of empathy can be a constraining factor on professionals developing a sufficiently sceptical and reflective approach to the information and observations that are made through their contact with high need parents and children. Unless information is challenged and analysed for consistency and relevance there will be a danger of collusion developing. MO expressed a   overview report baby E publication version Page 72 of 90 strong desire to create a better life for her child and professionals wanted to help her achieve that but were not able to identify the contradictory information or give enough inference to the barriers confronting MO from her personal and family history, life style and relationship with FI.   348. MO’s history of substance misuse was a significant factor in this case. The nature of addiction and the very significant pressures upon MO required a more informed approach to how for example evidence of MO continuing to access street drugs was viewed. By allowing the information to be regarded as a ‘blip’ or departure from the norm, it created a dynamic between MO and professionals that such ‘lapses’ were unlikely to attract significant attention. Individuals who want to disguise behaviour and attitudes will derive encouragement. There was a difference in how the behaviour was handled between the specialist substance misuse services in Calderdale and Lancashire. In Lancashire there was a more proactive and assertive response although this was not located firmly enough within a multiagency plan of work.   349. The first meeting of the MAPLAG in May 2011 discussed FI’s mental health and his prohibited contact with his previous children although the circumstances were not known and were not adequately enquired into for several more weeks. MO was consistently described as pleasant and engaging well with services and it was understood that she intended to leave the relationship with FI; this was a belief that persisted even when she made contradictory statements and FI also made clear his intention that he fully intended to maintain the relationship. Although MO described him as being controlling which had escalated since MO had become pregnant, it is not apparent that this was understood by the various professionals in contact with her.   350. The impact of coercive relationships on a vulnerable woman such as MO erodes their emotional and practical capacity to leave a relationship especially during and just after pregnancy.   351. Concern was expressed about FI’s mental health especially when he was using crack cocaine. Although follow up action to ascertain more detailed information about FI’s previous children was agreed this was not allocated to CSC.   352. Subsequent meetings of the MAPLAG were advised that MO was intending to establish an independent household. It is also apparent that great encouragement was taken from MO’s apparent determination to not use street drugs although the significance for her of being reliant on a continued methadone script was probably not fully appreciated.   353. When MO disclosed having used street drugs shortly before the birth of Baby E this was regarded as a ‘blip’. This optimistic treatment of information   overview report baby E publication version Page 73 of 90 about evidence of opiate and other substance use persisted after she moved to Lancashire largely it seems because of how MO was represented to professionals in transfer information and the belief that MO was not in relationship with FI.  354. MO’s declaration of intent to leave the relationship with FI was accepted at face value. The inconsistencies between what MO was stating as her plan and the apparent refusal of FI to accept that he would not be involved in the care of Baby E was not recognised or explored.  355. A more appropriately informed and sceptical approach might have explored the significance of MO’s history of substance misuse, the implications of this for when she was under stress such as the ending of a relationship, pregnancy and plan to move to another area.   356. Of equal importance was the limited understanding about the barriers facing MO in leaving FI. MO would have been feeling vulnerable as a pregnant woman. There was limited evidence of a research aware approach of the potential barriers that MO might have to confront; for example, a research aware practitioner would understand that women experiencing abuse and violence often minimise the violence, believe that the abuse or violence will not happen again or that the relationship is different to previous violent relationships, feel embarrassed, have low self esteem and lack self confidence, are scared about the future in respect of having somewhere to live, having help with looking after a baby (especially a sick and premature baby) or becoming socially and economically isolated.   357. Although MO presented as a woman determined to leave an abusive relationship it was apparent that she had failed to achieve this on previous occasions. It was apparent that certainly after MO moved to Lancashire she sought to conceal the fact that her relationship with FI had not ended. She had expressed her anxiety about having Baby E taken from her and was therefore strongly motivated to keep any concerning information away from professionals.   358. Cleaver and Freeman25 note that families are often reluctant to admit to a history of problem drinking or drug use or mental illness because they assume it will result in social workers taking punitive action. Subsequent research reinforces this finding.  359. For similar reasons, families can be eager to conceal domestic violence. Farmer and Owen’s research26 suggests that hidden domestic violence may                                          25 Parental Perspectives in Cases of Suspected Child Abuse. Cleaver, H, and Freeman, P. (1995) London: HMSO. 26 Child Protection Practice: Private Risks and Public Remedies. Farmer, E. and Owen, M. (1995) London: HMSO.   overview report baby E publication version Page 74 of 90 account for many mothers’ seemingly uncooperative behaviour and, further, that confronting families with allegations of abuse can compound the mother’s vulnerable position. For example, child protection conferences were often ignorant of whether or not children lived in violent families because in the ‘face of allegations of mistreatment couples often formed a defensive alliance against the outside agencies’ (Farmer and Owen 1995, p.79).   360. In this case it is possible to see that a defensive alliance developed between MO and FI. The disguised compliance with professionals visiting the home provided false reassurance and meant that missed appointments were for example not a source of immediate concern.  361. The abuse that both parents had experienced as children was another area that deserved more informed reflection.   362. Gaps in the sharing of information left all professionals without a complete picture but when episodic incidents occurred they were not apparently seen as symptomatic of longer term historic patterns that went back to the childhoods of both parents.   363. With hindsight, one of the most significant puzzles is why nobody took more interest at an earlier stage in the absence of information about the family generally and about FI in particular; this is partially explained by the cognitive or emotional processing of information about MO and her circumstances. It also reflected the behaviour of people under considerable workload pressure who did not have sufficient challenge from a supervisor or lead professional.  364. The apparent co-operation of some parents may result in practitioners applying the ‘rule of optimism’ cited in an earlier section. This stems from a number of assumptions, the strongest being that parents love their children and want the best for them, and that children’s lives are better if they stay within their family or kinship arrangements, even if that home is very dysfunctional.   365. The application of the rule of optimism may result in overly positive interpretations of what parents say and of the behaviour and circumstances observed. Research suggests that ‘over-confidence in “knowing” the parent or carer, might lead to misjudgment, over-identification with parents or (professionals) not seeing concerns about children.27’   366. In these circumstances practitioners may too readily accept parents’ explanations of events and be reluctant to challenge them. Insufficient                                          27 The Child, the Family and the GP: Tensions and Conflicts of Interest in Safeguarding Children. Tompsett, et al. 2009 London: Department for Children, Schools and Families. Although the research is discussing GP practice the learning point is applicable across a much broader professional group.    overview report baby E publication version Page 75 of 90 attention to parents wanting to keep aspects of their lives private is another factor; for example disguising aspects of lifestyle and relationships. This was a feature in this case and was a significant contributory factor.   367. Research and SCR findings have also identified that professionals tend to evade frightening confrontations (Brandon et al. 2009, 2010; Department for Education 2010c; Lord Laming 2009). The research suggests that when professionals feel unsupported or must visit alone, visiting and child protection enquiries might not always be as thorough as they could be (James 1994; Denny 2005; Farmer 2006)28. Several of the IMR authors comment on how professionals felt when they went into the house (crowded, voices in other rooms, not sure if they can insist on seeing all of the house, sense of intimidation) and the thoroughness of enquiries was a factor in this case  Issue for consideration by the LSCB  1. How will the lessons in regard to assessment and focus on the child be incorporated into local single assessment frameworks?  2. Are the different protocols and frameworks such as MAPLAG, CAF, pre birth assessment and Integrated Pathways a help or a hindrance to supporting effective exchange of information and providing help quickly and effectively?   Professionals did not feel sufficiently self confident about their role; some of this reflected inappropriate and pragmatic allocation of tasks arising from organisational stress.  368. Several of the IMRs refer to individual practitioners visiting the house and finding several people in the home. This had some influence on what was discussed on some of the visits. At least one of the professionals referred to asking to see the house but was dissuaded by MO. A lack of certainty about how far to press the issue was evident. Matters were complicated when one of the practitioners who were co-located with CSC in Lancashire was asked to undertake a home visit. The practitioner was very experienced and a skilled and qualified health professional but not a social worker.  369. The last visit to the home when the practitioner felt intimidated was the subject of a discussion with managers.                                            28 These sources are cited in the Children’s Needs – Parenting Capacity Child abuse: Parental mental illness, learning disability, substance misuse, and domestic violence; Cleaver, Unell and Aldgate; 2011 TSO.   overview report baby E publication version Page 76 of 90 370. The emotional and psychological impact on practitioners is a significant factor in complex work such as safeguarding children.   Issue for consideration by the LSCB  1) How are practitioners helped to develop the level of confidence and clarity and able to achieve sufficient sceptical curiosity and challenge in their work with vulnerable families?   4.3 Responses to incidents or information Enquiries and management of information did not identify the underlying patterns of behaviour, inconsistencies and inherent suspicion of professionals.  371. The interaction and relationship between professionals and vulnerable families and requires considerable empathy, professional knowledge and interpersonal skills.  372. Reference has been made to how despite MO’s expressed intention to leave FI and her description of the coercive nature of their relationship MO was unable to achieve that objective.   373. The absence of an adequate family history of either parent and the lack of follow up to enquiries with other local authorities on FI’s previous children left important gaps in the knowledge that professionals had.   374. It was highly unlikely that FI would be able to accept the relationship with MO was ending when she had become pregnant with his baby. FI made it clear that he knew where MO was intending to move.  375. None of the inconsistencies and contradictions aroused any sceptical curiosity. For some services such as CSC in Calderdale, there was a preoccupation with the plan for MO to move outside their area and this apparently allowed people to assume they had no responsibility.   376. MO and FI were from disrupted family backgrounds and their life style that had involved the use of drugs had implications for their social integration and was significant in the way in which MO worked with agencies aiming to support her and Baby E.   377. It remains unclear if MO was intending to misdirect professionals in Calderdale in regard to her intentions to leave FI. It became apparent in November 2011 that MO and FI were disguising their relationship from professionals; they were concerned that CSC would become involved and the potential implications in regard to whether they would be considered able to care for Baby E.    overview report baby E publication version Page 77 of 90 378. Once the final referral was made to CSC MO sought to manage the response by stating her willingness to participate in an assessment and the importance of understanding FI’s history.  379. Without understanding the underlying patterns to the relationship and the impact of their family history the exchange of information focussed on what was largely reported by MO. With a clearer understanding about their history and the implications for how MO and FI would perceive professionals such as CSC there would have been opportunity for sceptical curiosity and a capacity to anticipate that reluctance, resistance and misdirection might be an underlying pattern to family and professional interaction.    380. Apart from the MAPLAG there were never any structured interagency discussion and sharing of information. There was a high reliance on individual telephone calls, email correspondence and fax. This contributed to a piecemeal picture and undermined opportunity to identify emerging patterns.   381. The work on refreshing the CAF in Lancashire will provide opportunity to review thresholds and referral pathways.  Issue for consideration by the LSCB  1) Are the skills for completing appropriate individual and family histories and the use of chronologies sufficiently embedded in service expectations and practice?  4.4 Longer term work Insufficient multi agency understanding about the significance of substance dependency and the implications for working with parents and their inconsistent engagement contributes to inference and interpretation that lacks balance    382. The influence of empathy that is highlighted in regard to the emotional response to MO’s circumstances have implications for longer term work with parents with longstanding substance misuse.  383. Problematic drug use and misuse of alcohol by parents or people caring for children can and does cause significant harm to children and has implications especially for very young and dependant infants.    384. Children living in households where there is a parent with a drug or alcohol dependency will be susceptible to several risks; these range from poverty exacerbated by an inability to maintain a routine of work as well as diverting household income to funding the purchase of substances as well as increasing the risk of inconsistent care that exposes children to the risk of immediate physical harm and longer term emotional damage.    overview report baby E publication version Page 78 of 90 385. A persistent factor in this case was the non recognition other than by the Inspire service in Lancashire that MO was dependent upon maintaining her physical and emotional stability with a regular methadone prescription. Several professionals mistakenly regarded MO’s substance dependency as being a largely historical problem that she had overcome and therefore were not sensitised to the potential for relapse and especially during times of heightened stress.   386. This is difficult area of practice where on one hand professionals are trying to establish a relationship of trust with adults who will not want to be open about issues such as relapse. If adults and professionals are both minimising the issue it becomes a source of significant risk in households where children are very young and dependant.   387. Research which explores the association between parental problem drug misuse and child abuse suggests parental drug use is generally associated with neglect and emotional abuse29. Parents who experience difficulty in organising their own and their children’s lives are unable to meet children’s needs for safety and basic care, are emotionally unavailable to them and have difficulties in controlling and disciplining their children30. The chaotic lifestyle and tendency to allow other users into the home may also place children at increased risk of harm31.    388. High levels of parental criticism are also associated with the formation of insecure attachments as children grow older. Research suggests that children living with opiate-using parents are at increased risk of harm because these mothers were observed to rely on harsh verbal responses when communicating with their children.32    389. The Inspire IMR highlights that in November 2012 there appeared to have been a change in the substances used by MO that was identified at a doctor’s appointment on the 10th November 2012 where she tested positive for methadone, heroin and crack cocaine.  The fact that heroin and crack cocaine were detected indicated very recent usage (compared to other substances that remain detectable over a longer period of time).                                            29 ‘Working with substance misusing parents as part of court proceedings.’ Representing Children 14, 36–48. Velleman, R. 2001 30 When Parents Use Drugs: Key Findings from a Study of Children in the Care of Drug-using Parents. Dublin: The Children’s Research Centre. Hogan, D. and Higgins L. (2001) 31 Research Review: Child Care Proceedings under the Children Act 1989. London: Department for Constitutional Affairs. Brophy, J. (2006) 32 ‘Annotation: the psychological development and welfare of children of opiate and cocaine users – review and research needs.’ Journal of Child Psychology and Psychiatry 39, 609–619 Hogan; 1998 and cited by Cleaver et al.   overview report baby E publication version Page 79 of 90 390. This information was not passed on to the midwife until the 17th November.  The recovery worker understood that the health visitor was going to arrange a multi-agency meeting following a discussion on the 17th; however this did not take place.  The recovery worker for Inspire did not follow this up with the Health Visitor as the situation had escalated in the following week resulting in a Section 47 referral being made.   391. There are several references to MO trying to circumvent the tight management of her methadone treatment. MO’s access to other sources of methadone or her use of street sourced drugs was not given any significance.   392. The speed with which MO had physically deteriorated in November 2011 is commented upon in previous sections of this report.   393. Although the MAPLAG, ICP, CAF as well as statutory assessments of a child in need were variously identified as frameworks to assess Baby E’s circumstances, none of these achieved an adequate parenting assessment that had been agreed across the various people working with the family. This is distinct from the separate point that is made later about the absence of tools being used to help professionals make difficult judgments.   Issue for consideration by the LSCB  1. Do practitioners have sufficient knowledge appropriate to their role and responsibilities in regard to domestic abuse and substance dependency to understand the implications for safeguarding children?  4.5 Tools The use of tools for collating, sharing and analysing information are not sufficiently embedded into multi agency working to promote analytical discussion and to help reveal underlying patterns of behaviour and risk especially in regard to very young children.  394. Opportunities to complete an agreed programme of assessment of needs or risk were not taken in this case; there were discrete and specific assessments such as Baby E’s weight and MO’s mood but these could not provide the whole picture. Reliance appeared to be given to the use of the MAPLAG when MO was living in Calderdale and may have been misunderstood as representing an assessment and providing false reassurance. This is a protocol for the sharing of information and as such relies on participants having evidence and information that is collated and contributes to analysing relevant factors.   395. In this case there were basic enquiries required in regard to the history of both parents that were not undertaken with sufficient speed or rigour. Information and evidence about domestic abuse and substance dependency   overview report baby E publication version Page 80 of 90 and the mental health of both parents were aspects that had a bearing on their capacity to care for their baby.  396. This can be a challenge when several different services comprising different professional backgrounds and training are working with a family. Questions such as whether a child is receiving a good enough level of parenting can be subjective as well as reflect different levels of o understanding around areas such as patterns of attachment for example. Tools help navigate and provide points of reference.   397. The effective sharing and analysis of information within a framework of appropriate and child focused assessment is a perennial challenge for multi professional teams or groups of workers and has been described and discussed in national research, inspections of children’s services as well as being a regular feature in local and national serious case reviews.   398. In Calderdale there was no social or family assessment completed. Information was discussed at MAPLAG although this had limited success in securing the level of multi agency action that was agreed at the meetings. The MAPLAG is a multi agency protocol although there was apparent confusion about its purpose and status. For example CSC believed it was a meeting where they were assisting health professionals in their work.  Arguably, the use of MAPLAG may have diverted attention from other recognisable protocols such as CAF or assessing unborn children.   399. CSC in Calderdale did not complete any assessment. In Lancashire, the decisions about assessment were dictated by the workload and organisational stresses that were operating at the time. After MO moved to Lancashire and the decision by CSC in that county to convert the initial assessment to a core assessment did not secure basic enquiries quickly enough and the use of a health practitioner to complete the assessment further undermined the process; this is not a criticism of an individual practitioner but a reflection upon the circumstances that prevailed at the tie and had an impact on how the case was managed and decisions were made.   400. The national framework for assessment is facing radical reform following the publication of the Munro Review and the subsequent consultation on the revisions to Working Together and other national guidance. Local areas will be expected to develop their own local assessment frameworks and standards. In the absence of national guidance in the future, Calderdale and Lancashire will have to ensure that there is clarity about local assessment and a clear understanding about how it achieves appropriate levels of practice.   401. A further aspect in this case is the extent to which the CAF is used as a record of referral rather than being a multi agency process that draws relevant professionals together to work with parents. By the time a CAF was   overview report baby E publication version Page 81 of 90 being completed in Lancashire there were safeguarding concerns being identified.   402. A common challenge for all professionals is how to give sufficient focus to the needs of children. It is a theme revealed in this review and which is reflected in national studies33 and concerns the extent to which questions about what a child means to a parent and what the parent means to that child in respect of their emotional care and security are not routinely explored. The same report offers reflection on the important relationship between having a good understanding about all aspects of maltreatment and its relationship with the development of children.   Issue for consideration by the LSCB  1. How does the training and development of professionals undertaking or contributing to single assessments across all services provide sufficient understanding about child development and childhood vulnerability?  Opportunities are insufficiently developed for professionals to routinely enquire about the prevalence of domestic abuse and understanding coercive relationships as abuse.  403. Reference was made earlier in this report to the national pathway screening in Wales for domestic violence that encourages primary health workers such as health visitors and GPs to routinely inquire about a history or experience of domestic violence.   404. NICE are currently undertaking national research on how social care, health services and those they work with can identify, prevent and reduce domestic violence.   405. It is outside the scope of this SCR to discuss how domestic abuse is prevented. There is debate about the mixed evidence regarding the efficacy of screening pathways.   406. For the purpose of promoting effective safeguarding practice it is legitimate to reflect on the importance of all professionals in direct contact with young pregnant women having sufficient understanding about the prevalence of domestic abuse that encompasses coercive behaviour as much as more explicit physical and verbal abuse.  407. In this case, MO described how much she felt controlled by FI and it was apparent that he had been unable to allow her to end the relationship. The                                          33 Brandon, Sidebotham, Ellis, Bailey and Belderson. Child and family practitioners’ understanding of child development: Lessons learnt from a small sample of serious case reviews Department for Education May 2011   overview report baby E publication version Page 82 of 90 increased risk of violence during and soon after the birth of a child was not explicitly recognised in this case.   Issue for consideration by the LSCB  1. What measures can be taken to encourage more routine enquiry and identification of domestic abuse and identifying sources of help and support?  4.6 Management systems Organisational stress has an impact on the capacity of individual professionals and teams to function appropriately in regard to carrying out statutory functions and providing the level of co-ordination the case required  408. This review has highlighted the extent to which the performance and decision making of professionals can be adversely affected by the functioning of other systems and organisational arrangements around them.  409. In Calderdale there had been a recent statutory inspection of children’s services that had identified serious shortcomings. Some of those shortcomings are reflected in the way this case was managed and were further exacerbated when several senior managers left the service.   410. The impact on organisations dealing with a significant event will frequently involve a period of instability that further exacerbates the level of organisational challenge. Complex work such as safeguarding children relies on recruiting and retaining practitioners who have the motivation, skills and capacity to work effectively. The FRT service was highly reliant on temporary social workers; the fact that almost 75 per cent were agency staff no doubt undermined a culture that local practitioners were working for local children; this may have contributed to the mindset that gave a lower priority to completing an assessment on a child known to be leaving the local area. The logic remains unclear why no adequate assessment was undertaken in regard to Baby E prior to his discharge from hospital and the transfer of information from Calderdale to Lancashire CSC took place after MO had taken her own discharge.  411. In Lancashire, there were other organisational stresses. These related to the amount of work being undertaken in the area that MO moved to, the influx of new and inexperienced staff and the need to provide training and development.   412. This led to some pragmatic decisions being made. An example is the decision to convert the initial assessment to a core assessment. This is not   overview report baby E publication version Page 83 of 90 necessarily a bad thing to do; for example research by David Thorpe34 and others showed that by reducing initial assessments could free capacity to develop relationships with families and improve the opportunity for enhanced assessment. Professor Munro’s recommendation to end the distinction between initial and core assessments is being implemented across England.  413. Another example of organisational stress having an impact on how professionals behave and make judgments is the decision to use the co-located health practitioner to complete the assessment.   414. The fact that organisations undergo periods of stress is not unusual or especially insightful. The learning to come from this review is to reflect upon the extent to which there was sufficient awareness and acknowledgement of the difficulties. This required local managers to be communicating up their line of accountability as much as senior leaders ensuring that appropriate systems of culture and accountability are identifying when local parts of a service are struggling and becoming a source of risk. It is also important for external agencies to report evidence of organisational stress either in terms of escalation around an individual case or more strategic discussion with senior managers. The LSCB has an important role in monitoring the integrity and resilience of local organisations and arrangements.   415. In the David Thorpe study quoted in the earlier paragraph reference is made to the potential value of developing meaningful performance measures which enable managers to understand and control near and long term events35. Thorpe and colleagues describe the opportunities presented by a new approach that is not constrained by meeting national key performance targets (KPI) but involves the ‘identification of numerical and textual patterns and trends’. In this case a significant factor was the influence of local and national KPIs in regard to the timeliness of assessments but did not identify the risk to quality or insufficiently addressing outcomes for Baby E.   416. The dismantling of national guidance and the increasing emphasis on local areas taking responsibility for the performance of their services will increase the need for developing meaningful measures that promote good outcomes for children.  Issue for consideration by the LSCB                                           34 RIEP & ADCS Funded Safeguarding and Promoting Welfare Research Project; Thorpe, Denman and Regan; September 2011  35 Thorpe et al distinguishes a performance measure from a performance indicator as being ‘a far more active, continuous conversational process involving scrutiny and analysis’ compared to an indicator that is a ‘single numerical signal that does not carry any explanatory power’.    overview report baby E publication version Page 84 of 90 1) What are the factors that ensure organisational stress is identified and the strategies for managing that challenge are appropriate and are understood by relevant stakeholders?  2) What measures of performance (rather than targets) will be required to support and provide evidence about the effectiveness of local single assessment frameworks?   The delivery of services in areas of high need and deprivation lead to erosion of thresholds of concern and the adoption of locally normalised attitudes and behaviours  417. The process of normalisation is an increasingly well understood influence on human and professional behaviour and decision making. Although it is not made explicit in the IMRs the challenge of delivering services in areas of acute poverty and high deprivation is commented upon in regard to the work of specific services such as the children’s centre.   418. The area where MO and Baby E lived in Lancashire is within the top one per cent of socially deprived areas in England. Families are presenting with extremely high needs such as poverty, ill health, domestic violence, substance and alcohol misuse, infant low birth weight, teenage mothers, isolated single parents and homelessness. The children’s centre has between 2,500 and 3,000 service users registered at any one time and by definition a significant proportion of families and children is vulnerable.     419. The CSC author comments on whether resources are sufficient to meet the level of demand.  420. The impact on professionals working in areas is that they can begin to normalise behaviours that tolerate issues such as substance dependency and adults who do not want to engage and seek to keep professionals from seeing their children.   Issue for consideration by the LSCB  1) Is there additional work required in regard to the formulation and allocation of resources especially in regard to indicators of need and workload?  4.7 Issues for national policy  421. The problems associated with no common system of recording patient information are highlighted in this serious case review.   Peter Maddocks, CQSW, MA.   overview report baby E publication version Page 85 of 90 Independent author 19th October 2012 CONFIDENTIAL    overview report baby E publication version   Page 87 of 90 5 APPENDICES Appendix 1 - Procedures and guidance relevant to this serious case review Legislation  The Children Act 1989  Section 11 of the Children Act 2004 places a duty on the key people and bodies described in the Act36 to make arrangements to ensure that their functions are discharged with regard to the need to safeguard and promote the welfare of children. The application of this duty varies according to the nature of each agency and its particular functions. The Section 11 duty means that these key people and bodies must make arrangements to ensure that their functions are discharged having regard to the need to safeguard and promote the welfare of children and this includes any services that they contract out to others.  Section 17 imposes a duty upon local authorities to safeguard and promote the welfare of children in need.  Section 47 requires a local authority to make enquiries they consider necessary to decide whether they need to take action to safeguard a child or promote their welfare when they have reasonable cause to suspect that a child is suffering, or is likely to suffer significant harm.  These enquiries should start within 48 hours. The local authority is required to consider whether legal action is required and this includes exercising any powers including those in section 11 of the Crime and Disorder Act 1998 (Child Safety Orders) or when a Baby Has contravened a ban imposed by a Curfew Notice within the meaning of chapter I of Part I of the Crime and Disorder Act 1998.  Section 46 provides the Police with Powers of Protection to take children into police protection where a constable has reasonable cause to believe that a child would otherwise be likely to suffer significant harm.  The Children Act 2004  Section 10 requires each local authority to make arrangements to promote co-operation between it, each of its relevant partners and such other persons or bodies, working with children in the authority’s area, as the authority consider appropriate.  The arrangements are to be made with a view to improving the wellbeing of children in the authority’s area – which includes protection from harm or neglect alongside other outcomes.  This section is the legislative basis for children’s trusts arrangements.                                           36 Local Authorities, including District Councils, the Police,  National Offender Management Service, NHS bodies, Youth Offending Teams, Governors/Directors of Prisons and Young Offenders Institution, Directors of Secure Training CONFIDENTIAL    overview report baby E publication version   Page 88 of 90 Section 11 of the Children Act 2004 places a duty on the key people and bodies described in the Act37 to make arrangements to ensure that their functions are discharged with regard to the need to safeguard and promote the welfare of children. The application of this duty varies according to the nature of each agency and its particular functions. The Section 11 duty means that these key people and bodies must make arrangements to ensure that their functions are discharged having regard to the need to safeguard and promote the welfare of children and this includes any services that they contract out to others.  Safeguarding Procedures  The local safeguarding children procedures  The procedures provide advice and guidance on the recognition and referral arrangements for children suffering abuse. This includes emotional abuse that involves causing children to feel frightened or in danger. The procedures also cover physical abuse of children. The procedures also describe abuse involving the neglect of children that includes failing to protect children from physical harm or danger or the failure to ensure access to appropriate medical care or treatment. This includes describing distinct action to be taken when professionals have concerns about a child, arrangements for making a referral, and the action to be taken. The procedures cover arrangements for the ACPC (now superseded by LSCB) to ensure there are effective arrangements that promote good interagency working and sharing of information and training. The procedures describe specific responsibilities for all agencies contributing to this serious case review.  Other local procedures relevant to this serious case review  Multi-Agency Pregnancy Liaison and Assessment Group (MAPLAG)  The MAPLAG is a local procedure implemented in Calderdale but not in Lancashire. The protocol applies to all professional services working with women and their partners who are using drugs or misusing alcohol during pregnancy. The protocol is not a substitute for the LSCB child protection procedures in Calderdale. The protocol is based upon a model developed in Sheffield and was introduced in to Calderdale following a previous serious case review. The MAPLAG is intended to encourage pregnant women who are using drugs or misusing alcohol to seek early ante natal care and to develop an action plan that also encourages communication between all relevant professionals working with the pregnant woman. The MAPLAG has been highlighted as an example of good multi agency practice by inspections of services in Calderdale.                                           37 Local Authorities, including District Councils, the Police, National Offender Management Service, NHS bodies, Youth Offending Teams, Governors/Directors of Prisons and Young Offenders Institution, Directors of Secure Training Centres. CONFIDENTIAL    overview report baby E publication version   Page 89 of 90 National guidance38  Working Together to Safeguard Children (2010)  The national guidance to interagency working to protect children is set out in Working Together to Safeguard Children: A guide to inter-agency working to safeguard and promote the welfare of children. The guidance includes safeguarding and promoting the welfare of children who may be particularly vulnerable. This guidance is likely to be significantly reduced by the coalition government.  Framework for the Assessment of Children in Need and their Families 2001  The guidance in respect of the Framework for the Assessment of Children in Need and their Families is issued under section 7 of the Local Authority Social Services Act 1970 and is therefore mandatory.   The framework sets out the framework for ensuring a timely response and effective provision of services to children in need. It makes clear the importance of achieving improved outcomes for children through effective collaboration between practitioners and agencies. The framework sets out clear timescales for key activities. This includes making decisions on referrals within one working day, completing initial assessments within seven working days and core assessments within 35 working days. As part of an initial assessment children should be seen and spoken with to ensure their feelings and wishes contribute to understanding how they are affected. If concerns regarding significant harm are identified they must be subject of a strategy discussion to co-ordinate information and plan enquiries. Child protection procedures must be followed.  Assessments should be centred on the child, be rooted in child development that requires children being assessed within the context of their environment and surroundings. It should be a continuing process and not a single or administrative event or task. They should involve other relevant professionals. The outcome of the assessment should be a clear analysis of the needs of the child and their parents or carers capacity to meet their needs and keep them safe. The assessment should identify whether intervention is required to secure the well – being of the child. Such intervention should be described in clear plans that include the services being provided, the people responsible for specific action and describe a process for review.                                            38 The election of a coalition government in May 2010 may result in changes to guidance and policy developed by the previous government. CONFIDENTIAL    overview report baby E publication version   Page 90 of 90 Common Assessment Framework (CAF) The CAF is a key part of delivering direct services to children that are integrated and focused around the needs of children and young people. The CAF is a standardised approach to conducting assessments of children’s additional needs and deciding how these should be met. It can be used by practitioners across children's services in England. The CAF promotes more effective, earlier identification of additional needs, particularly in universal services. It aims to provide a simple process for a holistic assessment of children's needs and strengths; taking account of the roles of parents, carers and environmental factors on their development. Practitioners are then better placed to agree with children and families about appropriate modes of support. The CAF also aims to improve integrated working by promoting coordinated service provisions. All areas were expected to implement the CAF, along with the lead professional role and information sharing, between April 2006 and March 2008.      1     Serious Case Review  Baby E   Lancashire LSCB Response to Findings    June 2013   2  Findings 1, 6 and 9 How will the lessons in regard to assessment and focus on the child be incorporated into local single assessment frameworks? How does the training and development of professionals undertaking or contributing to single assessments across all services provide sufficient understanding about child development and childhood vulnerability? What measures of performance (rather than targets) will be required to support and provide evidence about the effectiveness of local single assessment frameworks? Working Together 2013, which became operational on 15 April 2013 details how each Local Authority should develop and implement a single assessment framework. In Lancashire, this process is well underway and the LSCB hopes to approve the final documentation by the end of summer 2013. The development of this framework has been carried out with partner agencies so that all practitioners will feel some ownership of the process.  The roll out of the single assessment training has been agreed and will involve all partner agencies. This is being funded and facilitated by the LSCB. The issues about family history and chronologies will be integral to this training, as will child development. A mechanism for reviewing and evaluating the success of the framework will be developed using qualitative measures about the impact on children's' lives. Alongside this work to develop the single assessment framework, the Common Assessment Framework (CAF) has been refreshed in Lancashire, along with the Continuum of Need and Threshold guidance. There are plans to launch this refreshed guidance and documentation from Autumn 2013, and again this includes significant multi-agency training programmes.  Meanwhile, the basic principles of child development and vulnerability are built into all single and multi agency training and LSCB interactions with practitioners. The LSCB runs bite-sized briefings for staff on a variety of child related topics, best practice panels for practitioners, formal multi-agency training and regular large briefings about the findings from serious case reviews. Theories about hypothesizing and 'professional dangerousness'1 are covered in all of these outlets. Practitioners get involved in many case reviews, not just Serious Case Reviews, where they can reflect on practice and have the opportunity to share learning and build their skills and knowledge.                                                             1 “Professional dangerousness” is a process whereby individual practitioners and agencies can be drawn into maintaining situations of risk unintentionally, for example, by being overly optimistic about a child’s safety despite evidence to the contrary. Professional dangerousness can exist at an individual, agency or societal level.  3  Finding 2 Are the different protocols and frameworks such as MAPLAG (Multi Agency Pregnancy Liaison and Assessment Group), CAF, pre birth assessment and Integrated Pathways a help or a hindrance to supporting effective exchange of information and providing help quickly and effectively? Lancashire LSCB considered the MAPLAG process as used in Calderdale, but felt it appropriate firstly to review existing processes. Consequently, reassurance was sought about pre-birth processes across the County. Feedback from midwives and health practitioners reassured Lancashire LSCB that introducing a new, additional process was not only unnecessary, but could potentially confuse what is a well-functioning process. The pre-birth protocol in Lancashire was refreshed and re-launched at around the time of this review being completed, and generated a great deal of discussion and awareness-raising amongst relevant practitioners. Lancashire partner agencies have recently launched a Multi Agency Safeguarding Hub (MASH), which will provide a very quick and effective process of sharing information through the co-location of professionals and recording systems.  Details about how this works, along with much more information about improving the way agencies work together with families in Lancashire can be found via this hyperlink: Lancashire Childrens Trust - - Lancashire Improving Futures Programme (or at www.lancashirechildrenstrust.org.uk/resources) Finding 3 How are practitioners helped to develop the level of confidence and clarity and able to achieve sufficient sceptical curiosity and challenge in their work with vulnerable families? Lancashire LSCB recently launched multi-agency safeguarding supervision standards for all agencies to adopt. In addition, Children's Social Care has launched a strategy to ensure all their staff supervision allows space and time for 'reflection' about work with families. This will allow individuals to challenge their thinking about their work and ensure they are applying enough sceptical curiosity. In addition, the LSCB is currently undertaking a supervision audit across partner agencies and will consider the findings and take any necessary actions in due course. Practitioners have the opportunity to become involved in many activities offered by the LSCB. Best practice panels run across the County, where practitioners can bring cases to share their learning and develop their practice. Bite sized briefings are offered on a variety of topics, and large multi-agency briefings run several times a year to feedback learning from serious case reviews. Throughout all the interactions we have with practitioners, in whatever training or forum, we promote theories about  4  hypothesizing and 'professional dangerousness', to help practitioners challenge their own and others' thinking about families.  The LSCB is hoping to develop practitioner forums this year, which will provide an additional outlet for practitioners to come together to share best practice and learn from one another.   Finding 4 Are the skills for completing appropriate individual and family histories and the use of chronologies sufficiently embedded in service expectations and practice? Following this review, the LSCB sought assurance from partner agencies about their use of chronologies, and there are some issues that relate to systems that can make this difficult. However, the message about histories and collating historical information are reinforced in all of the forums previously detailed. In addition, the MASH will allow the sharing of those histories on a multi-agency basis in a much quicker and more efficient manner.  The LSCB is currently undertaking an audit on neglect and the early support and identification of neglect across partner agencies, and this will provide more evidence about how histories are being used to determine future risks.   Findings 5 and 7 Do practitioners have sufficient knowledge appropriate to their role and responsibilities in regard to domestic abuse and substance dependency to understand the implications for safeguarding children? What measures can be taken to encourage more routine enquiry and identification of domestic abuse and identifying sources of help and support? The LSCB has chosen the 'toxic trio'2 as the focus of its quality assurance work for the coming year. This will include seeking a large amount of quantitative, qualitative and outcome information that demonstrates the impact agencies are having on the lives of children affected by parental substance misuse, mental ill health and domestic abuse. The implications from the findings of this work will be considered by the LSCB and appropriate actions taken.                                                             2 The term “toxic trio” is used to describe the co-occurrences of mental health problems, substance misuse and domestic abuse in families.  5  The LSCB delivers training about the 'toxic trio' through formal courses and also briefings. In addition, the work around supervision will encourage reflective practice. (See also comments below about practitioner survey)  Findings 8 and 10 What are the factors that ensure organisational stress is identified and the strategies for managing that challenge are appropriate and are understood by relevant stakeholders? Is there additional work required in regard to the formulation and allocation of resources especially in regard to indicators of need and workload? Lancashire LSCB has recently completed a practitioner survey across all agencies to determine practitioner views about their employing agencies. This included views about training and support available, along with confidence in tackling certain issues (such as domestic abuse). More than 700 practitioners responded to this survey and the LSCB has required agencies to take action in regards to the findings. The survey can be viewed via this hyperlink: Lancashire Safeguarding Children Board The LSCB has strong links to the Children's Trust in Lancashire and shares information and vies about need within the County. The LSCB is also to publish imminently a thresholds guidance document, to run alongside the refreshed CAF and Continuum of Need. A programme of training will be delivered alongside this.    Nigel Burke Independent Chair Lancashire Safeguarding Children Board July 2013  