Death of a 13-week-old child due to injuries consistent with trauma. In all there were 41 separate injuries including fractures to her ribs and spine. Child N's mother and her partner were convicted of offences relating to her death and are serving prison sentences. Learning includes: the importance of accessing and analysing historical information about families; the potential risks from the mother's new partner were not understood; the need for practitioners to comprehend fully the significance of bruising to non-mobile infants; transfers of case responsibility between teams, individuals and services were problematic and would have benefitted from a more collaborative child centred approach; inconsistent understanding of the significance of faltering weight and growth measurements in babies; the over reliance on members of the extended family as a protective factor; and the failure to reassess when different information emerges. Recommendations are made in the following areas: antenatal identification of need and risk; background family information; bruising policy; case transfer; poor weight gain, neglect and faltering growth; and assessment of extended family.
      
 Title:  Final report serious case review: Child N. LSCB: Hertfordshire Safeguarding Children Partnership Author: Jane Doherty Date of publication: 2022  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.                                      Final Report Serious Case Review:  Child N           Author: Jane Doherty  March 2022    2 1  Case Summary             Introduction  1.1 Child N was 13 weeks old when she died of injuries that were consistent with trauma. In all there were 41 separate injuries including fractures to her ribs and spine. At the time of Child N’s death, the family were involved with numerous agencies and Child N and an older sibling were subject to a Child in Need plan.  1.2 Child N’s mother and her partner who were caring for her at the time, were convicted of offences relating to her death and are serving jail sentences.   1.3 It was agreed to undertake a Serious Case Review (SCR) to learn lessons from how the agencies worked together with this family.                 Brief Background   1.4 The SCR highlighted that the family had a history of involvement with agencies with Child N’s older sibling. Mother was also known to services as child. As a teenager she experienced abusive and chaotic relationships which was a repeated pattern in her adulthood.  1.5 Mother separated from Child N’s father prior to her birth and a new partner had very quickly joined the family.   1.6 Prior to Child N’s death, concerns were raised about disputes with the neighbours and in the family home, mother’s poor mental health and adult aggression towards the older sibling. There were worries about Mother’s new partner and alleged offences of harmful sexual behaviours.  1.7 The family were resistant to engaging with the help offered and could be challenging to work with.  Members of the extended family were seen as supportive and had a good relationship with the children. Relationships between the adults however could be volatile and problematic.  1.8 As Child N developed there were further concerns about her poor weight gain (faltering growth), domestic abuse incidents between the parents and the impact of the wider family’s unpredictable relationships. In addition, a number of bruises were noted on Child N.    The key lessons  • The review noted the importance of accessing and analysing historical information about families.  Records about Mother’s previous pregnancy were not accessed, and her history of previous relationships was missing from assessments. Both would have supported a fuller multi agency risk assessment.  • The potential risks from Mother’s new partner were not understood. These were in relation to alleged harmful sexual behaviours and concerns about how his   3 unmanaged neurological condition manifested. More detail and analysis of these static risk factors was needed.  • The absence of a multi-agency response to bruising noted on Child N and the lack of formal child protection procedures, demonstrated the need for practitioners to comprehend fully the significance of bruising to non-mobile infants. The existing multi agency protocol was not followed, indicating that practitioners did not understand how this policy supported their work to safeguard children.  • Transfers of case responsibility between teams, individuals and services were problematic in this case and would have benefitted from a more collaborative child centred approach.  • Multi agency plans remained static and were not updated when new concerns emerged. This served as a reminder of the importance of dynamic risk assessment and planning.  • There was an inconsistent understanding amongst some professionals of the significance of faltering weight and growth measurements in babies. Where this is an issue there is a need for a closely monitored management plan.  • The over reliance on members of the extended family as a protective factor and the failure to reassess when different information emerges, was a feature in this case and resonated with reviews in Hertfordshire 1.9 The review benefitted from the oversight of an experienced panel of senior managers from across the multi-agency partnership in Hertfordshire.   The review was further enhanced by involving and consulting with a range of practitioners involved with the family.  1.10 Despite opportunities offered, family involvement with the review was limited. Prior to publication the key lessons were shared with one member who requested it.  2 Recommendations Six recommendations were made to the Partnership, and they are noted below. As a significant period has lapsed since the death of Child N, considerable progress has been made.  Antenatal identification of need and risk  The HSCP should review improved arrangements for the antenatal pathway and  satisfy itself that the referral system is working in a way that; • Identifies the most concerning families of unborn babies   • Refers them in a timely way   • Midwives have access to known information held by their organisation such as concerns in previous pregnancies    2.1  Background family information   The HSCP should seek assurance through audit that current approaches to  assessment obtain and take sufficient account of, family background and   4  previous experience such as sexual harm, ADHD and parental mental  health  difficulties    2.2  Bruising policy    Work began immediately by HSCP to ensure that practitioners understand the significance of bruising in infants and the need to take action. This includes the revision to the referral pathway to make it clearer, increased awareness raising of the existing policy (front-line practitioner events, audits of practice, visual aids and dedicated individual agency resources) and this continues to remain a primary focus for safeguarding partners since the learning from this review emerged.  In addition, through regular audits of practice in this area, the HSCP should be assured of its continued high profile and partner agencies’ consistent compliance with its application. If a practitioner makes a decision not to adhere to the Bruising Policy this is escalated to a senior manager to review. 2.3   Case transfer  HSCP to ensure that current arrangements for transfer of case responsibility  across all agencies reflect and mitigate against, risks associated with such  transfers, so that practitioners and supervisors are vigilant in ensuring that  tasks and information have not been lost.  2.4  Poor weight gain and neglect / faltering growth  HSCP to ensure that key professionals in all agencies (not just health  professionals) understand the significance of poor weight gain (particularly in  small infants), how it is measured and understood and how this  should be  managed. Further, the Partnership to ensure that this issue is being properly  reflected in child protection and child in need plans.          Assessment of extended family  2.5 The appropriateness on grandparents to protect children (and failure to change the assessment when the relationship fails) is a finding from three Herts SCRs. HSCP need to ensure that this learning is embedded, particularly when staff change.              Jane Doherty             Independent Social Work Consultant             March 2022     