Fractured skull to a 13-month-old boy in March 2017. Parents sought medical advice because of a swelling to John's head but were not able to explain how the injury had occurred; they advised the paediatrician that he was a very active child with a habit of head banging. Some weeks later, following a change of manager at Children's Social Care (CSC), a child protection conference was arranged, John was placed on a child protection plan and care proceedings commenced. In August 2016, John bruised his face whilst trying to crawl, but the GP did not refer the episode to CSC; a couple of months later mother took him to GP with a torn frenulum after which the GP did send a referral to CSC who decided no further action was required. Lessons learned: the role of the father was largely absent in practitioner records; professional curiosity is especially important for unexplained injuries; the case mapping exercise undertaken by the social worker and team manager used the Signs of Safety model but focused too much on the present and did not take into account historical concerns. Recommendations include: ensure that practitioners are reminded about the effect of their intervention on families and importance of involving them in the formulation and delivery of plans; ensure that multi-agency safeguarding hub (MASH) workers are clear about whether parental consent has been given and for what purpose; advise MASH workers that formal feedback should be given to GPs who make a referral regarding a possible non-accidental injury.
      
 Title:  Serious case review on John: executive summary: born February 2016, date of serious incident March 2017. LSCB: Bexley Safeguarding Children Board Author: Felicity Schofield Date of publication: 2018  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.                           Page 1 of 7    Bexley Safeguarding Children Board    Serious Case Review on John               Executive Summary  Born February 2016, date of serious incident March 2017                Independent reviewer: Felicity Schofield   Date of Publication – September 2018       Page 2 of 7  1. Introduction 1.1 The subject of this Serious Case Review (SCR) is a young boy, John. John is a pseudonym, chosen in consultation with his family. 1.2 John suffered a fractured skull in March 2017 when he was 13 months old. His parents had sought medical advice but were not able to explain how the injury had occurred. John has an older half-brother, born in 2010, about whom there have been no concerns and who is not the subject of this SCR.  1.3 This SCR was commissioned because some weeks after John’s injury a new manager within Children’s Social Care Services (CSC) reviewed the way the case had been managed and expressed serious misgivings about the safeguarding actions that had taken place following John’s injury. As a result of these concerns, a child protection conference was arranged, John was placed on a child protection plan and care proceedings were commenced. 1.4 This Review covers the time period from John’s birth in February 2016 through to a child protection case conference in June 2017.  Three key practice episodes within this 17 month period are described and analysed in detail. Both practitioners and John’s family contributed to this analysis. 1.5 The Review  has sought to understand what can be learned from the safeguarding activity that took place during this period and in particular to identify ways in which professionals might respond more effectively to unwitnessed or unexplained serious injuries in the future. 1.6 John has subsequently made a full recovery. He has continued to live with his birth parents and the care proceedings were discontinued. Following a further period of social work support, the case was closed to CSC in January 2018. 2.0 Background to the Period covered by the Review 2.1 The mother’s first child was born in 2010. Between March 2011 and April 2015 there were three anonymous referrals to CSC alleging that the mother was neglecting her son. These reports were investigated by CSC and not substantiated and, therefore, the service did not remain involved with the family. 2.2 In the period leading up to her pregnancy with John, the mother received some help from a local early help service. She was given advice about managing her older son’s behaviour which she found helpful. This service had ended before John was born. 2.3 John’s mother was identified as vulnerable during her pregnancy with him. She had a history of depression, categorised by her GP as mild, and her partner had a son who suffered with an inherited syndrome which had resulted in a physical impairment. The mother agreed to a referral for additional support from the Best Beginning team of midwives and thereafter she met with them every two weeks.  Page 3 of 7  3.0 The Period covered by the Review (February 2016 to June 2017) Key Practice Episode 1 (October 2016) 3.1 Towards the end of October 2016, the mother took John to the GP because a few days earlier he had injured his mouth. In fact he had torn his frenulum, which is the fold of tissue inside the mouth that joins the upper lip to the gums.  3.2 A torn frenulum is a rare injury which can be a sign of abuse and the GP decided that given the nature of the injury, together with the mother’s other vulnerabilities, she should make a referral to CSC. The GP discussed this proposal with the mother, who gave her consent.  3.3 The team manager and assessing social worker in CSC decided that no further action was required because ‘safeguarding concerns had not been identified’. This decision was reached without making any contact with the GP, the mother or the health visitor. The GP was informed of and accepted CSC’s decision. 3.4 In these circumstances, an assessment, in consultation with partner agencies, would have been the most appropriate course of action to take. It would have provided CSC with a fuller picture of the family and enabled them to determine whether or not the family would benefit from some extra support.  Key Practice Episode 2 (March 2017) 3.5 On an evening in March 2017, John’s parents took him to an Urgent Care Centre because he had a lump on his head. They did not know how he had got the injury. In view of the fact that this was an unwitnessed injury, the doctor who saw John referred him to the Paediatric Emergency Department, in line with the agency’s safeguarding policy. The parents were equally keen for John to be seen by a specialist. 3.6 Further tests showed that John had a skull fracture and he was admitted to hospital. The hospital staff were concerned because this was a serious injury for which the parents could offer no explanation despite the fact that John would have been expected to be distressed following the injury. There were no other external signs of injury. 3.7 John remained in hospital pending further investigations. Despite the fact that non-accidental injury was being seriously considered, CSC made no enquiries about John’s sibling’s welfare and no plan was discussed with the hospital staff regarding the parents’ contact with and care of John in hospital. John’s parents were given contradictory messages. A formal child protection investigation was not commenced until several days after he had been admitted.  3.8 The decision that it was safe to discharge John home was taken by CSC after the police decided that there was insufficient evidence to continue with a criminal investigation. Two separate plans were drawn up following two different meetings, one for relevant professionals and a second which Page 4 of 7  focussed on the support which could be offered by the extended family. Despite both these meetings being minuted, those minutes and the accompanying plans were not shared with either the parents or the attendees of the meetings.  3.9 The CSC team manager left her job on the day that John was discharged from hospital. There was confusion about whether or not there should be a child protection case conference and a decision was taken that this was no longer necessary. Key Practice Episode 3 (After John’s discharge from Hospital, March to June 2017) 3.10 The first few weeks after John’s discharge from hospital were an opportunity to assess the family situation and to test out the hypothesis that his serious head injury had been accidental. However, once he returned home there seemed to be an acceptance that his injury had been accidental and the general level of concern decreased. There was no reference in the CSC records to the safety plan or to the actions that had been identified in it.  3.11 John had been at home for 11 weeks when the new manager in CSC identified concerns about the original response to his head injury. During this period, the parents had met the requirements of both the safety plan and the support plan. The social worker had been undertaking an assessment, which had still to be completed. There had been no further injuries or new concerns identified. 3.12 Given the length of time that had passed since John’s discharge from hospital, a robust assessment and review of the family situation could have informed the strategy meeting which was arranged by the new manager and potentially avoided the need for either a case conference or care proceedings. 4.0 Findings Referrals and Parental Consent 4.1 When the GP referred John to CSC, she did so with the mother’s consent. However, enquiries were not made of other agencies following that referral before making a decision to take no further action. One of the reasons for this decision was because the social worker did not think they had the mother’s consent to approach other agencies.  4.2 It is vital that workers are clear about consent, whether it has been given and for what purpose. The social worker could have asked the parents for their consent to approach other agencies. 4.3 The role of the father was largely absent in practitioner records despite the fact that he stayed in the hospital with the mother and was present at all subsequent meetings.    Page 5 of 7  Unexplained/Unwitnessed Injuries 4.4 Unexplained injuries are the most difficult for practitioners to investigate and respond to appropriately. Contributions from all the key agencies are necessary in order to agree a way forward. For these reasons, it is vital that health, police and social work perspectives are taken into account. In the absence of a crime and with an injury that may or may not have been accidental, the social work perspective can be the deciding factor in those early decisions. In this case CSC were guided by their colleagues from health and the police without contributing their own early social work assessment of the family situation. 4.5 Professional curiosity is especially important for unexplained injuries and must be maintained not just at the beginning of an investigation but throughout any subsequent monitoring period.   4.6 In the absence of an explanation, any initial conclusion regarding an injury can only be made ‘on balance’ and in the weeks that follow practitioners must continue to be alert to the possibility that their initial conclusion was incorrect. Involving parents & sharing plans 4.7 The failure to agree a plan across agencies whilst John was in hospital potentially put both John and his sibling at further risk. 4.8 Later on, the failure to share the plans with either family members or other relevant professionals potentially compromised their ability to follow and monitor those plans. Strategy meetings 4.9 An early strategy meeting including police and health colleagues was needed to ensure the child’s safety whilst further enquiries were made. Simply being admitted to hospital is not a sufficiently robust plan for a child who may have suffered a serious non-accidental injury. Action needed to be agreed with regard to the parents’ contact with him whilst in hospital and with regard to his siblings. Without such guidance, hospital staff were left in a very difficult position and neither child was adequately safeguarded. Use of the Signs of Safety (SOS) Model 4.10 Bexley uses the SOS framework as a practice model across agencies as a means of helping practitioners to develop a common language to assess risk of harm in families. Signs of Safety has become one of the most widely adopted research-based programmes in child protection services in England. It is a strengths-based approach which stresses the importance of working alongside families. It is, however, just a model and it cannot be assumed that its introduction will necessarily improve the quality of decision-making. 4.11 In John’s case, the case mapping exercise undertaken by the social worker and team manager focused too much on the ‘here and now’ and did not take into account historical concerns. The case Page 6 of 7  mapping was also not informed by any social work assessment. Initial danger statements and safety goals were not created in line with expected practice standards. The safety plan was essentially a timetable of activities that the mother was expected to participate and engage in. Discharge planning & continued monitoring 4.12 The practitioners involved in the child protection investigation decided that ‘on balance’ John’s injury was accidental. Given the uncertainty regarding this conclusion, the early weeks following John’s discharge required a robust multi-agency plan which could test out this hypothesis and contribute to a fuller assessment of the family. The parents, the members of the wider family who had been asked to support them and practitioners needed to understand their respective roles, why there was an ongoing concern and what needed to happen in order to offer assurance (or otherwise) that John and his sibling were safe. These processes were insufficiently robust.  The use of the Child Protection procedures & Case Conferences 4.13 There is no doubt that a fracture in a young baby is a potentially serious incident. If John had been discharged pending a child protection conference it is likely that the assessment of risk would have been more robust. 4.14 A child-in-need plan could have served the same function but only if it was given a similar priority to a ‘child protection case’ which did not happen with John. 5.0 Recommendations The Safeguarding Partnership should:  (1) Ensure that the recommendations identified to improve practice within the single agencies’ reports are implemented  (2) Share the findings from this SCR with practitioners across the partnership, ensuring that the findings regarding the following areas are highlighted; • The timeliness of strategy discussions and meetings, assessments and the review of child-in-need plans • The importance of sharing plans and minutes of meetings with families and practitioners • The importance of ensuring that parents are given clear, consistent and timely messages regarding safeguarding concerns  (3) Seek assurance that practitioners are routinely considering the role of and including fathers in their work with families  (4) Ensure that practitioners are reminded about the effect of their intervention on families and of the importance of involving families, as appropriate, in the formulation and delivery of plans.   (5) Ensure that MASH workers are clear about whether or not parental consent has been given and for what purpose. Page 7 of 7   (6) Advise MASH workers that formal feedback should be given to GPs who make a referral regarding a possible non-accidental injury   (7) Consider whether practice guidance is required in relation to unwitnessed/unexplained injuries, including the importance of practitioners maintaining a professional curiosity throughout the duration of their involvement with a family.  (8) Seek assurance that the ‘Multi Agency Strategy Meetings Joint Health, Police and Children’s Social Care Practice Guidance’ has changed practice and that health colleagues are now routinely included in strategy meetings and discussions.  (9) Ensure that the Signs of Safety approach is consistent with the requirements of Working Together and the Child Protection Procedures and complements the Statutory Guidance.                     