Death of a newborn infant in September 2020. Child E was born with no brain activity after a breeched labour and delay in the parents accessing medical care, with their life support being switched off the day after birth. Learning includes: professionals should understand that some parents with a long history of intervention may be resistant to professional involvement; there are limitations to child protection information sharing arrangements when it comes to missing people; information sharing on missing people requires joint data to be made available on risk factors to predict the likelihood of specific harmful outcomes. Recommendations include: safeguarding practitioners use joint supervision to reflect on progress made against intervention plans when there is limited engagement and risks remains unresolved; joint agreement and understanding of a missing person incident enables action to be taken, including the most appropriate use of police powers; practice should be led by continuous assessment of need for children and families, with assessment including therapeutic input and, when appropriate, joint intervention by children and adult's services; parents who have a history of repeated removals of babies, and a history of adverse childhood experiences (ACEs), require support and joint intervention from adult and children's services; local partnerships should explore how they can engage with providers of private baby scans to raise safeguarding standards.
      
 Title:  Local child safeguarding practice review (LCSPR): Child ‘E’. LSCB: Camden Safeguarding Children Partnership Author: Wendy Thorogood Date of publication: 2021  This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC.  This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above.                            1      LOCAL CHILD SAFEGUARDING PRACTICE REVIEW (LCSPR) CHILD ‘E’           Author: Wendy Thorogood, Independent Nurse Consultant  2   CONTENTS  1. Introduction - Serious safeguarding incident ................................................................. 3 2. Brief case background .................................................................................................. 3 3. Scope for a Local Child Safeguarding Practice Review (LCSPR) ................................. 4 4. A brief chronological overview of Child E’s case ........................................................... 4 5. Focus of the Review ..................................................................................................... 6 6. Learning in action  ...................................................................................................... 14 7. Recommendations ...................................................................................................... 16 8. References ................................................................................................................. 17              3  1. INTRODUCTION - SERIOUS SAFEGUARDING INCIDENT  1.1 Child E was born with no brain activity on 16th September 2020 at Borough B Royal Infirmary Maternity Unit, after a breeched labour and delay in the parents accessing medical care. Child E was put on life support immediately after the birth, and the life support was switched off on Thursday 17th September 2020 at approximately 15:00. Child E died 6 minutes later. 1.2 Child E’s parents are understood to have fled from London to Borough B having attempted to conceal the pregnancy because the unborn baby had been placed on a pre-birth Child Protection Plan. The Mother attempted to give birth in the Bed and Breakfast accommodation where the couple were staying in Borough B, however ended up calling an ambulance and attended hospital when mother was in distress.   1.3 When the parents arrived at the hospital, the Mother was examined and found to be in advanced labour. The parents concealed their identity and did not make it known to the hospital that there was a risk that baby was in breech so the hospital initially tried to proceed with a natural labour. The hospital quickly discovered that the baby was in breech and the labour was much higher risk. Child E was born via emergency C-section with no brain activity and was immediately connected to life support. Due to the parents’ irregular presentation of events, borough B hospital promptly worked with County B Police force colleagues and identified that the parents had given a false identity and determined their true names.   2. BRIEF CASE BACKGROUND  2.1 Child E was the fifth child born to the parents. Their oldest child was removed as a baby and is in long-term foster care. Their 3 younger children are Looked After by Borough A.  2.2 Mother and Father came to Borough A in 2018 whilst pregnant with their second child.  Both parents   are reported to have significant learning difficulties. Mother is estimated to have a learning age of a 9/10 year old and father is estimated to have the learning age of an 8/9 year old (as recorded in a Psychologist report undertaken in a previous set of care proceedings in 2019). Both parents are recorded within Borough A’s Children’s Safeguarding and Social Work records  as not understanding any of the safeguarding concerns raised during proceedings and not having the capacity to learn the skills required to safely care for a young child due to the extent of their cognitive functioning. 2.3 Following a pre-birth assessment unborn Child E was made subject to a Child Protection Plan in April 2020 under the category of neglect. Due to COVID-19 most of the pre-birth Child Protection Plan during pregnancy was managed through telephone contact.  2.4 On the 3rd July 2020, parents left their residence in Borough A and took most of their belongings with them. In response, a national missing person alert was undertaken by Borough A’s Children’s Safeguarding and Social Work.  Information was also updated on the Child Protection Information System (CP-IS) as per protocol, outlining the concerns of the allocated social worker. A photo of each parent was shared.  2.5 For the period of time they were absent from Borough A, they would not disclose their location. The allocated social worker and midwife maintained weekly telephone and text contact with them. Within this contact, parents were regularly advised to seek medical attention around Mother’s health and her potentially high-risk (breeched) pregnancy.     4  3. SCOPE FOR A LOCAL CHILD SAFEGUARDING PRACTICE REVIEW (LCSPR)   3.1 As set out in Working Together 2018,  a Rapid Review took place in September 2020 with colleagues in Boroughs A and  B. Emerging learning themes identified at the time were:  How the multi-agency network shared concerns of ‘significant medical risk at birth’ for unborn missing cases.   How the multi-agency network provided support to non-engaging parents with learning difficulties, especially if pregnancies are short periods apart and they have suffered multiple removals of their children.   How a specialist service could help parents with learning difficulty/disability to understand the risks, work with services and offer support with the child protection system.   A review of how CP-IS (Child Protection Information Sharing System) is used in England. It is new to NHS 111 but embedded regionally in London and not accessible to all Ambulance Services nationally.   3.2 Following the Rapid Review meeting the Borough A’s Statutory Safeguarding Partners recommended to the National Panel that the case provided an opportunity for local learning.  3.3 The National Panel supported the decision to carry out a cross-borough Local Child Safeguarding Practice Review (LCSPR).  This commenced in November 2020. 3.4 An Independent Reviewer, Wendy Thorogood, who has a health background, experience in the themes covered in this case was appointed. 3.5 A chronology of key events was compiled across agencies in Boroughs A and B in December 2020.  A well-attended practitioners’ learning event took place in January 2021 with open dialogue and collective reflection on practice.   3.6 An Action Learning - Emerging Themes report was presented to the LCSPR panel in February 2021.  3.7 On 4th February 2021, the HM Coroner (in Borough B) decided that the case would be taken to an Inquest. The Inquest was formally opened on the 10th February 2021 and directions were given on reports, statements and timelines. This report has been requested to be shared with the Coroner in May 2021.  4. A BRIEF CHRONOLOGICAL OVERVIEW OF CHILD E’S CASE:  4.1 Child E’s parents are Catholic, white Irish and related by a grandfather. Both have reportedly had a history of childhood abuse and intervention from services as children.  4.2 Concerns about contraception were raised by some professionals. The Mother informed the reviewer that she was not averse to using contraception, despite her cultural or religious beliefs, but she was resolute in her desire to have a baby and keep it. It is important to note that during this review it has been confirmed that she is pregnant again.  This is important information going forward to ensure the right support.  Learning Point: There was a gap of eight or so years between the first child and second pregnancy and presenting in Borough A.  It might be appropriate to review what intervention if any took place in their previous Borough/ Country of residence that prevented a pregnancy at that time, with the intention of exploring if it would affect current thinking and engagement and intervention.      5  4.3 The pregnancy under review was reported to the GP at around 4 weeks and referrals were made to Borough A’s Children’s Safeguarding and Social Work because of previous safeguarding concerns.  This was therefore not a late presentation or concealment of the pregnancy, but Social Care assessments and intervention were triggered immediately.  4.4 In June 2020) the Mother attended an ultrasound scan which determined that the baby was in breech position (28 weeks). There were no concerns at that point as babies continue to move and it was felt that there was a chance the baby would turn before the birth. 4.5 The parents have a history of aggressive disruptive behaviour, which included neighbourhood disturbances involving the Police. This information was shared with Borough A’s Children’s Safeguarding and Social Work are via the parents, and was not formally reported by Borough A Police, this information should have formally been part of the ongoing pre-birth child protection conference planning. 4.6 Child E’s parents went missing prior to the birth, however they did maintain contact with their allocated social worker and midwife in Borough A, although they did not disclose their location. 4.7 It is now understood that Child E’s parents fled from Borough A to Borough B, although they were indicating they were going to another borough, arguably to avoid intervention at birth.  This is a repeated pattern of behaviour. During the 2nd pregnancy they had presented in Borough A whilst the first child was in kinship care in another borough. Example of good practice: Unborn Child E had been placed on a pre-birth Child Protection Plan and information was promptly shared with Countries/Boroughs where the family had a connection.   4.8 There was a high level of activity once the parents were identified as missing. They kept communication open with the social worker and midwife, mainly via text messages.  Both professionals encouraged the parents to inform them of their whereabouts and urged them to seek medical help by presenting at any hospital. They also reminded the parents of the risks involved in a breech presentation and delivery. The parents reported to the Healthcare Safety Investigation Branch (HSIB) after the death of Child E, that they had paid for a private scan and that the baby ‘was okay’ and that the baby was ‘still in a breach position’.   4.9 A missing person’s alert was sent out nationally via the NHS route. Information was updated on the Child Protection Information System (CP-IS) network as per protocol.  4.10 The parents gave false names and past-history when calling for an ambulance. This was key, as it led to a delay in identifying them on the CP-IS system.  4.11 The Mother reported to the Independent Reviewer that she was unaware she was in active labour, although this was her 4th pregnancy, with one being a previous breech presentation. On admission to hospital the Mother was 10 cm dilated, indicating advanced labour.  Meconium1 was visible on admission.  Both parents failed to report to staff that the Child E at the last scan was in a breech position. 4.12 Child E was born with no brain activity following an emergency caesarean procedure. She died the following day in the presence of both parents.                                                                   1 Meconium presenting in the fluid surrounding the baby means the baby is suffering from stress and the mother is in active labour. Intervention by medical staff is vital to continuously electronically monitor baby’s heart beat and the effects of contractions on the unborn baby. External cephalic version (ECV) – turning a breech baby in the uterus ECV is usually performed after 36 or 37 weeks of pregnancy. However, it can be performed right up until the early stages of labour. ECV should be carried out by a doctor or a midwife trained in ECV in a hospital where the mother can have an emergency caesarean section if needed. Around 50% of breech babies can be turned using ECV, allowing a vaginal birth. But if the mother is at term/overdue, as in this case, and her waters have broken and she is having contractions,  research suggests it is too late for an ECV. https://www.nhs.uk/pregnancy/labour-and-birth/what-happens/if-your-baby-is-breech/   6  5. FOCUS OF THE REVIEW   5.1 This LCSPR examined the work undertaken one year prior to the serious incident, and the period immediately after the incident to consider key episodes from historic records in order to triangulate information.  5.2 Key areas explored:   Impact of COVID-19 during the time scale of the intervention.  Case work and intervention   How the multi-agency network shares concerns of ‘significant medical risk at birth’ for missing person cases  The cycle of pregnancy and removal of babies  How the multi-agency network provides support to non-engaging parents with learning difficulties  The risks of private scans  Areas of good practice and areas of learning have been highlighted.  5.3 The Review heard from professionals involved about their experiences of working with Child E’s family at the time, and about any issues which were affecting them or their agency which may have impacted their work. The Review took place online with the support of a workbook provided so professionals would have the opportunity to reflect personally on their involvement. The questions included in the workbook were:   What worked well and what challenges were there?  What influenced the actions or hindered them? Systems issues?   Why did things happen or did not happen?   Was this case unique or is it similar to others?   If, on reflection of your work, you have learned how you, agencies or systems could or should have done something differently – let us know.  Have we identified the right lessons from this case?    5.4   IMPACT OF COVID-19 ON RISK ASSESSMENT AND HOME VISITING DUE TO NON-ENGAGEMENT 5.4.1 All practitioners were in agreement over the unprecedented challenges to support and safeguard Child E’s family due to the COVID-19 restrictions in 2020. This was not a family that professionals could easily engage with virtually. The only technology they would use was a phone and they preferred to text and speak not video call. 5.4.2 They disengaged with many appointments; For example, they refused to attend hospital unless both could be present, which was difficult due to COVID-19 restrictions.  However, we heard from staff that special measures were in place to accommodate their needs and to ensure engagement by allowing the partner to be present at all appointments, and by doubling up the appointments to include scans at the clinical assessments.  5.4.3 From the discussions with all staff, the Independent Reviewer does not believe COVID-19 to be the barrier to the care and assessments offered, more that the parents chose to disengage and used COVID -19 as an excuse.   7  5.4.4 The parents, under the restrictions of COVID-19, were able to abscond. Furthermore, additional benefits and a maternity grant received during the restrictions enabled the purchase of bus tickets, as reported by the parents.   Example of good practice 2: Borough A’s Children’s Safeguarding and Social Work and Health colleagues fully understood the importance of keeping up contact during COVID-19 and no evidence has been found to suggest that any element of care offered was missed because of the restrictions. Borough A’s Social Work team and Health went out of their way to safeguard Child E, with additional attention to detail including having an Emergency Protection Order outlined in readiness for the delivery.  5.4.5 The parents were unrestrained in contacting staff frequently if they wanted something, sometimes creating a hectic environment.  This could be viewed as them setting their own terms of engagement and intervention. It is important for professionals to be aware of this and communicate with families accordingly. 5.4.6 In order to do so the professional needs to set clear boundaries (firm ground).  Professionals should endeavour to present intervention more as a learning culture than a compliance culture, enabling the professional to use their expertise to assess needs wherever possible with the cooperation and understanding of the family, ensuring they receive the appropriate help without dictation or pronouncements. It seems likely in this case that, because of their learning difficulties, that Health and Social Work tried every way possible to engage with the family, and there is evidence that this was taken advantage of by the parents.  5.4.7 There were joint meetings between the midwife and social workers for when supervised contact visits with their older children were arranged. However, the parents often did not attend (DNA) although great persistence was demonstrated by the midwives and social worker to keep the contact going, leading to additional investment and time to accommodate their needs. 5.4.8 During the period of this review, it was clear all professionals had tried hard to engage with the parents. However, there are outstanding medical tests such as historic genetic screening which still needs to be completed. The parents avoidance of all pre-birth conferences reflects the resistance to intervention from services which led to a lack of measurable progress and risks remained.   5.4.9 The parents struggled to attend key appointments, would overstate co-operation and compliance, and often seemed to minimise professionals’ concerns. The parents were focused on being able to prepare for the baby by providing equipment and funding. Seemingly believing that was what was being asked of them and thus, in their view, overcoming the barrier that had led to their last child being removed, without fully understanding the risks being presented. They presented as aggressive and threatening when challenged, making unjustified claims of progress being made and actions carried out. In the view of the Independent Reviewer, the parents not attending the child protection case conferences indicated a refusal to address key issues, minimising the                                                                  2 Government policy and the literature research on children’s services all emphasise the importance of agencies working together and the value of partnership structures. Consistent evidence indicates that parents and children are best served if the support on offer is joined up and well-coordinated’. It would be appropriate to recognise that although services may be provided in one setting, there is still a risk of services not being joined up, because of different agencies (and competing interests/perspectives) involved. (Warren, 2010).  8  importance of intervention, whilst focussing on other issues that have little relevance or benefit for the unborn Child E. Arguably, they appeared to show no understanding of the reasons for past children being removed from their care, with an element of selective disengagement.  Learning point: Professionals should understand that some parents with a long history of intervention may be resistant to the involvement of professionals, rather than resistant to change in itself, particularly where they feel professionals are exercising power over them. This is a key learning point for all involved to reflect on and consider what might be done differently.  5.4.10 Recorded evidence showed the professional relationship with parents was designed to ensure the parents felt respected and avoided judgmental language or assumptions about their behaviours or motivation.  The Independent Reviewer found recorded evidence of such conversations within the records which is an example of respectful practice. 5.4.11 The couple are related by a grandfather 3 and appear totally interdependent on each other and have few friends or close family to support them or that they would trust.  In these circumstances there is an inherent risk of genetic complications, although the clinical significance is uncertain in Child E’s post mortem and would require further testing of the parents. Genetic screening remains an unaddressed intervention which has been requested by medical professionals historically and is key for any future children to be informed of any possible risks to growth and development. 5.4.12 The parents were openly hostile and aggressive at times. At the practitioner event, learning in action was witnessed, strategies were discussed on how to overcome this and how to a re-evaluate risk and better engage with the parents.   Example of good practice: A good example was shared in relation to the Father’s behaviour at the bedside of Child E and the interaction with the Doctor, who had the ability to set boundaries with the Father, diffusing his escalating anger and leading to cooperation in a stressful situation.  5.5 CASE WORK AND INTERVENTION   5.5.1 The role of children’s safeguarding social work service: The children’s social worker was proactive and available to the parents and was often contacted many times a day. The social workers’ ongoing dedication and commitment was exemplary, along with her historic knowledge of the case, she was a key connection between other professionals.   Example of good casework and use of supervision: This case had been subjected to independent audit and was graded as an example of outstanding practice with good understanding of risk assessment. The records reflect the importance of good supervision and reflection in a case where parents are desperate to keep their baby, yet do not have the understanding or capacity                                                                  3 Key fact: Consanguinity refers to relationships between blood relatives e.g. first cousins, which is common in a number of different cultures. Families from all communities can be affected by genetic disorders therefore tests need to be performed and any risks identified.     9  to provide for the child's basic care needs consistently. This case was time consuming and frustrating leaving all staff involved emotionally drained.  Independent supervisor’s comments: “SW has worked tirelessly on this case, and the content of the file is evidence of the hard work and commitment put into the challenge of maintaining a supportive relationship with the parents whilst holding onto the focus of prioritising the needs and safety of this unborn baby”.  5.5.2 Role of  Health and Adult Social Care services:  In November 2018, the parents were referred by Borough A’s Children’s Safeguarding and Social Work for an assessment for eligibility for services from Borough A Learning Disability Service (LDS), the specialist, integrated adult learning disability team. The parents were assessed by two clinical managers from LDS who judged them not to have a ‘global learning disability’. Measuring IQs is difficult and therefore eligibility is based on adaptive functioning as well as IQ.  Both parents showed good communication skills at the initial contact assessment, including life skills, and demonstrated a high level of adaptive functioning 5.5.3 Throughout Borough A’s Children’s Safeguarding and Social Work assessments and reports, the parents were referred to as having learning ‘disabilities’.  Learning ‘disability’ is a much higher level of impairment than having learning ‘difficulties’ and the generic  use of the term could have influenced how professionals worked with this family.  5.5.4 During the care proceedings for Child E’s siblings, the parents were identified by a court appointed psychologist as having a learning disability/global developmental delay. The purpose of this report was to determine the parents’ ability to care for their children by assessing their behavioural functioning and capacity for change.  Namely, to adjust and think through how their judgements and actions affected their children’s safety and welfare. They were not able to demonstrate the ability to sufficiently meet the needs of their children, nor prioritise them over their relationship with each other. The parents had limited awareness of their impact on others. It is evident in the case records that any decision about capacity to parent was determined by both information about any ‘disability’ as well as testing their functioning as parents.  5.5.5 What is perceptible is that the parents were not impaired to organise and run their lives as adults. Borough A’s Adult Social Care struggled to engage with the family who could not understand their role in their case.  At this point clearer guidance from Borough A’s Children’s Safeguarding and Social Work to Adult Social Care could have helped, including joint work to facilitate a shared understanding of the families’ needs. These parents had a number of vulnerabilities. Adult Social Care’s telephone calls to the parents were reported by them as unhelpful. The parents were not able to understand what the “Adult Service could do for them”.  It appears the parents had a fixed agenda about with whom they would engage with and they did not see themselves as in need of additional services. 5.5.6 Arguably, Borough A Learning Disability Service were constrained by how their service is commissioned.  The service which is required for this family is not currently available.  This would require a bespoke therapeutic package of care and specialist intervention.  Adults who have suffered childhood abuse rarely get the service they require, yet lifelong impacts of abuse are well documented and supported by research. The outcome frequently manifests itself in poor physical health with a consequential impact on Social Care time and budgets.  5.5.7 A point of discussion was how social care assessments could provide a person-centred joint Children and Adult Social Care support package, which promotes continuity of care and communication with partner agencies. The assessment carried out was not a true reflection of this family’s needs and capability to change because Adult Social Care were not fully aware of the past risks.  There should have been closer working between Borough’s Adult Social Care and Children’s Safeguarding and Social Work services to understand their needs considering the emotional impact of their childhood including life skills and ability.   10  5.6  THE CYCLE OF PREGNANCY AND REMOVAL OF BABIES:  5.6.1 This case reflects the perpetuating emotional cycle of getting pregnant, giving birth and having the baby removed.  Professionals rarely have access to a robust intervention for the consequences of having a baby removed at birth, which is a traumatic experience for both parents and baby.   5.6.2 It is clear these parents have had long-term involvement with child protection services. They had personal   experience of the system as disadvantaged children and built up extensive knowledge which could include mistrust of interventions, seeing this as a negative experience rather than a service that is designed to promote change. 5.6.3 They first became parents at a young age, with few positive resources to bring to parenthood. Historic family abuse and court involvement, which is typically adversarial, can compound parents’ difficulties, exacerbate mental health problems and prompt a return to coping strategies such as misuse of drugs and alcohol, and aggression towards authorities, undermining  recovery. Professionals struggled with this in this case. 5.6.4 Although there is a clear consensus that children must be protected from harm, there is a strong moral and economic argument for continued work with parents beyond the conclusion of court proceedings to prevent repeat family court appearances and removal of additional infants.  This involves relationship based longer-term professional help. 4 5.6.5 Integrated commissioning for proactive intervention for such families is therefore required and should be developed. The cost for each child going through the system is between £140,000 -£250,0005.  5.6.6 Integrated commissioning may be an effective way to achieve successful transitional care for adults who are without diagnosable health conditions or meeting the thresholds for Adult Social Care. They arguably require a service offering intervention and support to improve life chances and choices. However, this innovative relational approach to commissioning requires a local partnership recognition of common values, vision and joint ownership between relevant stakeholders.  5.6.7 Professionals worked hard to address the parent’s challenging behaviours and lack of engagement. Working with resistance and denial were common features and reflected in supervision. Arguably, understanding the resistance at a deeper level may have resulted in better understanding of the fear, stigma, shame and ambivalence the parents presented with as vulnerable adults with unaddressed needs. Joint working with Adult Social Care is required to be strengthened and commissioned so therapeutic services are available in order to deliver change. 5.6.8 The services provided did not meet the parents’ complex needs to effect a holistic change. Were the parent’s expectations constrained by the services available? This remains an area which is unaddressed nationally for adults who require support and intervention but will not reach the threshold as vulnerable adults. Once a child is removed focus shifts to the child in care, leaving a gap in services for the parents who may require therapeutic intervention.                                                                  4 “Regarding the high rates of removals at birth that we have uncovered in this study (60% of all repeat cases), we urgently need to establish best and humane practice in these difficult circumstances to ensure professionals work in partnership with mothers as far as possible and that clear pre-birth plans are in place at a timely point. We need to see agencies routinely seeing pregnancy as an important window for change – pre-birth help needs to start much earlier.” https://www.nuffieldfjo.org.uk/app/nuffield/files-module/local/documents/Executive%20summary_Born%20into%20care%20literature%20review_December%202019.pdf   Arguably, there is no statutory obligation to offer any support when a child is removed: while a mother’s/father’s multiple needs may result in child protection concerns, Cathy Ashley, Chief Executive of the Family Rights Group charity, says that “on their own, the parent’s need doesn’t meet adults’ services threshold for intervention and support”. This is something for all partners to consider within your locality when you are faced with this situation of such cases to break the cycle. 5 https://dera.ioe.ac.uk/2710/1/Microsoft_Word_-_PLR0910078Blazey_Persson.pdf.    11  5.7 HOW THE MULTI-AGENCY NETWORK SHARES CONCERNS OF ‘SIGNIFICANT MEDICAL RISK AT BIRTH’ FOR MISSING PERSON CASES  Definition of ‘missing’: “Anyone whose whereabouts cannot be established will be considered as missing until located, and their well-being or otherwise confirmed. All reports of missing people sit within a continuum of risk from ‘no apparent risk (absent)’ through to high-risk cases that require immediate, intensive action”. (Home Office 2002 and OASys 2006).  5.7.1 There was a historic flight risk. This was a family with historic poor engagement including absconding to avoid social work intervention.  5.7.2 There was recorded evidence that the parents intended to go to another borough to have Child E and therefore a contingency plan was put in place. Professionals’ concerns were due to the family history and risks to the unborn baby. Initial cross-borough discussions took place early and all relevant partners were involved and consulted without delay, including an Emergency Protection Order application in readiness.   5.7.3 Borough A’s Children’s Safeguarding and Social Work sent out the national missing alert to Health in a timely fashion, once the parents were identified as missing. This included using the CP-IS system to update current information, reflecting the April 2020 review of the policy.  The CP-IS[2] system is not fully embedded with all Health partners and in this case the ambulance service did not have access to CP-IS.  Borough B confirmed that their process is to review CP-IS alerts for every A&E attendance along with unscheduled maternity attendances. Although, the information provided on CP-IS is not detailed, it alerts Health professionals if a family have an open social work case and provides useful contact details. Health alerts concerning missing families still varies across England therefore all areas should regularly review their Missing Policy to ensure the system is up to date.  5.7.4 There were initial concerns raised about the practicalities of the missing person process but no errors were identified in the system or the reporting. The service was reviewed nationally in April 2020, giving clear local guidance, however the system cannot function effectively where false identification is used, as was the case with these parents.  The hospital receiving the emergency call used the CP-IS system and were able to challenge and determine their true identity and hence their links with Borough A’s Children’s Safeguarding and Social Work.    5.7.5 The fact that during COVID restrictions, the parents were able to access both  additional benefits and the maternity grant, and thus abscond, illustrates the benefit of a closer collaboration with the Department for Work and Pensions (DWP) who now have a dedicated safeguarding team. It would have been an effective and efficient way of identifying where the parents had settled. 5.7.6 Borough A Police were involved in strategy meetings around this case from 5 months into the pregnancy. At that stage there were no additional significant concerns regarding health risks, the main concern focusing on non-engagement. To enable officers to undertake a thorough assessment of the case it would have been necessary to disclose the historic medical risks to justify a review by the Police of personal data.  Even then, it is apparently unlikely that the family would have reached a threshold to trigger additional powers such as finances and mobile phone investigations. The family would have not been able to be detained by the Police, even if they were located, although there could have been a notification to the local Social Care and health services. 5.7.7 Nearing the birth of Child E there was a lot of activity and contact with the family mainly between the midwife and social worker, however the family refused to disclose their whereabouts.  Borough A Police disagreed with the term “missing” in its purest form as contact was being made via the phone. It was at this point it would have been prudent for the professionals involved to follow the formal                                                                  [2]  https://digital.nhs.uk/services/child-protection-information-sharing-project  12  steps, such as the Escalation Policy, to ensure the Mothers and unborn child's welfare and safety remained paramount.  5.7.8 Effective partnership working is vital in order to ensure that positive outcomes for children and families are central to all assessment, planning and intervention. This includes the need to consider differing views and experiences which evidence the value of exchanging ideas and developing critical thinking in regards to how best to achieve improved outcomes. 5.7.9 Staff are very used to the term ‘missing’ for children, though not so much for adults. The category of missing is critical to the clarification of roles and immediate action. Police are the lead agency for the investigation of missing children, although arguably this is less clear for adults.  Every year an estimated 200,000 people go missing in the UK. In some cases, missing adults may have made a choice to leave and ‘start their lives over again’, but the vast majority of missing people, children and adults, are vulnerable and need protection and support.  5.7.10 The use of police powers would have assisted in identifying their whereabouts, triggering support and advice to the family and formally linking with local services for intervention and further assessment.  5.7.11 Prompt application of Borough A’s Escalation Policy would have ensured strategic leadership oversight and could have supported and triggered a police led investigation.  5.7.12 It is common for the Police’s strategic lead for missing persons to have a senior role in leading the Forces’ response to dealing with vulnerable people. Senior leaders are responsible for building and developing partnerships together with other statutory and non-statutory partners. 5.7.13 Reducing the harm to those who go missing, including through a tailored, risk-based response, ensuring agencies work together to find and close cases as quickly as possible at a local and national level.  Learning Point - An indicator of harm There is always a reason for a person to go missing. Understanding the circumstances will allow the police and other relevant authorities to tackle any potential causes of harm and identify intervention and safeguarding measures that can stop or minimise further episodes. Going missing may be a symptom that something is wrong in a person’s life. This can often be described in terms of push and pull factors that push people away or pull them towards something, e.g., being pushed away by abuse or financial problems, or being pulled towards exploitation.  5.7.14 In July 2018, the All-Party Parliamentary Group for Runaway and Missing Children and Adults carried out an Inquiry into safeguarding missing adults who have mental health issues. Recommendations from the subsequent report included the need for better multi-agency working, with a significant role for the Health and Social Care sectors in the response to missing adults. The report identified that this multi-agency approach could improve all stages of a missing investigation: risk assessments, response at the point of return, ongoing support and prevention. 5.7.15 People go missing because of a myriad of reasons and no one episode is the same. The only common factor across all missing episodes is that people are at increased risk of harm and may need support. We can only do what is right for missing people by working in a truly multi-agency way. There needs to be clearer criteria for describing a missing person as vulnerable.  5.7.16 It was clear in this case it was to avoid removal of the unborn baby which has been a repeated pattern of behaviour and will continue until the family receive the right intervention and help required.       13  Learning point  CP-IS has its limitations as do the local arrangements for sharing information on missing people. Risk assessment is broadly thought of as clinical or actuarial assessment. Best practice requires joint data to be made available on the power of individual risk factors – or combinations of risk factors – to predict the likelihood of specific harmful outcomes. Attempts at developing such measures are very much in their infancy and still require improvement nationally. Information sharing between trusts can still be hit and miss.  Joint risks need to be jointly owned and recorded more accurately. Nationally, at present, harm is inconsistently recorded in a missing person report, whether suspect or victim.  Repeated missing episodes elevates risk, which can place the police in a complex situation within the constraints of the Human Rights Act and bearing in mind that “all people have the right to a private life”.  Arguably, it is best practice to seek medical intervention for a birth of a baby. Nevertheless, it is not law. In this case, if the family had been found earlier, they could have linked with local Social Care and Health for intervention.    5.8     HOW THE MULTI-AGENCY NETWORK PROVIDES SUPPORT TO NON-ENGAGING PARENTS WITH LEARNING DIFFICULTIES/ DISABILITIES 5.8.1  Services nearly always have room for improvement.  This review was commissioned because of the desire to explore ever-evolving reflections to support developing successful strategies for encouraging participation or deciding on interventions where non-engagement is a serious risk to the child’s safety and welfare.  Example of good practice: This report identified that professionals had anticipated problems ahead of this review, with good use of arrangements in place to facilitate parents’ participation, such as joint parental access to the clinical appointments.   5.8.2 Staff were aware of issues such as low literacy levels, however the suggestion of learning disabilities rather than difficulties set a pathway that was not a true reflection of this family’s needs. This assessment should have reflected a better understanding of need when considering this family’s complexities, resulting in a service requiring therapeutic input and joint intervention by both Children and Adult Services with the aim of improving life chances. 5.8.3 Parental reactions to intervention by the removal of a baby from possible harm is both, emotionally and physically complex, leading to fear and mistrust and possibly a general hostility towards authority based on previous poor contacts with agencies. This couple are extremely complex and require a therapeutic service that needs to be bespoke to ensure it will meet their needs.  5.8.4 There is ample research into a repetitive cycle of birth and repeated removal of babies due to the potential for neglect and abuse. Parents who have a history of adverse childhood experiences (ACEs) require support and joint intervention from Adult and Children’s Services including all partners.   5.9 THE RISK OF PRIVATE SCANS  5.9.1 More than 200 outlets across the UK now sell ultrasound scans, with hundreds of thousands being carried out each year. The Royal College of Radiography have long debated the risks with supporting evidence of women not being told about serious conditions and abnormalities.  14  5.9.2 If it was the case that the parents accessed private scans, this interaction could have identified where they were and should have raised safeguarding concerns if they were linked in to wider partnerships. This service has no links to the NHS and remains unregulated. Businesses that provide this service normally have a disclaimer indicating that it is not a medical scan but one that offers ‘reassurance’, although it can miss or fail to refer serious problems to the parents and the NHS. This is an area that has been identified in other reviews and the associated risks should be nationally debated. The fact that these parents state they had a scan indicates a level of critical thinking and a level of capacity as they wanted to monitor the baby’s health away from the NHS, and this should have informed the assessments. 5.9.3 The Care Quality Commission says there is good quality care in the industry but it has a "growing concern". 5.9.4 Private baby scanning studios offer a variety of services, however they are unregulated and do not comply with any professional duty of care or responsibility or the identification of safeguarding concerns. Whilst this is something that requires national debate, it is also an opportunity to explore what is on offer in your local area and gain engagement into your local partnership. 5.9.5 This family told informed professionals that they had paid for a scan and there were considered to be no issues with the baby’s development. The business providing the service would have no understanding of the social concerns or risks to the unborn baby.  6. LEARNING IN ACTION - AREAS CONSIDERED:           6.1 Within the reflective practitioner’s event, learning in action was witnessed, leading to positive challenge between the different police forces. The debate that followed led to the police reviewing the actions taken and an immediate change to practice.  There are no legal orders  available until the baby is born although Child Protection Plans do provide powers to work within the law to enable services to work together to keep an unborn child safe from harm. Whilst Child E was unborn, the only way to locate the family was through the parents. This is an opportunity to think about how to work with vulnerable parents who go missing and agree a threshold to activate missing persons’ enquiries.   6.2 There could have been joint supervision for Borough A or a ‘stop and think’ 6  or local area’s equivalent meeting to reflect on risks and concerns and revisit any outstanding actions.  6.3 Where joint supervision across organisations is commonplace for staff, they report they have the opportunity to jointly assess activity and progress, or lack thereof, particularly in challenging cases in a safe environment.  This way all partners report they have a stronger working relationship, breaking down the risk of silo working.  The blend of services’ reflections bring a different view leading to a shared perspective.     6.4 Finding the family earlier could have been beneficial in order to identify if Child E had been born. It would not be about criminalising the parents but rather putting safety planning in place.                                                                    6 Stop and think meetings (or borough equivalent) are an effective means of bringing together all professionals involved in a case to reflect on progress so far and the impact of intervention, whilst, considering all risk and threats. Without good evidence, do not be over-optimistic about progress. Share information with other professionals regularly and check on their view of progress made to challenge your assumptions, hypothesise about possible underlying issues that parents may not want to face, consider evidence carefully and reflect on the quality of parental engagement and motivation to change when progress is not being achieved. This would ensure all professionals are fully aware of case developments. This form of joint case supervision and case review would be seen as best practice, and should be ongoing in a complex and perplexing case and written into local policy.  15   6.5 At the point of the Mother being missing and overdue a strategy meeting in Borough A (with Children’s Safeguarding and Social Work, Police and Health) was held to ensure all partners were aware of the risks involved, principally an unassisted delivery in breech position. A missing alert/report was opened at this stage.  Professionals need to balance the parents’ rights in relation to privacy (HRA 1998) and police powers to trace them if reported missing in specific circumstances.   6.6 At the commencement of the strategy meetings, depending on the risk assessment, consideration should be given for police to initiate a missing person’s enquiry at the most appropriate time so the use of their powers and resources can be most effective.   6.7 Through the course of the strategy meetings it would be useful if the topic of ‘When to report the person missing’ is continually reviewed so that the most appropriate use of powers and resources can be utilised.     16  7. RECOMMENDATIONS  7.1 JOINT SUPERVISION - Safeguarding practitioners need to able to review the impact of their involvement when there is limited engagement and the risk remains unresolved. Joint supervision can be way of achieving reflection on progress made against the plan of intervention in the best interest of the child and the family.   7.2 TIMING OF MISSING PERSON ENQUIRIES - A joint agreement and understanding of a missing person incident enables a decision on action to be taken including the most appropriate use of police powers. An investigative approach that is cyclical rather than linear will enable the police service to work effectively with other agencies. Multi-agency processes should be based on a problem-solving approach and if necessary, the appropriate use of an Escalation Policy, to enable strategic oversight and appropriate, responsive decisions to be made.  7.3 JOINT ASSESSMENTS AND INTERVENTION - Labels should not be a barrier to intervention. Practice should be led by continuous assessment of need for children and families.  The assessment should include therapeutic input, consultative conversations and, where appropriate joint intervention by both Children and Adult Services with the aim of improving life chances.  7.4 SUPPORT FOR PARENTS WITH REPEATED REMOVALS- Parents who have a history of repeated removals and adverse childhood experiences (ACE) require support and joint intervention from Adult and Children’s Services. This requires all partners to develop a deeper understanding to prevent this persistent cycle of birth and removal causing emotional and physical harm to the parents. Professionals need to consider a jointly commissioned bespoke care package which provides specialist, social and therapeutic intervention as appropriate 7.    7.5 PRIVATE BABY SCANS - Private baby scans are unregulated and do not comply with professional duty of care or responsibility or the identification of safeguarding concerns. Local partnerships should explore how they can engage with them to raise safeguarding standards.                                                                           7 https://www.pause.org.uk/independent-department-for-education-evaluation/ Learning Point: Positive Choices service run by Suffolk  council work with parents have had one child removed within the last two years and have expressed a wish for support, and for their lives to be different service for parents in their own right is a example of good practice: https://www.suffolk.gov.uk/children-families-and-learning/keeping-children-safe/positive-choices-service/    17  8. REFERENCES   1. An exploration of the experience of co-dependency through interpretative phenomenological analysis.   A thesis submitted for the degree of Doctor of Philosophy By Ingrid G. F. I. Bacon  College of Health and Life Sciences Brunel University August 2014  2. Babies Removed at Birth: What Professionals Can Learn From ‘Women Like Me’ Wendy Marsh Jen Leamon First published: 27 February 2019  3. NSPCC 2018 https://www.nspcc.org.uk/preventing-abuse/child-protection-system/children-in-care/statistics/  cited June 2018    4. Conti, G, Morris, S., Melnychuk, M., & Pizzo, E.  (2017) the economic cost of child maltreatment in the UK: a preliminary study. London: NSPCC  5. Department of Children and Families, July 2016. Keep on caring. Supporting Young People from Care to Independence. www.gov.uk/government/publications  6. refer to FACTS – Looked-after Children’s outcomes- www.firststaruk.org  7. NSPCC 2018 https://www.nspcc.org.uk/preventing-abuse/child-protection-system/children-in-care/statistics/  cited June 2018  8. Kelly, E., Lees T., Sibieta, L. & Waters, T. 2018 Public Spending on Children in England: 2000 to 2020.  Institute for Fiscal Studies. Children’s Commissioner June 2018  9. Harrison, N. (2017) MOVING ON UP: Pathways of care leavers and care-experienced students into and through higher education. University of West of England, Bristol  