Death of a 3-and-a-half-month-old girl in May 2021. Child X was in the care of foster parents when she was found unresponsive in an unsafe sleeping position. Learning includes: joint working between midwives and social workers should be a core element of discharge planning for vulnerable new babies, even when they are going to foster carers; rigorous checks and assessments of foster carers taking on infants; gaps in supervision can occur when services use agency staff who might not have the appropriate knowledge and skills to undertake safe practice with vulnerable families; where there are concerns that a child has been harmed, there is a need for equivalent response when the child is in the care of foster carers as in the care of their birth parents. Recommendations for the safeguarding partnership include: a campaign to raise awareness of safe sleeping arrangements for infants to include 'what if' questions; to seek assurance that independent fostering agencies comply with standard 10 of 'Fostering services national minimum standards' (2011), relating to suitable physical environments; to ensure managers and supervisors are aware of the importance of following up in supervision that safer sleeping arrangements have been checked by social workers and health professionals; all services ensure that their staff are aware of the neglect toolkit and bruising of non-mobile infants guidance.
      
 Title:  Child safeguarding practice review: Child X. LSCB: Sutton Local Safeguarding Children Partnership Author: Nicola Brownjohn 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.                           Child Safeguarding Practice ReviewChild X2021/22Author: Nicola Brownjohn11CONTENTS2Introduction by Independent Author23Terms of Reference34Background: Child X55Key Aspects of Timeline56Immediate Learning Following the Rapid Review117Analysis of Practice and Decisions Made128Single Agency Learning239Learning Points2610Recommendations for the LSCP3111Appendices322INTRODUCTION BY INDEPENDENT AUTHORChild X was a White British infant. She died in May 2021, just three and a half months old.Child X was in the care of foster parents at the time of the death due to a court decisionthat the child was not safe in her mother’s care following the birth.I have not been able to speak to the child’s birth parents and so take this opportunity togive my condolences for the loss of their child.The aim of a child safeguarding practice review is to use a learning approach, not blame.That does not stop the use of critical challenge of agencies or partners when analysingthe practice and decisions made during the life of Child X. It is important that the themesunderlying the circumstances of Child X’s death are explored to enable Sutton to takeforward any changes to practice, or professional learning, which are needed to preventother child deaths.2Child X was placed in a well evidenced1, unsafe, position to sleep. Had the infant beenplaced in the recommended way, on her back, in an uncluttered cot or Moses basket, andin the same room as the carers, her death might have been prevented. Any discomfort ordifficulty in breathing could have been noticed and action taken to save her life.3TERMS OF REFERENCE3.1 IntroductionOn 3 June 2021, the local authority made the decision that the reported incident of theunexpected death of an infant in foster care met the criteria for a notification to the nationalChild Safeguarding Practice Review Panel. The decision was made on the grounds that Child Xwas a looked after child at the time of their death. The incident took place in the LondonBorough of Sutton and the investigation into this case by the Metropolitan Police andmedical experts is yet to be concluded. Ofsted has also been notified about the incident.Sutton Local Safeguarding Children Partnership (LSCP) asked partners to complete achronology to gather the facts about the case and implement any early learning from thefindings. A rapid review meeting was held on 7 June 2021, and it was agreed that the casemet the criteria to undertake a Local Child Safeguarding Practice Review (LCSPR) underWorking Together 2018. The rapid review report and decision was sent to the National Panelon 18 June 2021. On 13 July 2021, the National Panel confirmed their agreement with thedecision to carry out a LCSPR.It was acknowledged that it would not be expected that the LCSPR would not be completedwithin the statutory six-month timescale due to the Coronial and potential criminalinvestigation.3.2 Purpose and scopeThe purpose of this LCSPR is to identify and explore learning in order to improve servicedelivery and outcomes for children.The scope of this LCSPR is a period from 19 May 2020 to 19 May 2021 covering professionalinvolvement during the pregnancy of Child X, birth, and placement in foster care.1 Out of routine: A review of sudden unexpected death in infancy (SUDI) in families where the childrenare considered at risk of significant harm (July 2020).3The context prior to this period will be captured through agencies summarising keyinvolvement prior to these dates. It is not within the scope of this review to engage directlywith the foster carers, mother, father, and extended family unless the independent reviewerrecommends this and would then be subject to legal advice given the criminal investigationto establish the cause of death.Following the feedback from the National Panel it was confirmed that the independentreviewer should focus on the following four key areas:1.Concerns about how possible neglect with the foster carers was identified and howthis was acted upon.2.The significance of the response to the bruise noted the day before the death.3.An exploration of the relevance of any cultural factors relating to the foster carers;and4.What the foster agency was doing to monitor the foster carers in relation to trainingand supervision.It must be clarified whether anything could have been done differently at either period tosafeguard Child X and prevent their death from occurring.The LCSPR will also draw on the findings from the National Panel’s second national review:Out of routine: A review of sudden unexpected death in infancy (SUDI) in families where thechildren are considered at risk  of significant harm (July 2020).3.3 MethodologyThe review has been conducted using individual management reports to look at the systemwithin which the practitioners were working. The methodology is informed by systemsmodels for undertaking reviews.The basis of the approach is to consider:●The wider perspective of practice at the time of the incident●The research underpinning the decisions made●Evaluation of the case in respect of what it tells the LSCP about Sutton practiceIt had been expected to be able to facilitate a practitioner event. However, this was notpossible due to the police investigation. Although it was possible to meet with the keymanagers in the services involved.43.4 Agencies involved●Sutton Children’s Social Care●Sutton Health and Care●Children of Colour Independent Fostering Agency●Primary Care●Epsom and St Helier NHS Trust●Cafcass4BACKGROUND: CHILD X4.1 Child X was identified as an unborn infant to be at risk of harm and, therefore, wasrecognised by agencies as needing to be protected once born. The child was madesubject to a child protection plan in September 2020, pre-birth, due to concerns arounda substantial history of parental substance misuse, domestic violence, and mentalhealth.4.2 Child X was white British, born, in February 2021, to a mother who was known for misuseof substances, including during the pregnancy, and who had previous children in the careof the Local Authority. The father was initially unidentified, but once found indicatedthat he wanted to maintain contact with the child but not to take on the care.4.3 Assessments were undertaken of some family members to care for Child X, but thesewere unsuccessful in finding a suitable placement.4.4 Child X remained with the mother in hospital after birth until the decision for the motherand child to be separated was taken by the court.4.5 Child X was placed with Black African foster parents. They were known to Sutton CSC asthey were carers of other children.5KEY ASPECTS OF TIMELINEThe main aspects of the timeline of Child X’s brief life are set out as key episodes. Thisenabled the reviewer to then draw out specific areas of practice for analysis.5.1 Episode 1: Pre-birth assessment and birth5.1.1 The Local Authority had entered proceedings relating to Child X on 26/11/2020. A pre-birthassessment,parentingassessmentandindependentDomesticAbuseVulnerability Act assessment had taken place before her birth with recommendationsof separation.55.1.2 Child X was born by caesarean section in February 2021. The infant was assessed asbeing in good health and no signs of any impact of substance misuse by the motherduring the pregnancy. The child protection plan that was developed on 16 November2020 set out that the mother and baby would remain in hospital, following the birth,pending a discharge planning meeting, the outcome of any necessary tests and thedecision of the court regarding the care of Child X.5.1.3 The Cafcass Guardian (CG) had asked the court to consider making an interim careorder to allow the mother and baby to be placed together in a foster placement.However, the court decided the risks were too great given the mother’s history andpresentation during pregnancy.5.2 Episode 2:  February 2021: Decision regarding the care of Child X following thebirth5.2.1 When Child X was four days old, the London Borough of Sutton, Allocated SocialWorker (ASW) submitted a statement to the court and a recommendation forseparation of mother and baby. On the same day, the ASW submitted a placementrequest identifying that both a mother and baby placement and an individual babyplacement should be sought, with a required date of two days later. The ASWidentified that the court had not yet made the decision of whether therecommendation of separation would be agreed.5.2.2 The following day, the court agreed the separation. However, the placements team hadnot been able to find an in-house carer. Ultimately there were two potential carersidentified from the request to Independent Fostering Agencies who met the criteriaset by the social worker.5.2.3 The final choice of carer was based on the information that they were known to Suttonas they were caring for other children and had provided a stable placement for severalyears. It was noted that although they were not a cultural match to the child it wasreported by the Children Looked After team that they had a “wealth of experience” tomeet her cultural needs.5.2.4 On the same day, Child X was taken by a duty social worker (DSW) to the placementaddress. On attendance at the carer’s home the DSW identified concerns relating tothe preparation of the carers to receive Child X, that the home environment,6particularly upstairs appeared somewhat tired and a little grubby and also that Child Xwould be on her own in a small box room. The DSW advised the carers to obtain thenecessary equipment needed for Child X which included bottles needed immediatelyand a Moses basket. The DSW informed the carer that the ASW would be in touch thefollowing week. It is recorded that the DSW contacted the ASW to relay her concerns. 5.2.5 There was a plan for Child X to have three supervised contact sessions a week, withtheir mother.5.3 Episode 3: February – April 2021: Monitoring of child within the placement andcontact with birth mother5.3.1 Placement5.3.1.1 Five days after Child X was placed with the carers, there was managementsupervision for the ASW. Subsequently, there was a virtual video visit undertaken bythe ASW nearly two weeks after the child was placed. Child X was seen with thefoster mother.5.3.1.2 The midwives undertook home visits in February 2021 and reported no concernsabout Child X. They undertook a final visit during the first week of March and notedthat the foster carers were coping well. The midwives discharged the baby to thecare of the health visitor, Children’s Social Care and GP. During the midwifery visitsthere were no notes recorded regarding the sleeping arrangements.5.3.1.3 An All About Me CLA review2 was held virtually, once Child X had been in theplacement for two to three weeks. Within the review it identified that Child X wassettling in well at the placement. Child X was not seen at the review. It wasdocumented that Child X was asleep. There were no concerns raised regarding thecare provided to Child X. Child X was reported as healthy, with a Looked After medicalarranged for the following day.5.3.1.4 During March, Child X was reviewed by paediatricians for the initial, health reviewunder statutory LAC requirements and for a neonatal follow up in relation to asystolic heart murmur. No concerns were noted by the paediatricians.2 London Borough of Sutton approach to Looked After Reviews to ensure that reviews and meetings are childfocused.75.3.1.5 A physical face to face visit was arranged by the ASW in April 2021 but cancelled bythe carer. A rearranged, virtual, visit took place a few days later.5.3.1.6 No concerns were raised or identified in the CLA review or at any of the virtual visits.The recording summarises that the baby was settled with the foster carers.5.3.2 Contact with birth mother5.3.2.1 Contact between Child X and their mother was provided in line with the care plan.Records indicate that there were a total of forty-six contact sessions facilitatedbetween the 16/02/2021 and the 18/05/2021, with only one cancelled due to acourt hearing. There was consistency of service with two main supervisors observing42/46 of the sessions.5.3.2.2 On a number of occasions, it was recorded that the foster carer was either late fordrop off or to collect Child X after contact. It was suggested that juggling childcarearrangements for children of different ages was the primary reason for this. Theimportance of punctuality was discussed with the foster carers. On some occasionsthe carers did not provide nappies, wipes, or milk for Child X. This resulted in theparent making up an emergency bag which was left at the centre to ensure Child Xhad the correct provisions.5.3.2.3 The contact records state that in general, Child X presented well. It was recorded thatthe foster carer would dress child X in the new clothes that the birth motherprovided. On four of the forty-six contacts, the supervising contact worker discussedChild X’s presentation with the carer which included bringing Child X to contact withunclean blankets, a grubby face and neck, a sticky face and neck and injection plasternot removed after 4 days, suggesting Child X had not been bathed. 5.3.2.4 It was noted that within many contact sessions from March onwards, that Child X hadperiods of being unsettled due to wind. Advice was recorded as provided to thefoster parent and communicated within the contact book. On 17/03/21 the fostercarers were given the leaflet by the NHS regarding the making up of the bottle andthe safe storage.5.3.2.5 Child X was registered at the GP practice in March 2021, by the foster mother. ThePractice were aware of the Interim Care Order.85.3.2.6 Child X was seen for her eight-week baby check in early April 2021, brought by thefoster mother. No concerns were raised in the notes of the red book. There wasdocumentationgivingthefostercarersthe right to provide consent forimmunisations and health care.5.3.2.7 The foster mother was noted not to raise any concerns about Child X. The fostermother was asked about feeding and the measurements of Child X were consistentwith normal growth.5.3.2.8 There were two health visitors (HV) involved with Child X, following the birth as thesubstantive HV who had been involved antenatally had retired. A new birth visit wasundertaken in February 2021. There is no written record made of any healthpromotion discussions regarding safe sleep, although it was reported that these hadtaken place. There is comment regarding formula feeding, umbilical cord healed, andthe child health record being completed.5.3.2.9 Child X had an Initial Health Assessment as part of the process for Children whobecome looked after, in March 2021. At this assessment it was recorded that Cowand Gate milk was given six times per day, usually every four hours and that theinfant suffered from hiccups and possets but no sign of reflux or colic. The volumereported was around two hundred mls per kg per day which was on the upper endof what would be recommended for the age. There was no record of discussionregarding safe sleep. Child X was noted to have a heart murmur and was due to havean echocardiogram and a hip ultrasound due to findings from the baby checkexamination prior to discharge from hospital.5.3.2.10 Child X was then seen by a second Agency HV in April 2021. The infant was seen andweighed and measured at the foster carer’s home. The infant was reported to bemaking good steady growth. It was reported that Hipp Organic formula milk wasbeing given as the infant was struggling with wind, so the foster carers changed theformula which had reportedly improved the issues. It was reported that gripe waterwas also used. The foster carer was signposted to use vitamin D for Child X.Immunisations confirmed to have been booked, Hip scan reported to be clear andechocardiogram appointment was outstanding. The HV shared this information withthe allocated Social Worker.95.4 Episode 4: May 2021: Bruise noted5.4.1 On 06 May 2021, the foster mother rang the HV line for advice about teething and theDuty Health Visitor called her and advised that the teething powder she had was safeto be used as Child X was now of the age to be given it.5.4.2 On 18 May 2021 the birth mother and the contact supervisor observed a bruise to theback of Child X’s ear. There was also a noticeable long scratch by the right eye and thatChild X had very long fingernails. The bruise was described as being around the size ofthe top of a pencil. The bruise was brought to the foster carer’s attention at the pointof collection /handover. The carer was recorded as saying she may have done it on thecar seat. No further action or notification is recorded.5.5 Episode 5: 19 May 2021: Child X taken to hospital and death confirmed5.5.1 It was reported that the baby was fed at 11pm on 18 May and put to bed at 12am. Thebaby was put to sleep in a large cot, face down. The baby was found unresponsive inthe morning by the male foster carer.5.5.2 The CCTV footage from the bedroom on the night of the incident showed Child Xsleeping. Around 3am Child X woke for one minute and again at 7am. Child X was notchecked on either of these occasions. The foster carers did not check on Child X until8.45am. The foster carers said they laid the infant on their front because of being sick.5.5.3 The foster carers reported being light sleepers and would have heard the infant wake,but the Police reported that this did not appear to be the case given the evidence fromthe footage. The foster carers were awake in the morning and dealing with the otherchildren but did not check on Child X.5.5.4 On the day of the death the manager for the foster agency visited the home andchallenged the foster carers regarding the state of their bedroom. The response wasthat the foster father was trying to pack to take a trip due to a bereavement. It wasnoted that Child X had a separate bedroom with a cot. It was noted that there was amattress with two pillows, cuddly toys at the top and the bottom of the cot. Themanager described the cot as “crowded” and not in a “good state.”106IMMEDIATE LEARNING FOLLOWING THE RAPID REVIEWThe rapid review carried out in June 2021 identified the following learning which was sharedacross the services involved with infants:●Professionals need to recognise that children in foster placements can be vulnerableand at risk because of neglect. It is important that professionals demonstrateprofessional curiosity when there are concerns about the state of the home.●There is potential learning about the differences in caring for children and babiesregarding the cultural background of the foster carers, which will need to beexplored in more detail.●The Independent Fostering Agency (IFA) will review its procedure and the fosteringhandbook to ensure that supervising social worker visits are adhering to these andinclude viewing the upstairs of the home and the sleeping areas of the children.●There was an assurance that unannounced home visits to foster carers have alsobeen continued by the IFA. The IFA is also reviewing its training programme toensure that it includes training about the safe care of infants. The IFA will follow upwith the foster carers about the multiple occupancy registration with the GP toensure that they understand that this is not permitted for people who are visitingtemporarily on a tourist visa. The same approach to ensure the safety of infants infoster care home will be taken by the Local Authority.●The use of locum health visitors for first visits where there are recognisedvulnerabilities will be reviewed to ensure that these visits are undertaken bypermanent staff. The concerns about the foster carers have resulted in a S.47 childprotection investigation and learning from this will be shared internally and with thepartnership.●The LSCP will need to seek assurance that the multi agency protocol about bruisingin non-mobile babies is applied by all professionals in contact with infants.●Home visits by professionals must be undertaken in person, face to face for childrenwhere there are risk factors relating to sudden unexplained deaths in infants.Procedures will be reviewed to ensure that the baby’s sleeping arrangements areviewed by the health visitor.117ANALYSIS OF PRACTICE AND DECISIONS MADE7.1 Effective Practice7.1.2 Pre-birth, professionals worked together, as would be expected, to develop a plan tokeep Child X safe following the birth.7.1.3 Following the birth, agencies were informed and carried out the required childrenlooked after procedures.7.2 How are children kept safe within foster care placements?7.2.1 Concerns about how possible neglect with the foster carers was identified and howthis was acted upon7.2.1.1 Child X was not seen in person regularly by the professionals overseeing her care.Instead, they saw her via video calls. However, the CSC IMR noted that there was ahome visit for the other foster children on 13 April 2021, but it was not notedwhether Child X was seen. There was no evidence of collaboration between the twosocial workers.7.2.1.2 Therefore, it is concluded that there was insufficient consideration about the level ofcare being provided by the foster carers, despite the reports that the foster carerwas late for the contact sessions, or that Child X was seen, at times, by the contactsupervisor and birth mother as being presented dirty and with an ‘unkempt’ blanket.7.2.1.3 The CSC IMR found that there were reports of Child X progressing well in theplacement but limited evidence of the conversations with the foster carers to fullyunderstand how they were caring for her and responding to her needs.7.2.1.4 When Child X was seen by the GP, the GP considered that the foster mother wasexperienced as they had other children registered at the practice. The GP did notdiscuss with the foster carer the sleeping arrangements for Child X at home anddiscussions about safe sleeping do not form part of the template for the eight-weekbaby check.7.2.1.5 The HV service was undergoing challenges due to staff shortages at the time. Thismeant that Child X had three different HVS allocated between pre-birth and the timeof her death. The IMR author reported that this was not usual for the service.However, it meant that during Child X’s time at the foster placement there was noconsistency of HV provision, and her care was provided by agency staff who did not12complete the assessments and visits to the standard expected by the organisation.The agency HV1 reported that the 6–8-week check had been undertaken at 10weeks. The home was described as cluttered but tidy. No concerns were notedabout the care provided. HV1 reported that the foster mother was advised not toleave Child X unattended whilst in a prone position and not to be placed to sleep inthat position. When asked about the sleeping arrangements the foster mother saidchild X slept in a cot but there was no check on where the cot was placed. However,the HV1 did report that she had advised the foster mother to place Child X on herback, feet to the bottom of the cot with no soft toys in the cot. She reported that thefoster mother nodded in agreement.7.2.1.6The foster agency’s expectation is that the first visit, by the supervising socialworker, should take place within the first week of the baby X being placed andweekly welfare telephone calls should be made. In addition, the agency requirementis that a home visit should take place every month, with flexibility depending on theneeds of the child and the support required. This expectation did not change duringthe pandemic.7.2.1.7 The Agency’s supervising social worker (SSW) phoned the foster mother on15/2/2021, three days after the child was placed, and reported that the placementwas going well and visited on 18/2/2021. According to the supervising social worker,baby X had just returned from contact, and she was upstairs in her car seat. Fosterfather brought baby X downstairs who was still in her car seat. Baby X was asleep.This was not challenged by the SSW.7.2.1.8During this visit, it was reported that the SSW most of her time downstairs, did notcheck any of the accommodation except “looked into” baby X’s room and describedit as “being ok.”7.2.1.9 It was confirmed that monthly visits had taken place by the SSW who had carried outone home visit in person, and then virtual visits. A virtual tour of the home was partof the meeting with the SSW who had been in regular contact with the foster carers.Concerns had been identified about the state of the home and it was described asdated and cluttered. There were boxes and suitcases around the home as the fosterfather was waiting to go to Africa.137.2.1.10 During the agency lead’s visit to the home of the foster carers (following theincident) the police officers took her to the room that Child X was sleeping in. Theagency was unaware that Child X was sleeping in the room alone. It was confirmedthat there are safe sleeping guides included in their foster care handbook butrecognised that the training had been insufficient. When the foster mother wasasked about placing Child X on her front, her response was that it was due to Child Xhaving a lot of wind. They would tap her back and lay her on her front downstairs, sothey did the same thing at night upstairs.7.2.1.11 It was confirmed in the meeting with IMR authors that the foster mother had notmentioned to any professionals that she was placing Child X on her front to sleep. Itwas confirmed that Ofsted had carried out a visit to the Fostering Agency, followingthe reporting by the fostering agency about the death of a child in care. It wasconfirmed that the foster carer's father had recently passed away which led to himpreparing to travel to Africa. The Independent Fostering Agency agreed to updatethe chronology to ensure it covers the activities undertaken by staff following theplacement, and after the death was reported.7.2.2 Significance of the bruise noted the day before the death7.2.2.1The bruise was noted behind the ear whilst Child X was at the contact centre. Thiswas described as the size of a pencil top rubber and a scratch to her eye. The CSCIMR author found evidence that the contact supervisor uploaded the transcriptwithin 1 hour of the session ending yet found no reference to alerting the centremanager or ASW.7.2.2.2The Contact supervisor rightly noted it and raised it with the foster carer. However,the explanation was accepted. There is no evidence to suggest that the cause wasnot an accident as described by the foster carer. However, the policy for bruisesfound in non-mobile children is for a safeguarding referral and child protectionmedical.37.2.2.3If the cause was due to an accident in the car seat, it was an indicator that thefoster carer was not used to handling a young baby.3 Sutton LSCB (2016) Multi-Agency Bruising in Non-Mobile Children Guidancehttps://www.suttonlscp.org.uk/lscp-protocols.php147.2.2.4In the post-mortem there was no evidence of physical harm and so it is concludedthat the significance of the bruise was that it should have been seen as a red flagthat the standard of care was not at the required level.7.2.3 Check on what the foster agency was doing to monitor the foster carers in relation totraining and supervision.7.2.3.1 The Fostering Agency IMR author found that the carers’ bedroom of the home hadnot been routinely checked by the SSW as they reported that it was not arequirement and that they felt the need to respect the foster carers’ privacy. Themanager confirmed that this was incorrect and there had always been anexpectation that SSWs should see the whole accommodation.7.2.3.2 The CSC IMR noted that there were no records to indicate how Child X was matchedwith her carers. It was known that the placement was not a cultural match and wasmitigated within the placement agreement that the carers had “a wealth ofexperience” to meet Child X’s cultural needs.7.2.3.3 However, the CSC IMR identified that these foster carers had no professionalexperience of caring for a new-born. There was reference in the records that theyhad previously cared for a baby. However, this was found to be a much older mobilechild.7.2.3.4 It is recognised that the carers would have cared for their own children but notedthat their youngest child is now eleven and that new research and practice onchildcare and safe sleeping is constantly changing and evolving.7.2.3.5 The expected practice was that the placement team would filter appropriatecandidates for the foster care, but the final selection is left with the social worker.The CSC IMR author concluded that, in Child X’s situation, the screening was notrobust and relied heavily on the Panel approval of age range 0-18. There was also areliance on the report that the carers had two other children placed with them andthat this was a tried and tested placement. This missed the need to be sure thatfoster carers are capable of caring for young infants. In this case, it was known thathealth professionals had seen Child X regularly, either at the hospital or GP practice,and that the HV was visiting monthly.157.2.3.6There were variable accounts of the condition of the home. The social workervisiting the other children in the home noted that the house appeared homely andthere were lots of baby items in the living room.7.3 An exploration of the relevance of any cultural factors relating to the fostercarers7.3.1 Within the CSC IMR it was noted that there was cultural sensitivity but that thisproduced a barrier to effective working with the foster carers. It was reported that theASW proposed a face-to-face visit but perceived avoidance from the carer. Then theASW asked the foster mother if she had been vaccinated for Covid-19 and was stronglychallenged by the Fostering Agency SSW that this information was confidential andreminded that some people do not want to be vaccinated for many reasons. It wasreported that the ASW perceived this to be a cultural issue and felt unable to explorethis further for fear of being culturally insensitive. This should have been raised atsupervision to empower the practitioner to reflect on how to address the responsefrom a colleague from another service. This incident was not picked up by theFostering Agency IMR, perhaps due to the SSW not reporting it.7.3.2 The IMRs from the health services did not identify any cultural issues or evidence as tothe extent of cultural competence.7.3.3 Given that the infant was placed with foster carers from a different racial, and cultural,background, it would have been constructive for the practitioners to undertake somejoined up working in assessing how the needs of Child X would be met by the fostercarers.7.4 Adherence to Policy and procedures7.4.1 When the bruise was noted, the contact centre should have made a referral toChildren’s Social Care via the Multi-Agency Safeguarding Hub (MASH) to enable accessto a paediatric opinion as set out in the guidance on bruising in non-independentlymobile infants.44 Sutton LSCB (2016) Multi-Agency Bruising in Non-Mobile Children Guidancehttps://www.suttonlscp.org.uk/lscp-protocols.php167.4.2 The Fostering Agency IMR noted that there were records indicating that Child X hadbeen sleeping in a Moses basket in the foster carers’ room. However, the report thennotes that the manager reported there was no room for a Moses basket or a cot in thecarers’ bedroom. Yet, the IMR noted that the agency’s safeguarding policy is clearabout babies sleeping on their back, and not face down. The Agency IMR noted thatthe SSW acknowledged that they did not discuss safe sleeping arrangements with thefoster carers, including exploring in any depth where baby X was sleeping. Nor was theSSW aware of the agency’s policy that a baby should sleep in the carer’s bedroom.7.4.3 In the Fostering Agency IMR there was detail regarding the Child Safety Plan dated18/2/2021 (6 days after baby X was placed). This was completed by the SSW. Therewas a note that Child X would be in her own bedroom with the foster carers regularlymonitoring her and attending to her needs. It was not clear whether these documentswere sent to other key professionals. However, the child safety plan document isevidence that it was known that Child X would not be sleeping in the carers’ bedroom.This should have been shared within the SSW supervision and with other professionalsto enable this to be addressed with the foster carers.7.5 Supervision, decision making and management oversight7.5.1 Within the HV service IMR, there was consideration that the agency HVs had notreceived sufficient management oversight to effectively take on a safeguardingcaseload. There were gaps in the records, and they did not receive safeguardingsupervision. Following Chid X’s death, changes were made in regard to themanagement and supervision of agency HVs. Had there been supervision providedthen there would have been an opportunity for the practitioners to reflect on theirobservations and advice being given regarding safe sleep and feeding.7.5.2 The Cafcass IMR found that the CG had not sought situational supervision as expected.This was a missed opportunity to consider the needs of Child X once in the fosterplacement.7.5.3 The CSC IMR confirmed that there were two supervision sessions held within thereview period. These were held in the timescales set by the local policy anddemonstrated management oversight. However, there was no recorded discussionabout observed interactions between the foster carers and the infant. This could have17enabled some reflection of how the carers were coping, the feeding issues, and anycultural considerations.7.5.3 The Fostering Agency IMR found that the SSW had monthly supervision, apart from theApril session which had been arranged but did not take place. There were reflectionsof the SSW and manager within the IMR that showed insight into how the supervisioncould have been strengthened if it had been in greater depth regarding the standard ofcare provided by the foster carers, safe sleeping and how the child was being seen.The Fostering Agency acknowledged that it did not have a supervision policy butcommitted to develop one.7.5.4 Within services visiting the home, or making contact virtually, there was insufficientfocus on seeing the child. There were reports of the infant being in discomfort due towind or colic, but there did not appear to be joint working to ensure that there isconsistent, evidence based, advice provided for parents or carers of young infants.7.5.5 Those supervising staff who are working with families where there are youngchildren should be aware of the need to check, within supervision, that thepractitioner has access to accurate information regarding feeding and sleepingarrangements. Additionally, the supervisor should check on the practitioner’sconfidence to have the appropriate conversations with parents/carers.7.6 Partnership Working7.6.1 Joint Working7.6.1.1 The CSC IMR found that there were records that Child X displayed significantdiscomfort/wind during many contacts. However, this was not shown to have beenchecked in the placement. It was noted that the foster mother was given adviceabout holding the baby in a prone or ‘Superman’ position which appeared to help. Itwas not evident from records whether this was explored with the health visitor.7.6.1.2 The foster carers reported that they had changed the milk formula and the fostermother was given advice by the contact supervisor on preparing and storing milk.However, again, there was no report of this information being shared with the HV.Although the HVs did provide feeding advice, it is not clear to what extent they wereaware of the continued colic related problems.187.6.1.3In the Fostering Agency IMR, it was reported that CSC did not share concerns aboutthe state of the home with the SSW. Meanwhile in the CSC chronology it is notedthat concerns were raised by the duty SW with the ASW that the carers were notprepared for a new-born baby in relation to feeding and that the infant would besleeping in a large cot in a cluttered room on her own. This was a missed opportunityto share observations of the home.7.6.1.4 After the death, the foster carers were reported to have acknowledged that, becauseof the health concerns and baby X suffering from colic, they put her face down. Thissuggests that they did not comprehend the risks of placing infants in a proneposition, despite reportedly having been advised on safe sleeping measures. Theyappear to have been trying to cope with the infant’s colic and making decisionsabout changing the milk formula. They had advice from health sources, socialworkers, and parent groups but still seemed to struggle.7.6.1.5 There was no communication between the Agency’s SSW, CSC and the HVs in relationto the need to discuss safe sleeping with the foster carers. It was reported that theHVs had discussed safe sleeping with the foster carers, which was denied by thefoster carers. This should have been a repeated conversation with the foster carers,being the responsibility of all workers involved with the infant and her carers.7.6.2 Responsibilities for Safe Sleep Advice7.6.2.1 In Child X’s case, it would have been of benefit for the professional network toconfirm who had undertaken a home visit and actively checked on the sleepingarrangements. As it was, the IMRs demonstrated that some professionals wereaware that the infant was sleeping in a cot in a separate room. There wereassumptions made, by some workers, that a Moses basket was being used. However,they did not confirm this was this case, or in which room it was placed.7.6.2.2 It was found, after the incident, that the cot was not clear of items that would placethe infant at risk of harm. Although there was professional advice given about whatwas needed for the infant to sleep safely, this was not interpreted as it should havebeen according to the Lullaby Trust guidance to make sure that there is a clear cot.55 https://www.lullabytrust.org.uk/safer-sleep-advice/clear-cot/197.6.2.3 Midwives undertook home visits in February 2021 and reported no concerns aboutChild X. During the midwifery visits there were no notes on the sleepingarrangements, although there were reported measures in place to discuss thesleeping arrangements pre and post birth.7.6.2.4 There were HV visits to the home and there were reported safe sleep discussions,although these were not adequately recorded in the notes.7.6.2.5The GP did not discuss the sleeping arrangements for Child X at home anddiscussions about safe sleeping do not form part of the template for the eight-weekbaby check.7.6.2.6Social workers visited the home, and some saw the room Child X was sleeping in butdid not record the details of the arrangements or challenge that the child should nothave been sleeping in a room alone at that age. On one occasion Child X was seen tobe brought downstairs, asleep in a car seat. This was not challenged by thesocial worker.7.6.3 Responsibilities for Advice on Care of Infants7.6.3.1 There were insufficient checks made on how the carers were managing the child’s‘significant discomfort/wind’ that was noted. There was no evidence of this beingdiscussed with the health visitor for follow up, or that the health visitors, knowingthat the milk formula was being changed by the carer, had explored whether thiswas in line with NICE guidance.67.6.3.2 Child X was reported to experience considerable discomfort/wind which led to theadvice to the carer to hold the baby in a prone position. This seemed to be anon-health professional providing this advice and it is not clear whether the adviceincluded to only do this when holding the infant.77.6.4   Safe Environment for Infants7.6.4.1 There were reports of the home being ‘tired and grubby.’ After the incident, it wasfound that the bedrooms were cluttered, and the home was overcrowded.However, there was no evidence of professionals questioning how the baby7 NICE (2021) Post Natal Care: NG194.https://www.nice.org.uk/guidance/ng194/chapter/Recommendations#postnatal-care-of-the-baby6 National Institute for Health and Care Excellence (NICE) (2021) Post Natal Care: NG194.https://www.nice.org.uk/guidance/ng194/chapter/Recommendations#postnatal-care-of-the-baby20would be cared for in such an environment. It is acknowledged that there wereno reports of actual concerns regarding the condition of the environment,however, it would have been of benefit to see evidence of professionalsundertaking further assessment.7.7 Was consideration given to considering or involving the father, if known toprofessionals?7.7.1 The birth father was identified but did not want to have contact with the infant. Thisled to the infant being seen regularly by her birth mother, but not her father.Additionally, the IMRs suggest that Child X was, in the main, cared for by the fostermother. The foster father was seen to carry the infant downstairs in a car seat whichwas inappropriate as the infant was asleep, but otherwise the professional contactappeared to be mainly with the foster mother.7.8 Staffing and resourcing; were there any barriers or specific issues that had animpact on practice?7.8.1 Impact of changes of staff7.8.1.1There was an inconsistency in the staff in contact with the foster family. Thisincluded different agency staff, some virtual contacts rather than home visits. Therewere professionals going into the home to see the other foster children placed there.This meant that there was a disconnect between the oversight of the needs of thechildren within the household.7.8.2 Rapid decisions in placement of young babies7.8.2.1 The Local Authority was expecting that Child X would be placed with her mother in aMother and Baby Unit. The court decision for an Interim Care Order (ICO) meantthat the Local Authority needed to find foster carers in rapid time. None of the usualfoster carers were available. However, there needed to be a quick placement forChild X. Subsequently, the foster carers allocated were known for the care of olderchildren and there was an assumption that they were able to care for a new-borninfant. This seemed to be based on the good feedback received in relation to theolder children.217.8.2.2 The way Child X was found a placement seems to be out of line with normal practicein Sutton. There would usually be more access to foster carers with experience ofyoung babies. However, on this occasion there were so few responses to therequest, that the Local Authority was extremely limited in options. The reason is notclear but considered to be a possible outcome from the Covid-19 pandemic which,at the point of the placement, had led to a further lockdown of the country.Nevertheless, the placement of new-born babies is not without its challenges inother cases. There was another Sutton case in September 2021 (Child Y) in which ayoung infant died whilst in the care of foster parents. These foster carers found theinfant was difficult to manage due to distress, leading to a need for a lot of holdingand cuddling. The foster carers were open with professionals regarding placing theinfant on their front to sleep, as they were more comfortable in that position.7.9 Incident reporting for looked after children7.9.1The incident at the contact centre when it was noticed that Child X had sustained abruise to her face, was not reported as an incident. It should have been but wasconsidered to be an accident as reported by the foster mother. It is important that allincidents for looked after children are reported to enable thorough monitoring of thecare of the child. There had been additional reports at the contact centre of the infantbeing brought in late, without the correct equipment and being unkempt. Had theseevents been reported as incidents then there might have been an opportunity for theprofessional network to raise questions about the quality of the provision of care.7.10 Impact of Covid-19 Pandemic7.10.1 Child X was born during a challenging period of the pandemic, when the country wasin lockdown. This meant that services were stretched in their capacity to act and inrestrictions to meeting face to face with families.7.10.2 Home visits were achieved by some key professionals involved with the foster carers;otherwise, virtual contact was made. There were limited checks made on the sleepingarrangements for Child X. This raises the question of whether professionals would,outside of the pandemic restrictions, usually check sleeping arrangements. If no, thenconsideration is needed as to responsibility for checking sleeping arrangements.Despite the Child Y case not meeting the criteria for a LSCPR, there was learning22identified in relation to the need for Children’s Social Care to review public healthmessages to carers about safe sleeping; and for midwives to see all areas where babiessleep.7.10.3 At this time there were concerns by individuals regarding the risks of meeting inperson. Therefore, it was reasonable to consider the necessity of face-to-face visits forsuch a young child. Additionally, at this point the vaccination programme wasunderway and the whole population were requested to be vaccinated. Therefore, itwas reasonable to ask the foster carers about their vaccination status. This could haveled to a risk assessment for face-to-face visits to be undertaken at the earliestopportunity.8SINGLE AGENCY LEARNING8.1      As part of the methodology for the review, agencies were asked to undertakeindividual management reviews to identify learning for their own services to takeforward. Agencies compiled and submitted to the LSCP for the reviewer to considerwithin the multi-agency context. The agencies will be expected to provide evidence tothe LSCP on the improvements made since completing the IMRs.8.2      Children’s Social CareCSC identified learning in relation to strengthening the arrangements for ensuring safeplacements for look after children:●Safe sleeping requirements to be included in the Placement Agreement andPlacement Planning Meeting ●Babies must be seen and observed face to face in their placement and theirbedroom/sleeping area directly seen    ●Matching with FC information and reasons to be included in child’s record●FC checklist tool to be completed as part of the screening process and madeavailable to the ASW to inform selection.●Review of visiting requirements to CLA in their placement in early months ofplacement - current policy is based on minimum requirement of once in first5 days and then six weekly. ●Case noting of significant events to be considered●Review of guidance for sharing concerns raised in contact8.3       Primary Care23The primary Care IMR set out how the specific GP practice would improve itssafeguarding systems. It is recommended that this learning be shared with all GPpractices in Sutton:●At each appointment where a baby under one is seen by a clinician, atthe Practice, then an opportunity should be made for safer sleeping tobe discussed and clearly documented in the GP record.●The home circumstances of the infant should be recorded in theeight-week check.●When registering a Looked after child, the details of the child’s socialworker should be recorded on the registration details.●When a child attends an appointment in the primary care setting andthey are known to children’s social care either on a child protection plan,child in need plan or a child looked after then even if there are noconcerns information needs to be shared with the social worker.●Clinicians, including doctors and nurses, who work as locums at thepractice should receive a copy of the child safeguarding policy in theirlocum pack.●The child protection policy at the practice should be adapted to includeinformation about Looked after children.●Following the registration of new Looked after children the practiceshould request details of all agencies involved in the child’s care toinform them that the child has registered with a new practice and torequest that relevant information is shared with the practice.8.4       Sutton Health and CareThe organisation presented a thorough review of the challenges for the healthvisitor service at the time of Child X’s birth. The IMR demonstrated immediateplans for improving the management of safeguarding cases when there is a highuse of agency health visitors:24●Team Leaders allocating safeguarding cases have been asked to allocateto permanent members of staff and if that is not possible due tonumbers, that a one to one with Agency or Bank Health Visitors isundertaken and records that they have read and are aware of the RecordKeeping Policy and Standard Operating Protocols to be clear as to whatmust be discussed at the contacts, that this is recorded and that they areusing the best and most current evidence.●Templates as guidance of what must be included for each mandatedcontact for Health Visitors have been developed, trialled by a cohort ofthe Health Visiting Teams, and edited as per feedback will be rolled outto all of the team in September 2021 to ensure that the aide memoireacts as a reminder of what must be discussed and subsequentlyrecorded to ensure the highest standard of practice.8.5           Children of Colour Fostering AgencyThe Fostering agency provided a comprehensive report completed by anindependentreviewer.Thereportidentifiedsubstantialareasforimprovement:1.Policy and procedures:●The agency to provide written clear guidance on its expectationregarding checking the accommodation/environment●Supervising social workers will be expected to go through therelevant policies and procedures with the foster carers in detail,including monitoring its application following a placement withfollow up in supervision.●Commission online procedures for foster carers.●Review how updated procedures are shared with foster carers.●Arrange a learning and development day/seminars with staff tostrengthen the quality of the foster carers and child’s records.●Review documentation to make it more child centred.●Strengthen supervision to ensure checks of the safe care planand risk assessment. These should be signed by the agencymanager.252. Supervision, decision making and management oversight:●Develop a supervision policy which sets out the expectationregarding supervision of staff and foster carers and ensures amore child centred approach.3. Partnership working●Plan to ensure that logs are sent automatically to the childcaresocial worker, health visitor, to inform the understanding ofdeveloping needs and the care required.4.Staffing and Resourcing●Review the need for previous safeguarding experience forsupervising social workers.●Review how the agency sets sanctions for foster carers notcompleting logs of the childcare.●Develop an escalation policy.5.Quality Assurance●The agency should seek multi-agency professional feedback andif the feedback is not received, escalate it to the relevantmanager.●Introduce an internal “auditing process” of agency practice.●Provide facilities for independent feedback from foster carers tomonitor the quality of the supervision provided by supervisingsocial workers.8.6       Epsom and St Helier NHS Trust (Midwifery)The Trust completed a review of the full care of the infant and included theinvolvement of midwives at the point of being placed with the foster carers.This identified the key aspect of midwifery responsibilities for checking thesleep arrangements for a new-born infant:●Maternity audit in relation to sighting and documenting thesleeping arrangements for babies.269LEARNING POINTS9.1It is positive that the rapid review undertaken by Sutton has already identifiedimmediate learning.9.2    The findings show six themes:●Unsafe sleep arrangements●Safe environments for infants●Quality of care for looked after infants●Supervision of staff working with vulnerable families●Indicators of neglect in infants●Policies and procedures: Impact of Covid-19 pandemic9.3These provide Sutton LSCP with areas to explore in how practices in safeguardinginfants can be strengthened. These should be considered alongside the learningfollowing the Rapid Review.9.4All agencies submitting IMRs also submitted their own recommendations whichneed to be taken forward to improve practice. The recommendations within thisreport focus on the LSCP’s oversight of local safeguarding practice.9.5 Unsafe sleep Arrangements9.5.1 Child X was placed in a prone position and had been subject to their mother’ssubstance misuse during pregnancy. These are two factors associated with anincreased risk of sudden infant death syndrome8. The Lullaby Trust (2013) foundthat infants placed in a prone sleeping position can be more difficult to arouse andhave changed autonomic control9 which can affect the control of the infant’s heartrate, respiratory rate, and other bodily functions.109.5.2 Since the ‘Back to Sleep’ campaign in 1991, there has been extensive research todemonstrate that young babies are at a high risk of harm if placed to sleep prone.Where the infant is suffering from reflux, then the advice is only to place proneunder medical advice.1111 https://www.lullabytrust.org.uk/safer-sleep-advice/sleeping-position/10 Moon RY et al. Sudden infant death syndrome. Lancet. 2007; 370:1578-879 The Lullaby Trust. (2013) Overview of Potential SIDS mechanisms.https://www.lullabytrust.org.uk/research/evidence-base/ : accessed 07 December 2021.8 The Lullaby Trust (2019) Evidence Base for SIDS. https://www.lullabytrust.org.uk/research/evidence-base/ :accessed 07 December 2021.279.5.3A number of SUDI incidents reported to the National Panel were associated withovercrowding within a home12. The foster home where Child X was living was notedto be overcrowded and the bedroom was cluttered. It is essential that health andsocial care practitioners are able to identify the risk factors related to overcrowdingand respond effectively.9.5.4 There are arrangements in place to advise parents and carers of the risks of unsafesleeping. These include pre-birth and post birth messages about the risks. However,Child X was removed from the parents after birth and placed with foster carers. TheNational Panel found that serious case reviews had promoted the need forprotocols for joint working between midwives and social workers and dischargeplanning for vulnerable babies.13 This should be a core element of dischargeplanning for vulnerable new babies, even when they are going to foster carers.9.5.5 In Child X’s case there was evidence of the Health Visitor and Midwife highlightingthe safe sleep messages to the foster carers. However, the National Panel reportidentified that safer sleep messages were not always received well by parents andnot‘hard-hitting’enoughregardingtheconsequencesofunsafesleepenvironments14. Some LSCPs have focused on strengthening their safe sleepmessages to include ‘what if’ discussions.15 This could be an essential discussionfor foster parents in their training for caring for infants. It is important that it iseveryone’s responsibility, and not left to health professionals.9.5.6 Sutton has since had a further case of a sudden death of an infant (Child Y) whilst inthe care of foster parents. Child Y had suffered withdrawal symptoms from theirmother’s substance misuse following their birth, which meant that the infant wasvery unsettled. The foster carers in this case were involved a week prior to the babybeing discharged from hospital. The foster home was reported to be immaculate,following the death, and a safe environment for children. However, the fostercarers knew the risks of placing a young baby in a prone position, reported their15 National Panel (2020) Out of Routine: A review of sudden unexpected death in infancy in families where thechildren are considered at risk of significant harm. p30.14 National Panel (2020) Out of Routine: A review of sudden unexpected death in infancy in families where thechildren are considered at risk of significant harm. p27.13 National Panel (2020) Out of Routine: A review of sudden unexpected death in infancy in families where thechildren are considered at risk of significant harm. p26.12 National Panel (2020) Out of Routine: A review of sudden unexpected death in infancy in families where thechildren are considered at risk of significant harm.28decision to the professionals, and accepted the risk management of keeping a closecheck on the baby, because that is how the infant slept well.9.5.7 Parents are entitled to make their own decisions regarding their baby’s sleeparrangements. However, for a looked after child then the corporate parent, theLocal Authority, should be assessing the risks and ensuring that the decision offoster carers is safe. In the case of Child Y, the decision making of the foster carersseemed to be overlooked due to the concerns being focused on the birth parents.This was an infant who required intensive parenting to the point that the fostercarer was concerned about transporting Child Y to the Contact Centre due to howunsettled the infant could be. There was no evidence that health or social careprofessionals reviewed the difficulties that the foster carers were having with theinfant to enable a safety plan to be agreed with the carers.9.6 Safe environments for infants9.6.1 As has been set out in the previous section, an associated factor in unsafe sleepdeaths is known to be overcrowded housing.16 However, the focus of the researchis on vulnerable families rather than foster carers. This would suggest that the focusneeds to be on the impression of the environment rather than the knowledge ofthe family.9.6.2 In Child X’s case, the bedroom sleeping arrangements were not checked byprofessionals. However, the child was in a foster placement which should have metwith the National Standards: Standard 10-Providing a suitable physical environmentfor the foster child, whereby the foster home needs to be able to comfortablyaccommodate all who live there.179.6.3 In the case of Child Y, in contrast, the environment was considered to be good.However, again the sleeping arrangements were not checked. The foster carersused a ‘Sleepy Head’ for the infant. The health visitor provided advice about its use,but it was still used, despite the advice that sleep positioners or pods are unsafeand should not be used.1818 Institute of Health Visiting (2022) Safer Sleep for your Baby.17 Fostering Services National Minimum Standards. (2011)https://www.gov.uk/government/publications/fostering-services-national-minimum-standards : accessed 07December 2021.16 National Panel (2020) Out of Routine: A review of sudden unexpected death in infancy in families where thechildren are considered at risk of significant harm. p40.299.7 Quality of care for looked after infants9.7.1 Usually in Sutton the foster placements used for infants are well known.Nevertheless, in the case of Child X, there had to be a rapid placement due to theoutcome of the court hearing. The foster placement identified was considered tobe of good quality as the carers had good experience. However, there was an errorin the judgement that they had experience of young babies.9.7.2This case demonstrates the vital need for rigorous checks and assessments to bemade of foster carers taking on infants19.9.8 Supervision of staff working with vulnerable families9.8.1This review demonstrated the gaps in supervision when services are stretchedand use agency staff who might not have the appropriate knowledge and skills toundertake safe practice with vulnerable families.9.8.2This review also shows the need for supervision of children looked after to focuson the observations of the care and to reflect on any incidents or risk indicators.9.8.3This review demonstrates that, particularly at times of stress on a service, thesupervision and oversight of practitioners, in health and social care, needs to bemaintained to a high level, using a reflective model.209.9 Indicators of Neglect or Abuse in Infants9.9.1 There were significant indicators that the carers were not coping in their duty toparent Child X. There was evidence of the carers struggling to manage the infant’scolic, arriving late at the contact centre, the infant appearing unkempt, and onoccasion having sustained a bruise. These could have been classed as physicalneglect, nutritional and lack of supervision of the infant.2121 Sutton LSCP (2018) Neglect Toolkit20 https://www.londonsafeguardingchildrenprocedures.co.uk/supervision.html19 HM Government. (2012)https://www.gov.uk/government/publications/training-support-and-development-standards-for-foster-care-evidence-workbook : accessed 07 December 2021.309.9.2 Sutton LSCP have a clear neglect toolkit that is readily available on the website, forpractitioners to use to help them to screen for neglect.9.9.3 Sutton LSCP has guidance for what to do when bruising is observed in non-mobileinfants.22 However, in this case, the guidance was not followed.9.9.4It is crucial that key policies and practice guidance is embedded within servicesworking with young infants, their parents, or carers, to enable an appropriateresponse which should lead to multi-agency risk assessments where there areconcerns that a child has been harmed. The same level of response should beprovided when the child is in the care of foster carers as in the care of their birthparents.9.10 Impact of the Covid-19 Pandemic9.10.1   In the case of Child X, the foster carers were able to access advice and to attendsupport groups. However, some practitioners were not able to provide face to facevisits.9.10.2   The impact on parents and carers of infants born during 2020-2021 has foundisolation and mental health concerns. For the infants, there is growing research tosuggest that their wellbeing and development was negatively affected by thelockdown periods of the pandemic. 232410RECOMMENDATIONS FOR THE LSCPNoRecommendation (to be discussed and agreed withthe LSCP)Lead Agency1To seek assurance that the Individual  ManagementReviews are being implemented by each agency.LSCP24 Parent Infant Foundation (2021) First 1001 Days. Working for babies Listening to local voices for a betterrecovery. https://parentinfantfoundation.org.uk/1001-days/resources/working-for-babies/23 House of Commons Petitions Committee. Impact of Covid-19 on new parents: one year on First Report ofSession 2021–22 https://committees.parliament.uk/publications/7477/documents/78447/default/22 Sutton LSCB (2016) Multi-Agency Bruising in Non-Mobile Children Guidancehttps://www.suttonlscp.org.uk/lscp-protocols.php312A campaign to raise awareness of safe sleepingarrangements for infants to include  ‘what if’ questions.SWL ICS,Public Health3To seek assurance that independent fostering agenciescomplywithstandard10oftheNationalMinimumStandards: Providing a suitable physical environment for thefoster child, whereby the foster home needs to be able tocomfortably accommodate all who live there 25LSCP, FIRO4To seek assurance that new-born babies and infants areplaced with foster carers who have completed safersleeping and paediatric first aid training.LSCP, FIRO5To seek assurance that managers and supervisors areaware of the importance of following up in supervisionthat safer sleeping arrangements have been checked bysocial workers and health professionals when they havemade home visits to new-born babies and infants.CSC, SuttonHealth andCare, Epsomand St HelierNHS Trust(Maternity)6All services working with children and families mustensure that their staff are aware of the neglect toolkit andbruising of non-mobile infants’ guidance.LSCP25 Fostering Services National Minimum Standards. (2011)https://www.gov.uk/government/publications/fostering-services-national-minimum-standards : accessed 07December 2021.323311APPENDIX11.1 SUTTON LSCP ACTION PLANNo.RecommendationRationaleActionLeadBy whenIntended impact1.To seek assurance thatthe IndividualManagement Reviews arebeing implemented byeach agency.To oversee that eachagency takes forwardlearning andimprovementshighlighted in theirinternal reviews.Each agency to provideevidence that the IMRaction plan has beenimplemented to theChild SafeguardingPractice Reviewsubgroup.LSCP31/03/2023Improved systemsand practices.2.A campaign to raiseawareness of safesleeping arrangementsfor infants to include‘what if’ questions.To reduce incidents ofpreventable SUDIC.To run a local campaignto raise awareness ofsafe sleepingarrangements.Public Healthsupported bySWL ICB31/03/2023Fewer preventableSUDICs.3.To seek assurance thatlocally commissionedindependent fosteringagencies comply withNational MinimumStandards.Foster carers have theknowledge,understanding andexperience to safely carefor infants, includingproviding a suitablephysical environment.To undertake an internalaudit of the placementof children withindependent fostercarers within the periodof June 2021 to June2022.LBS Head ofService forCorporateParenting27/10/2022Improvedindependentfosteringcommissioningprocess.34No.RecommendationRationaleActionLeadBy whenIntended impactTo provide a report tothe LSCP setting out theIFA commissioningprocess and highlightingkey findings from theaudit.4.To seek assurance thatnew-born babies andinfants are placed withfoster carers who havecompleted safer sleepingand paediatric first aidtraining.New-born babies andinfants should be placedin safe settings withappropriately trainedfoster carers.FIRO to include a reviewof compliance withtraining requirements forfoster carers caring fornew-born babies andinfants in the standingannual report to theLSCP QA subgroup.LSCP incollaborationwith the LBSFIRO30/09/2023New-born babiesand infants areplaced in safesettings withappropriatelytrained fostercarers.5.To seek assurance thatsupervisors understandthe importance of safersleeping arrangementsbeing followed up insupervision.Management oversightto ensure routine checksof safer sleepingarrangements are made,and that appropriatechallenge is provided,where required.The Named Nurse forSutton Health & Care toundertake a dip sampleaudit of records fornew-born babies andinfants and provideassurance to the LSCPQA Subgroup that safeNamed Nursefor SuttonHealth & Care31/03/2023Fewer preventableSUDICs.35No.RecommendationRationaleActionLeadBy whenIntended impactsleep has been discussedand recorded.The Named Midwife forEpsom & St Helier toundertake a dip sampleaudit of supervisionrecords for cases ofnew-born babies andinfants and provideassurance to the LSCPQA Subgroup.Named Midwifefor ESTHThe LBS QualityAssurance Service toundertake a dip sampleaudit of supervisionrecords for cases ofnew-born babies andinfants and provideassurance to the LSCPQA Subgroup.LBS QA Service6.All services working withchildren and familiesmust ensure that theirSigns of neglect areidentified early andaddressed in line withTo update the LSCPNeglect Toolkit tostrengthen the areasLSCP31/03/2023New-born babiesand infants areappropriately36No.RecommendationRationaleActionLeadBy whenIntended impactstaff are aware of theneglect toolkit andbruising of non-mobileinfants’ guidance.multi-agency guidance.relating to safer sleeping.safeguarded fromneglect.To update the Bruising ofNon-Mobile InfantsProtocol.To promote the LSCPNeglect Toolkit throughtraining anddissemination across thepartnership.To promote theNon-Mobile InfantsProtocol through trainingand dissemination acrossthe partnership.To undertake a survey toprovide assurance thatstaff are aware of theLSCP Neglect Toolkit.To undertake a survey toprovide assurance thatstaff are aware of the37No.RecommendationRationaleActionLeadBy whenIntended impactBruising of Non-MobileInfants Protocol.38