Multiple unexplained injuries to a disabled 2-year-6-month-old boy between October and December 2016. John suffered serious significant leg fractures more than once, with X-rays showing healing rib fractures; he was a child with disabilities who was not independently mobile and was pre-verbal. The case was subject to both Criminal Investigation and Family Court proceedings. Mother and partner initially arrested but the case was subsequently discontinued following evidence from doctors that a medical cause for the fractures could not be ruled out. John was known to health services for his developmental needs and social care as a Child in Need following incidents of domestic abuse. Maternal history of: child abuse, domestic violence and parental drug misuse. Father had a previous abusive relationship. Ethnicity or nationality is not stated. Learning includes: John's disability needs were a distraction leading to a lack of focus on the vulnerabilities/risks to John following domestic abuse incidents; where there is suspicion of a potential non-accidental injury a formal Child Protection Medical should be undertaken to assess risk and inform decision-making; the response to the third incident of domestic abuse was not robust and left John and siblings at risk of harm; the Child in Need plan was not child focused. Model: the review adopted a systems based approach. Recommendations to the LSCB: to seek assurance that the multi-agency response to domestic abuse is in line with its policies and procedures; to assure itself that the daily lived experience of children is central and captured in all the work partners undertake to promote their health and wellbeing.
      
    Serious Case Review No:  2019/C7595  Published by the NSPCC On behalf of an unnamed local safeguarding children board      This report was written by an independent author and is owned by the commissioning LSCB.  This report is published by the NSPCC with the agreement of the National Panel of Independent Experts.  Publication of this report by the NSPCC does not constitute endorsement of the contents. Copyright of this report remains with the commissioning LSCB.   0         John Serious Case Review  Published by an unnamed Local Safeguarding Children Board     1       Contents Page  1. Introduction; Methodology - Agency Involvement - The Process - Legal Situation - Family Participation – Limitation  2 2. Context ; Period under Review - Concise summary of the circumstances leading up to the Review - Parental background - The Family - The Child - Family dynamics  3 3. Narrative, Appraisal of Practice and Analysis of the Key Lines of Enquiry Introduction - Management of risk - Timeline of significant events - Presentations at Emergency Department  Key episodes of care and impact on multi-agency decision making; • The Strategy Meetings following the 3rd presentation to Emergency Department on the 25/10/16 – Learning and Recommendation  • Child Protection Medical – Learning and Recommendation  • Home Leave – Learning and Recommendation  Additional Influencing factors – Management of other pre-existing known vulnerabilities; • Domestic Abuse  - Learning and Recommendation • Child in Need - Learning and Recommendation  6 4. Conclusion Learning from previous Serious Case Reviews  17 5. Recommendations   18 6. Glossary  20 7. Appendix 1 Scope and Terms of Reference  21 8. Appendix 2 Factual Queries from John’s mother  24 2  1. Introduction  1.1   Initiation of the Serious Case Review  1.1.1 This review was commissioned by a Local Safeguarding Children Board (LSCB) in response to multiple unexplained bony injuries sustained to a disabled child between October 2016 and December 2016. John, the subject of this review, is a two and half year old child who was open to Children’s Social Care (CSC) as a Child In Need1 following two domestic abuse incidents.   1.1.2 The LSCB concluded that the circumstances of this case met the statutory requirements for a Serious Case Review (SCR) as set out in statutory guidance.2 The Independent Chair cited the following concerns:  • John had been seriously harmed suffering significant leg fractures on more than one occasion with x-rays suggesting the presence of healing rib fractures • John was a child with disabilities who was not independently mobile and was pre-verbal • There were concerns about how organisations worked together to safeguard John.   1.2 Methodology  1.2.1 The review adopted a systems based approach, which aimed to meet the learning and improvement requirements of statutory guidance. The review sought to understand: • Precisely who did what through development of agency chronologies and review of relevant documentation • The underlying reasons that led individuals and organisations to act as they did through conversations with Practitioners involved in the case. Where Practitioners were no longer in post, Managers of the Services provided organisational and service context.  1.2.2 The review was managed by a SCR Panel consisting of Senior Managers of the involved agencies, working with an Independent Lead Reviewer who is an experienced Lead Reviewer with a background in Health.  1.3 Agency Involvement  1.3.1 The following agencies were involved: • Children Social Care  • Clinical Commissioning Group on behalf of the GP • Children’s Community 0 -19 Services  • Hospital NHS Trust  • Police  • Child Development Centre • Voluntary Organisation                                                   1 Child in Need (CIN otherwise known as section 17) refers to children who are in need of support and services as defined in the Children’s Act 1989 revised 2004.  2 Working Together to Safeguard Children (DfE, March 2015).   3  • Public Health   1.4 The Process  1.4.1 The process used included: • Chronologies from all involved agencies. • Two group Practitioner and Management sessions took place to gather first-hand experience from Practitioners involved with John at the time and maximised learning opportunities to inform the review process. • An additional interview with a Practitioner unable to attend the above event. • The Lead Reviewer was given access to key documents and assessments.  • The Panel met on four occasions to discuss and progress the review.  1.5 Legal Situation  John and sibling two have since returned to mothers’ care. A judge granted a 1.5.1Supervision Order placing the children under the supervision of the Local Authority, giving the Local Authority the legal power to monitor the children's needs and progress, whilst the children live at home with their mother.  1.5.2 This case was subject to both Criminal Investigation and Family Court proceedings. Mother and partner were initially arrested for causing wounding with intent to do Grievous Bodily Harm and the children were taken into voluntary care. The case against mother and partner was later discontinued following the evidence of two independent expert doctors that a medical cause for John’s fractures could not be ruled out. The Crown Prosecution Service determined there was insufficient evidence to meet the burden of proof, beyond reasonable doubt, the level required for a criminal prosecution. This decision does not indicate innocence, but that conviction is unlikely. Suggestion that there may be a natural cause for John’s injuries does not mean this was the cause. There is no current criminal ongoing investigation.   1.6 Family Participation  1.6.1 Mother met with the Lead Reviewer and provided her understanding of the  professional’s  involvement and the support and services received by John, sibling  one and two, and herself.  Mother demonstrated insight into the needs of John and  her capacity to meet those needs.  1.7 Limitations  1.7.1 The Lead Reviewer would have welcomed an opportunity to speak to John’s father and mother’s partner, believing this would have provided greater insight and a different perspective on John, the family, the care given and the interface with Professionals, they declined involvement.   2. Context  2.1      Period under Review   2.1.1 The review period encompasses the period from the birth of John up until John was noted to have a spiral fracture of his right femur at two years of age.  2.1.2 There was significant involvement with a number of Health disciplines who were managing John’s extensive development needs.  4   2.1.3 Police involvement, until the Child Protection Investigation, related to attendance at three domestic abuse (DA) incidents with onward reporting to Children’s Social Care (CSC), as is routine when children are involved.  2.2  Concise summary of circumstances leading up to the Review   2.2.1 John, a two year old child, was admitted to the local Hospital Emergency Department in October 2016 from his GP. He was found by his mother’s partner to have an unexplained lump to the left side of the back of his head. Mother reported that she had not seen him fall, cry or injure himself. John was known to have marked Global Developmental Delay. Prior to this presentation John had been known to services on an outpatient basis due to his additional needs. He had had two earlier presentations to the Emergency Department. The Hospital Safeguarding Team had had no previous notifications about the family. This was the third presentation to Emergency Department, safeguarding children processes were commenced appropriately for an unexplained injury in a child who is not independently mobile. A referral to Children’s Social Care was made and a Strategy Meeting took place. As part of this process, investigations were requested to determine if John had any other signs of injury (skeletal survey, head computed tomography scan (CT), Ophthalmology Review). 2.2.2  John was permitted to go on home leave prior to these investigations being completed, which sits outside of usual process. The Hospital has implemented learning following a Commissioned Internal Review.  2.2.3 The minutes of the Strategy Meeting do not focus on the risks present due to John being a disabled child with unexplained injuries who is solely dependent on his immediate carers to meet his everyday needs. Instead, the minutes focussed significantly on mother’s own support needs and history of good engagement with services which detracted from the focus on the unexplained injury.  2.2.4 Once completed the skeletal survey report identified ‘Periosteal reaction seen along the shaft of left tibia. Shaft injury is of low specificity in non-accidental injury. This needs to be taken in the clinical context.’ It would appear that this information was not fully explained for a reader who was not medically trained and although shared with Children’s Social Care, was not shared with the wider multi-agency team to assist in risk assessment and decisions on how to move forward with the case, to ensure the safety of John and his siblings. No further reporting of this anomaly was requested at the time. 2.2.5 No further Strategy Discussions took place to clarify further decision-making and safety planning. John was discharged home on the 31st October 2016 following attendance for review in the Children’s Assessment Unit at the Hospital. 2.2.6 John was re-admitted via the Emergency Department at the Hospital on 6th December 2016 with a spiral fracture to his right femur. Child protection processes commenced once again as Clinicians were not clear that the mechanism described by the mother and her partner explained the presenting injury. 2.2.7 Another skeletal survey was undertaken and identified multiple fractures. As part of the Strategy Discussion, it was requested that an expert opinion be sought on the Radiology images. An expert opinion confirmed that there was a healing fracture of the left tibia.   2.3      Parental Background  2.3.1  Mother was known to Children’s Social Care and had been on a Child Protection Plan for fourteen months, within her own childhood, having been abused by a family 5  member. Maternal grandfather had a conviction for offences against children which mother indicated to the lead reviewer she was unaware of until after the birth of John. Mother indicated domestic violence and parental drug misuse were also issues she experienced and witnessed as a child.  2.3.2  Mother described herself as very rebellious. At the time of the critical incident mother had three children to two fathers and was in a relationship with partner.  2.3.3 Less is known of father’s background and he appeared to professionals to have been a constant in John’s life even after the couple separated.  2.3.4 Mother’s partner from March 2016, had been subject to a Child Protection plan, within his own childhood, for four months under the category of emotional abuse; no further details are known.  2.3.5 John was the second child for Mother and first for father. Mother and father were living together caring for sibling one at the time of John’s birth. There was an unsubstantiated allegation of rough handling made by sibling one’s father; he had seen bruising on sibling one but did not report it immediately. When he saw sibling one for contact next there were no injuries; he was advised to ring the police if he saw injuries again.  2.4     The Family             2.4.1 Mother stated when she and father separated; father abandoned John, and stopped seeing John altogether in March 2016; this was contrary to professional’s perceptions. Mother described this as sad as “John idolised his father”.   2.4.2 Mother stated her current partner visited the family home but did not live with the family. It is now known this partner had a child from a previous relationship and there was a serious domestic abuse incident between the couple. Partner’s mother supervised his contact with this child.  2.5      The Child   2.5.1  John’s gross and fine motor skills were delayed. At the time of the significant incident John could roll, pull himself to standing but could not walk. John’s global developmental delay meant that although he was able to communicate some of his needs through the use of different noises and cries he was unable to communicate verbally and therefore not able to give any indication of how his injuries occurred.  2.5.2 John received significant and appropriate input from Health agencies and for this reason; the Lead Reviewer has made no comment on the day-to-day care offered to John by Health disciplines within the community. There were multiple appointments Term used in report Relationship to child Age at the end of December 2016 John Subject of the review 2 years 10 months Mother Mother of subject 21 years Father Father of subject 21 years Sibling One  Half sibling  5 years 9 months Sibling Two Full Sibling 1 year 1 month Partner Mothers partner 25 years Maternal Grandfather Maternal Grandfather Not known  Maternal Grandmother Maternal Grandmother Not known 6  and assessments that parents complied with. Mother indicated to the Lead Reviewer that NHS helped with transport arrangements and her extended family supported her attendance at appointments.  2.5.3 Eight months prior to John’s fractured femur John was noted to have a low vitamin D level – whilst vitamin D was prescribed this was at a maintenance rather than treatment dose.   2.5.4 John was described by community staff as lovely, delightful, always happy and very inquisitive. John was reported to be anxious in new surroundings but did well in Hospital, eating pureed foods and settling with nursing staff.  2.6       Family Dynamics  2.6.1 Little is described in professional’s records about the parents or the family dynamics. Father was noted by the Children’s Continuing Care Nurse to be loving and caring towards John. On another occasion mother was reported to be affectionate and loving towards John throughout a visit.   2.6.2  The wider family were described only in terms of maternal grandfather and family members’ offences against children rather than any support they offered. Mother indicated to the Lead Reviewer she had a good relationship with maternal grandmother; “Maternal grandmother helps when needed”, and was from a large family who also stepped in when she needed them. 2.6.3 Mother informed the Lead Reviewer that she had been using marijuana at night when the children had gone to bed. Professionals did not know this. Mother stated she was “thinking she was doing great” as a parent but has since reflected she was “stupid and naïve”.  3.   Narrative, Appraisal of Practice and Analysis of the Key Lines of Enquiry   3.1      Introduction  3.1.2  This section will provide a focussed narrative, analysis and appraisal of practice pertaining to the key lines of enquiry, drawing out the findings of this Serious Case Review, with additional associated recommendations for LSCB and its partners. The findings relate to what has been learnt about the strengths and weaknesses in the multi-agency safeguarding systems.  3.2     Management of Risk   3.2.1  This section will consider the risk factors that were known and identified in this case    and the responses to those risks.            7  3.3    Timeline of significant events                                   3.3      Presentations at Emergency Department   3.3.1  First Presentation at Emergency Department by Parents   3.3.2  Aged 20 months parents reported that John had an unwitnessed fall resulting in a head injury. Parents reported he had vomited twice and was sleepy so they took him to the walk in centre where he was found to be drowsy. John transferred to the Emergency Department (28.10.15) by ambulance. The history given in Emergency Department was that this was an unwitnessed head injury whilst playing with siblings. There were no obvious signs of head injury noted. John now presented as alert and happy and was discharged. Mother was given head injury advice and the GP received a discharge letter. At the time of this presentation, John and his siblings were Children in Need following concerns of domestic abuse.    3.3.3 This attendance is John’s first presentation to Emergency Department. The history provided by parents at the walk in centre and Emergency Department appear to be different. Emergency Department did not complete the safeguarding information identifying if John was open to CSC. The letter to the GP does not make it clear that this was an unwitnessed fall. There were no visible signs of injury or injuries identified through investigations. The attendance was discussed within the next CIN meeting where mother was asked if John might have fallen off the settee. This indicates Professionals were taking account of their previous concerns of child safety; mother denied this was the scenario.   3.4     Second Presentation at Emergency Department by Mother   3.4.1   John attended the Emergency Department (10.09.16) aged two years seven months accompanied by his mother who reported an injury to his left foot. The alleged 02.02.14 John Born 09.04.14 DA between mother & father.  Referral to CSC 19.11.14 CAF completed 26.03.15 CSC completed assessment.  CIN plan 23.08.15 DA between mother & father 28.10.15 1st Presentation potential head injury reported by mother. No visible injury on clinical examination.  27.11.15 John’s sibling born 01.07.16 Case transferred from Family Support Team in CSC to Children with Disabilities Team 20.08.16 DA between mother & partner 10.09.16 2nd Presentation, potential leg injury   (Left foot) reported by mother. No visible injury on clinical examination 25.10.16 3rd Presentation Lump to head observed on examination 06.12.16 4th Presentation Fracture to leg observed on examination 24.07.15 Strategy Meeting Concern re older sibling            27.10.16      Strategy  Meeting      27.10.16 -29.10.16 Home leave from             Hospital between clinical investigations of Non Accidental Injury NAI 31.10.16 Discharged home managed under CIN  09.12.16 Strategy meeting Child removed from parents care  8  incident was unwitnessed but mother thought he might have twisted his foot after getting it stuck in between cot bars two days previously. An X-ray showed no bone injury. Mother was asked about involvement with CSC but she did not indicate John was being supported as a child in need. Staff within the Emergency Department did not contact CSC, accepting mothers’ explanation, which is usual practice as no clinical injury had been identified and health staff had no reason to question mothers account.   3.4.2  John’s attendance did not arouse suspicion; the explanation given was thought plausible and the delay in presentation was not viewed as significant when no obvious injury was found on clinical examination. However, this was the second presentation with parent reporting an unwitnessed injury. The Emergency Department did not complete John’s assessment on a paediatric record card, however there were questions regarding who John lived with and whether there was social work involvement. Mother reported they did not have a Social Worker although this was not accurate.    3.5     Third Presentation at Emergency Department by Mother      3.5.1   Six weeks later John attended the Emergency Department on the 25.10.16 aged 2 years 8 months with mother who reported a lump appearing on John’s head. No mechanism of injury was reported. There was no tenderness when the lump was pressed. Mother indicated they had no CSC involvement and no Social Worker. John was referred to the out of hours GP, as he did not require Emergency Care. John was subsequently admitted to the Children’s Ward following a referral from out of hours GP in relation to a possible head injury in a child who was not normally mobile and concerns regarding how the injury occurred plus John’s special needs and recent CIN status. This was known to the out of hours GP due to access to SystmOne (community health patient database). John was noted to have an unexplained swelling to the back of the head. Mother reported her partner had noticed the lump. John remained in Hospital overnight pending review by a Consultant Paediatrician the following morning due to concerns regarding possible non-accidental injury. Mother shared the name of the allocated Social Worker at the point of admission.  3.5.2  A ward Nurse made appropriate contact with the Emergency Duty Team (out of hours) CSC and according to CSC records shared that medical opinion at that point was that it was likely to be an accidental injury. This information was referred to the allocated Children with Disabilities Team for the worker to follow up.  3.5.3 John had a full body examination, the Consultant Paediatrician requested involvement of CSC and further investigations. A date was sought for a Strategy Meeting but this could not take place until the following day. The Paediatrician followed the policy for an unexplained injury and insisted that John remain in Hospital. The Paediatrician was concerned mother might attempt to remove John from hospital and sought the advice and assistance of police and social work colleagues; contingency plans were made. However, these contingency plans do not appear to have been considered as part of the strategy discussion the following day and would have served to focus on the potential risk to John.  3.5.4 Due to the clinical needs of John, there were two failed attempts to complete the full skeletal investigation. On the request of mother, John was allowed to return home for overnight care by his mother and her partner on two separate occasions, with final approved medical discharge home once the full skeletal investigation was undertaken. Discharge took place without further multi-agency discussion of the skeletal investigation results, which would have  informed the risk assessment of 9  possible non-accidental injury. The author is of the opinion that this was an serious systems failure; the clinical management of the presenting injury as a suspicious injury (non-accidental) was clearly evident, that expected practice in these circumstances should have been to hold a second Strategy Discussion to consider the medical opinion prior to John’s discharge home supported by current CIN Plan.   3.6  Final Presentation   3.6.1  On 6th December 2016, 6 weeks later, John attended the Emergency Department with an injury to his leg. Mother explained that she was not at home and John was in the care of partner who reported that sibling 1 had sat on John’s leg the previous evening. Safeguarding Children processes within the Hospital were initiated due to the delay in presentation and concern regarding the mechanism of injury. Mother was reported by Hospital staff to be very distraught and erratic when Professional concerns regarding the injury were explained to her. The skeletal survey identified additional fractures and an expert opinion was sought as per Strategy Discussion decision. Expert reports that initial skeletal survey anomaly was a healing fracture of the left tibia with new fractures noted on repeat skeletal survey; left radius, query fractures of the 5th, 6th, 7th and 8th ribs (images not clear) and a transverse fracture of the right radius in addition to the spiral fracture of the right femur. Multi-agency professionals had reported that the original anomaly was not shared with them during or after the first admission.  3.6.2 The management of these injuries followed expected routine Section 47 Enquiry, which resulted in John and his siblings being immediately removed from their mother and her partner’s care.   3.7.  Key Episodes of Care and Impact on Multi-Agency Decision Making   3.7.1 The Strategy Meeting following the Third Presentation to Emergency Department   on 25/10/2016   3.7.2 The purpose of a Strategy Meeting is to present and examine the facts, consider the risks to children, decide whether Section 47 Child Protection enquiries should be initiated/ continue and plan a safe way forward. The Strategy Meeting was chaired by an experienced Social Work chair, with good representation from senior colleagues within the Police and Hospital staff. There were a number of additional Health staff present who knew John and the family well e.g. Physiotherapist and Occupational Therapist, however the GP and Health Visitor who had knowledge of the family were not present having not been invited.  3.7.3  The Children with Disabilities Team and the Police were conducting a joint Section 47 investigation. The conclusion of the Strategy Meeting was that the case could continue to be managed as Child in Need. That decision was made on partial information and without waiting for all the Health investigations to be completed; it did not take into account recent concerns following the transfer of the case between CSC teams.  3.7.4  Given the known vulnerabilities and the commencement of clinical management pathway for non-accidental injury, there would have been an expectation that a second Strategy Discussion would have been scheduled to discuss and review the potential risks and management, once the Clinical Investigation reports were made available. As this was being managed clinically as a potential non-accidental injury, this should have been managed as a Section 47 Investigation. However, as it was not managed as a Section 47 Investigation, it lacked clarity on what the safety 10  arrangements were e.g. no direction on where it was deemed safe for John to reside whist awaiting investigations and results.  3.7.5 A number of the services, which had been involved with the family, had recently discharged John and were not invited to the Strategy Discussion. Professionals who knew the family prior to this incident had a positive view of mother’s parenting and had not been aware of the recent domestic abuse incident between mother and partner, the previous Emergency Department attendance, or recent non-attendance issues. Therefore, this information along with additional information regarding mother’s parenting, concerns about neglect and John being left unattended, change in the family structure and two recent house moves in quick succession were not considered.   3.7.6 The Children’s Social Care staff present, had only recently assumed care of John following transfer of the case to the Children with Disabilities Team, but also had a positive view of mother having visited the family home.   3.7.7  In relation to the injury there were a number of indicators of risk – John’s presentation to Hospital was delayed, there was no known mechanism of injury and the injury was unwitnessed. This was the third presentation of parental reported unwitnessed injury in a child with reduced mobility and no ability to communicate how these injuries may have occurred. There is lack of evidence that these vulnerabilities were adequately considered and discussed as indicators of risk in order to determine the appropriate actions to be taken as an outcome from the Strategy Meeting. In the absence of a clear focus on risk to John, the Professionals pre-existing positive perceptions of mother and the initial thoughts that this was likely to be an accidental injury appeared to have clouded the judgement of those present. There appeared to be a collective presumption that the results of forthcoming investigations would be normal.   3.7.8  It was brought to the Lead Reviewer’s attention at the practitioner’s event that the minutes of this Strategy Meeting were not considered by those involved in the Strategy Meeting to be an accurate reflection of the discussions that took place. However, it does not appear that any Professional at the Strategy Meeting challenged the content of the minutes once received.   3.7.9  The minutes, according to attendees, include information that was known within CSC but not discussed at the meeting, and does not record some of the discussion that practitioners recall. The Police information recorded as being shared, regarding partner, did not include the most recent domestic abuse incident. At the practitioner event as part of this review process professionals expressed the view, that had all the information been presented as in the minutes that followed, they may have formed a different opinion.  3.7.10  The minutes to the Strategy Meeting read as if a Child in Need (Child with Disabilities) meeting, did not capture discussion about risk, which is different to the recollection of attendees. The minutes were not recorded on the standard template for Strategy Meetings. However, most of the actions on the plan from the meeting pertain to ongoing management of John’s disability needs, rather than risk and the appropriate way forward in order to safeguard John, sibling 1 and sibling 2. Sibling 1 and sibling 2 were not considered during the meeting. There is now an updated format for these meetings to assist the chair to maintain focus on the presenting concerns and consider the risks.      11  3.8  Learning   3.8.1  The lack of focus within the Strategy Meeting on the vulnerabilities/risks to John including the presenting and recent unwitnessed alleged injuries reported by parent, recent domestic abuse incident and the risks presented by a close family member to the child/children. Coupled with a failure to appropriately follow processes and procedures, left John and his siblings vulnerable to further abuse. John’s disability needs were a distraction; this along with the  perception that mother was a ‘good’ parent, added to the lack of focus on the potential risks and risk management. Action planning was not robust and lacked safety planning for all the children. Systems and processes around minutes were not robust, allowing inaccurate recordings of Strategy Meeting discussions to remain on file. Late circulation of minutes meant attendees were not given an opportunity to consider or challenge the content in a timely fashion.   3.9  Recommendation 1: All agencies to provide assurance to LSCB that Strategy Meetings with particular consideration to Children with Disabilities, evidence sufficient consideration of risk and cases remain in Section 47 until all investigation results have been received and analysed by appropriate partners responsible to participate in the Section 47 Enquiry.  3.10   Child Protection Medical   3.10.1 There are a number of processes designed for use when a child has an unexplained or suspicious injury. There is a different approach when the suspicion is raised within the Hospital as part of an immediate clinical examination as opposed to a direct request for a child protection medical when safeguarding concerns have already been identified. If it is from within the Hospital, as in this case, an immediate referral is made to Children’s Social Care, a robust Paediatric examination takes place and appropriate investigations are ordered.  3.10.2 The Strategy Meeting minutes indicate there was a collective decision that ‘there was no need for a formal Child Protection Medical as no significant concerns’. This was explored with practitioners who indicated that as all the investigations that would normally be carried out as part of a Child Protection Medical had already been ordered and arranged there was no recognition of any additional benefit to conducting a formal Child Protection Medical. The fact that the resulting clinical management plan was for a full skeletal scan would have supported the management of a potential non-accidental injuries investigation was not highlighted at the Strategy Meeting and therefore did not serve to assist participating Professionals to focus on the risk to John. Conversely, the consideration that there was no requirement for a “Formal Child Protection Medical” appears to have been perceived as the injury being accidental/reduced risk of harm.  3.10.3 At the practitioner event, the Paediatrician indicated familiarity with the Child Protection Medical format; indeed, she had made use of that knowledge in this case. John had x-rays, a CT scan and an ophthalmic review that form part of a skeletal survey.  3.10.4 The fact that a full clinical investigation for potential non-accidental injuries was being progressed does not appear to have been discussed at the Strategy Meeting, which was a missed opportunity to bring the focus of the Strategy Discussion on track to explore the potential risk of harm to the child. Alongside this, what had not been recognised was the additional value of completing a formal Child Protection Medical report, which would include the analysis of the findings of the investigations and demonstrate evidence of significant harm. If this had been completed and 12  presented to the Strategy Discussion, the focus on the potential risk of harm to John and his siblings would have been evidently prominent.   3.10.5 An appropriate skeletal survey was undertaken. The findings were included within the comprehensive discharge summary and contained medical jargon “periosteal reaction seen along the shaft of the left tibia. Shaft injury is of low specificity in non-accidental injury. This needs to be taken in the clinical context.”   3.10.6 In the absence of a second Strategy Meeting, further discussion with multi-agency professionals and Health colleagues did not take place about whether further opinion was required on the skeletal survey in order to inform the management of risk. A copy of the skeletal survey was sent to CSC but without accompanying analysis would have little meaning regarding level of risk. In the absence of a clear understanding of the outcome of the skeletal survey and no scheduled follow up Strategy Meeting, it would be incumbent on the Paediatrician to ensure the report was in plain English and incumbent on the receiving Social Worker to seek clarification from the Paediatrician. A meaningful information exchange should have served to give a clear understanding as to whether the findings of the skeletal survey concluded that the injury was either probable non-accidental injury or not. In the absence of the report being presented to a timely second Strategy Discussion, this should have informed the need to call a further unscheduled Strategy Meeting or have been shared to inform the ongoing CIN support plan.   3.10.7  The Police and CSC understood that the skeletal survey was due to take place on the day of the Strategy Meeting. The plan was for CSC to call the Hospital at 5pm to check whether this had taken place. The Police understood that John would not be discharged from Hospital until all the tests were complete; this would be normal protocol. The Police expected a call later that day or the next day from CSC to update following the results of the skeletal survey. They did not receive any update until the following week when they learned of the delays and home leave; the tests were due to be complete that day. The Police raised concerns with CSC indicating that the plan was not to discharge John back into parent's care until they were satisfied all checks had been completed. This challenge did not result in further exploration by CSC or escalation by Police or in the absence of the outcome of the skeletal survey outcome report did not initiate discussion as to whether there was a need to hold a second Strategy Meeting at this time.   3.11    Learning   3.11.1  When there is suspicion of a potential non-accidental injury, a formal Child Protection Medical should be requested and undertaken in order to assess risk and inform decision-making.  3.12  Recommendation 2: LSCB to review procedures for Strategy Meetings to include the learning in respect of the following: • Minute taking • Authorisation of minutes • Distribution of minutes timescales • Challenge/ Escalation   LSCB: to review the procedures for Child Protection Medicals LSCB to disseminate across partner agencies and seek assurance this is embedded into daily practice.   13  3.13      Home Leave  3.13.1 John was allowed home leave before all medical investigations were complete which would  rule in or out a non-accidental injury. The initial decision to allow John home leave was taken as a single agency, outside of the Strategy Discussion, which may have increased risk to John at this time. Whether a child should remain in Hospital or alternate place of safety if fit for Hospital discharge, would usually be discussed and agreed at the Strategy Meeting with a clear plan. At the time of the Strategy Meeting, it was anticipated that the investigation would be completed later that day and there would be no significant injury. The minutes from the meeting state, “All members of the Strategy Meeting felt the incident was accidental and there were no other injuries present.” There was no clear contingency for if the investigations needed to be rescheduled. The investigations were rescheduled in order to meet the clinical needs of John.   3.13.2   The Consultant Paediatricians’ decision to allow home leave was influenced by a number of factors including the Strategy Meeting decision to manage the case as Section 17 rather than Section 47, mother and partners’ previous behaviours on being told John needed to remain in Hospital, the clinical pressures at that time and the belief that mother was a ‘good parent’. The initial decision to allow home leave formed the basis for the decision making of all the Consultant Paediatricians who reviewed John subsequently. There was a collective belief held by the Consultant Paediatricians that this was the right action to take, thus home leave continued without challenge. The Paediatricians had noted the decision of the Strategy Meeting to manage the case as Section 17 and were unaware that this decision was based on partial information accepting the Multi-Agency risk analysis conclusion that John was not at risk of significant harm.  3.14      Learning  3.14.1   Decisions could have been better informed by each Consultant Paediatrician, who all have responsibility for decisions made, had there been clarity on the level of significant harm and management of risk. The decision to manage the case as Section 17 before all investigations had been completed, adversely affected the decision-making around home leave, leaving John and his siblings at risk of further harm. As a result of the Internal Incident investigation conducted by the Hospital in the weeks following John’s admission in December 2016, any child subject to Child Protection investigations will not be allowed home until a reconvened Strategy Discussion has taken place.  3.15    Additional Influencing Factors  3.15.1   It has to be acknowledged that there were a number of pre-existing vulnerabilities, which should have served to inform the management of risk for a young disabled child presenting with unexplained injury. How these were understood and managed by professionals in this case needs to be captured as part of this review to provide context to the environment and lived experience of the child.      3.16     Management of other Pre-existing known Vulnerabilities  3.16.1    Domestic Abuse   3.16.2.  There were three domestic abuse incidents during the period under review. The first on the 09/04/14 was between mother and father when John was two months old; this led to Children’s Social Care (CSC) involvement. The information gathering and 14  initial assessment by CSC following the first incident was slow to be progressed, however the assessment did take into account the history of the case and the family.; it established concerns regarding a family member and maternal grandfather having unsupervised contact with the children and led the case into CIN.   3.16.3   The case remained open under CIN due to mother informing the social worker that maternal grandfather had been baby-sitting the children, which was concerning due to him possibly posing a risk to the children.   3.16.4   The second domestic abuse incident on the 23/08/15, when John was 18 months old (two months prior to the first head injury presentation) was between mother and father, after the couple had separated. The Police referred the incident to CSC for domestic abuse due to a verbal argument. Mother would have been eight months gestation with her third pregnancy at the time of this incident. John and his siblings continued to be managed with CIN support package at this time.    3.16.5   These first two incidents were appropriately referred to Children’s Social Care. All subsequent assessments refer to the history of the case and family. Information known to CSC was not consistently shared with partners and the delay in contacting partners meant opportunities for professionals to discuss the incident with mother were missed. Children’s Social Care continued involvement in isolation from partners in between receiving the referral and making the decision that the case met the threshold for CIN.   3.16.6   The third domestic abuse incident on the 20/08/16 was between mother and partner when John was 30 months old. This was three weeks prior to the second Emergency Department presentation time of mother reporting the unexplained foot injury. A member of the public who contacted the Police due to hearing a female screaming ‘Help me’ reported the incident. Police attended and established mother had an argument with partner. Mother, intoxicated, ran off from the Police. A further call was received from mother’s stepfather stating she had returned home. Mother and partner were both seen and officers established a verbal argument had taken place; no offences were reported. A non-crime domestic report and a DASH (Domestic Abuse, Stalking and Honour Based Violence) booklet were completed. The crime report was amber rated due to the fact there were three children in the family unit. The report was noted on the Multi Agency Safeguarding Hub (MASH) system three days after the event, it is not clear whether due process within MASH occurred on this occasion. There is no corresponding record within CSC.   3.16.7   Following the initial incident, a further call was received from another member of the public to the Police stating they could see a male and female fighting in the property. They had witnessed the male punch the female and throw her against the wall. Mother denied any assault to the attending Police; there is no evidence that enquiries were made with the witness. The details of this part of the incident were not referred through to CSC. There is no evidence that this incident was known by or followed up by the Social Worker. The Police crime report was seen by the Health Visitor twenty three days after the event and was subsequently discussed with mother. No further incidences of domestic abuse were disclosed during the discussion.  3.16.8.  There was a missed opportunity here to explore the relationship between the mother and her new partner and to understand the partners input to assist mother to care for John and his siblings, younger sibling being 9 months of age at the time of this incident. Exploration of partner’s previous abusive relationship and knowledge that he had a child where a family member supervised his contact, do not appear to 15  have been considered as part of the CIN on-going assessment or presented to the Strategy Meeting following the third presentation of John to Emergency Department to inform risk assessment.       3.16.9   Whilst all initial incidents of domestic abuse received a consistent approach by the Police, with onward referral to CSC, the second call out on the last occasion does not appear to have been shared with CSC or partners. On this occasion, an opportunity was missed for the Police to gather further evidence from the witness. Whilst this incident was referred to CSC, there is no evidence that this incident was known to, or given further consideration by, the allocated Social Worker within CSC. The case was being transferred from the Family Support Team to the Children with Disability team at this point; it is not clear whether this accounts for the lack of follow up. There is evidence that, on being informed of this incident some three weeks later, the Health Visitor followed up the concerns with mother, which is good practice. However, when mother informed the Health Visitor that the Social Worker was calling the following day this did not prompt the Health Visitor to contact the Social Worker. Of note, two days prior to the Health Visitor’s call to mother, John attended Emergency Department with mother reporting a probable unwitnessed foot injury; it does not appear the Health Visitor was aware of this at the time of her call and this was not followed up. Five and a half weeks later John attended the Emergency Department with a swelling to his head. The possible linkage between these injuries and domestic abuse was never explored. There were no CIN Meetings throughout this period reducing the opportunities for professionals to discuss the incident or decide if the case now met the threshold for Child Protection.   3.17  Learning  3.17.1   The response to the third incident of domestic abuse was not robust. The incident did not prompt further assessment within CSC and there was a lack of discussion within and between agencies, which left the children at risk of harm. The information with respect to the presentation of the unexplained injury to John and the Police attendance to domestic abuse incidents were never married up. It would appear that the professionals involved at the time did not consider the potential correlation between domestic abuse and John’s presentation to Emergency Department, which should have informed risk to the child and may have left the children at risk of harm.   3.18    Recommendation 3: LSCB to seek assurance that the Multi-Agency response to domestic abuse is in line with its policies and procedures, and that all referrals for domestic abuse, even when cases are open, are subject to risk assessment, information sharing, safety planning and are progressed in a timely manner.   3.19     Child in Need and Daily Lived Experience of the Child:   3.19.1   Prior to the presentations at the Hospital, the children were subject to Child In Need Plans; however, this review has established that the CIN processes were not always as robust and effective as one would expect.   3.19.2    CIN Meetings were often cancelled or lacked Social Worker presence. Practitioners indicated they had found this frustrating but these frustrations did not lead to any formal challenge. Mother voiced, “She had not seen the Social Worker in months”, however this also made no difference to the level of input. Social Work caseloads at this time were known to be high and to be impacting on their capacity to respond to 16  children’s needs. There were also identified issues around lack of supervision and managerial oversight.   3.19.3   New concerns did not always feature in any detail on the plan. For example, there was no robust plan of support for mother and the children at key times e.g. the birth of sibling 2.   3.19.4  The decision to move the case from the Safeguarding Team to the Children’s Disability Team meant that, in a very short space of time, there were changes in a number of key individuals who knew John and the family well. At the same time, support was being reduced.   3.19.5    Mother identified she received less support once the case moved to the Children with Disabilities Team. Plans developed on a Multi-Agency basis were slow to progress or not progressed; some actions were not complete at point of transfer. There was no evidence of managerial oversight of the CIN plan. Ofsted3 found that work with children in need was not as effective as work undertaken in child protection calling for improvement in the quality of plans.   3.19.6   The children were deemed CIN for approximately two years; there is no evidence that any further attempts were made to seek sibling 1’s views during this time, nor observe John’s responses to mother, father or partner. Whilst John’s developmental difficulties may have proved challenging, the views of sibling 1 also do not feature within any assessments. What are recorded are the views of mother and the wider family.   3.20    Learning  3.20.1   The CIN plan was not child focused. The children did not feature in terms of the risk to their emotional and physical wellbeing from witnessing domestic abuse.   3.20.2   The process and management of this case within CIN meant that it did not receive the same status or scrutiny as cases in Child Protection. Lack of supervision and managerial oversight meant that the plan lacked purposed and was not progressing as required. As a result, there was drift.   3.20.3  For babies and young children undertaking observations or interacting and play might be an appropriate way of establishing what their feelings and understanding of the world are. Having some knowledge of key attachments who is important to them and whom they feel safe with is important to action planning. As Sibling 1 developed Social Workers should have revisited, and used recognised tools e.g. the three houses template, within their assessments.   3.20.4   Ofsted4 found that assessments did not always include children’s experiences with many failing to capture the child’s voice through observation or direct work and plans were too heavily focussed on the needs of adults. Ofsted made the following recommendation – Ensure that children’s voices are fully reflected in assessments and plans. In this case, professionals were not recognising that young children can                                                   3 Ofsted (2017) Inspection of services for children in need of help and protection, children looked after and care leavers 4 Ofsted (2017) Inspection of services for children in need of help and protection, children looked after and care leavers 17  contribute to their assessments, or taking opportunities to talk to and listen to the children.  3.21   Recommendation 4: LSCB to seek assurance from CSC that cases held as Child in Need have robust management oversight, regular effective reviews and that plans are progressed with multi-agency partners in a timely manner which takes into account all needs, risks and the lived experience of the child.    3.22    Recommendation 5: LSCB to assure itself that the “Daily lived experience” of children and young people is central and captured in all the work partners undertake to promote their Health and Wellbeing.  4.    Conclusion  4.1   The response to the first two presentations to the Emergency Department were appropriately managed given the absence of injury following clinical assessment and that Hospital professionals would have had no prior knowledge of family’s involvement with CSC or Police domestic abuse notification. The Clinical Management and escalation of potential non-accidental injury were in keeping with the expected Clinical and Safeguarding procedures, following the two subsequent presentations of John to the Emergency Department.  4.2   Both Section 47 Enquiries were not sufficiently focused on risk, and safety planning was absent. The decision to de-escalate from Section 47 to Section 17 following the admission for a lump on John’s head, before results of investigations had been received, was key to all actions/inactions from that point on.  4.3   The lack of a robust plan around feedback of the medical investigations to other agencies meant the Police had closed the case before results were known and would not reopen the case unless formally requested to do so.  4.4      It is difficult to conclude whether the injuries that occurred after the domestic abuse incident could have been prevented. However, if a full assessment had occurred more would have been known regarding the partner and when the injuries occurred and links to this incident might have been explored.  4.5     The way that the Strategy Meeting was led and the competencies and confidence of all professionals who participated was a fundamental element of the decision making process in this case. The lack of focus on the risk posed to John and his siblings was significant and can be seen to have informed a collective professional flawed risk assessment, which resulted in a wrong decision to progress as Section 17 CIN, with a focus on support of the family of a child with a disability.  4.6    The clinical management of John’s third presentation to the Emergency Department was in keeping with investigation to consider a possible non-accidental injury. Based on the Clinical assessment, albeit not presented in the form of a Child Protection medical, had there been clarity of the clinical management as a possible non-accidental injury, this would have resulted in a greater degree of professional scepticism and need to maintain focus on risk. It could be argued that had professionals been provided with clarity that a probable cause of the injuries was likely to be explained as a non-accidental injury, the need to review the outcome of the skeletal survey results would have been given precedence. This would have served to inform professional decision making with respect to significant harm of John and risk posed to his siblings and the need to continue the Section 47 enquiry instead of the flawed decision to continue to manage as CIN. The specialist opinion would likely have been formally sought to inform a need to schedule a second Strategy Meeting and inform a contingency plan if John’s parents made any attempt to remove him from the Hospital setting until a second Strategy Meeting had taken place.   18  4.7   It is not possible to conclude that the subsequent injuries resulting in the final presentation to the Emergency Department some seven weeks later could have been wholly prevented. However, a robust risk assessment would have informed the need to update the Single Assessment and ensure an effective safety plan should have been in place to mitigate the assessed risk to John and his siblings.    4.8      Much of the learning within this review mirrors the findings of the Ofsted5 Inspection, which took place within weeks of the critical incident. Progression of the recommendations within Ofsted’s report will address many of the issues identified in this review.   4.7     Learning from Previous Serious Case Reviews   4.7.1     Consideration of recent local SCRs provides a critical ‘window on the system’. Two other SCRs in 2016 and 2017 covered similar timeframes to that of John. As in this case, there are reports of excessive workloads within CSC impacting on practice. These cases evidence an improving picture, which was supported by the 2017 Ofsted Inspection.   4.7.2      Additional SCRs in 2015 and a neighbouring LSCB 2017 have been considered as these relate firstly to a child with disabilities and secondly to injuries in a non-mobile baby.   5.  Recommendations   5.1   Recommendation 1:  All agencies to provide assurance to LSCB that Strategy Meetings with particular consideration to Children with Disabilities, evidence sufficient consideration of risk and cases remain in Section 47 until all investigation results have been received and analysed by appropriate partners responsible to participate in the Section 47 Enquiry.    5.2.    Recommendation 2:    LSCB to review procedures for Strategy Meetings to include the learning in respect of the following: • Minute taking • Authorisation of minutes • Distribution of minutes timescales • Challenge/ Escalation   LSCB: to review the procedures for Child Protection Medicals LSCB to disseminate across partner agencies and seek assurance this is embedded into daily practice  5.3       Recommendation 3:    LSCB to seek assurance that the multi-agency response to domestic abuse/domestic violence’s in line with its policies and procedures, and that all referrals for domestic abuse, even when cases are open, are subject to risk assessment, information sharing, safety planning and are progressed in a timely manner.                                                      5 Ofsted (2017) Inspection of services for children in need of help and protection, children looked after and care leavers 19  5.4    Recommendation 4:   LSCB to seek assurance from CSC that cases held as Child in Need have robust management oversight, regular effective reviews and that plans are progressed with multi-agency partners in a timely manner which takes into account all needs, risks and the lived experience of the child.     5.5    Recommendation 5:   LSCB to assure itself that the “daily lived experience” of children and young people is central and captured in all the work partners undertake to promote their Health and Wellbeing.                                           20        Glossary of Terms & Abbreviations  CAF Common Assessment Framework CIN Child in Need CSC Children’s Social Care CT Computed tomography scan  DA Domestic Abuse DASH Domestic Abuse, Stalking and Honour Based Violence GP General Practitioner LSCB Local Safeguarding Children Board  MASH Multi-Agency Safeguarding Hub NAI Non-accidental injury SCR Serious Case Review       21  Appendix 1 - Scope and Terms of Reference: John  Scoping Question Scoping Response  Safeguarding Board: Local Safeguarding Children Board What is the Board wanting to look at: Particular case/Practice theme/agency or multi-agency issue? Other agendas: • Trying out a new method of learning • Building internal capacity in the mentoring option • Extent of organisational sign up – is this something the Board supports? What about others? What about independent providers? The Serious Case Review Group recommended on 21st March 2017 that a Serious Case Review (SCR) should be undertaken following John sustaining multiple non-accidental injuries whilst in the care of his mother and her partner.  The Independent Chair made a decision to conduct an SCR on 21st March 2017 noted: 1. That John had suffered significant leg fractures on more than one occasion and these were seen as serious injuries as x-ray findings suggested the presence of healing rib fractures. 2. John is a disabled child not independently mobile and non-verbal. 3. There is also a concern about how agencies work together to safeguard John.  This review will be a tight focussed piece of work that will consider the role of statutory agencies and any commissioned services involved in this case. The focus of the review will be whether any of the professionals or any agency could or should have known that John who is disabled, not independently mobile and with global delay had sustained a number of separate fractures which included a spiral fracture of his right femur, healing fracture of the left tibia and other multiple fractures.  It should take account that on at least 2 other occasions the injuries to John were not fully investigated and that the period they were inflicted is believed to be no more than six months.   Does the SCR involve more than one Board? Is it a joint review or is there a lead LSCB? There are no other Local Safeguarding Children Boards involved in this review. Board preference Is the Board wanting to: • Use a specific model or methodology? • Try out something new? • Stick with the traditional way of doing things? The LSCB would like to involve frontline staff in a review to explore practice and system learning in relation to identification and exploration of injuries to children in children and to make some concrete improvements in multi-agency practice for children and young people, if this is found to be necessary.  The LSCB is open to using a range of methodologies and approaches and given the relatively recent nature of this case believes that traditional Interagency Management Reviews are not necessarily the most effective way of extracting the learning in a timely way.  Purpose of the Review What do the Board think they want to learn more about (this might be posed as a research question) (some re-ordering of the bullet points) Questions to draw out the multi-agency learning are: • How and why did workers and agencies miss that John had been seriously injured and could this have been prevented or identified earlier? What were the opportunities • How do we know that we are consistently keeping children presented at any agency safe? 22  Scoping Question Scoping Response  • How well did partners fulfil their child protection responsibilities?   These questions need to be linked and refined. • How the voices of the children were heard and how well were they responded to? • What was the safety arrangements for the children, how well known were they between the professionals involved and how robustly were they implemented?  • Did assessments take into account the history of the case and family?  It was agreed the key lines of enquiry would be drawn and distilled from these questions as appropriate. What Budget is available?   We have assigned a maximum of 15 days for the Lead Reviewer to complete this Review in accordance with the contracted schedule of works. What time period will be reviewed? The period from beginning February 2014 to end of December 2016 was reviewed in detail and prior to this any relevant information to the terms of reference will be included. When do you want the Review to start? The first meeting was held in June 2017  Who will be a member of the SCR Panel?   To be confirmed at Scoping Meeting but currently agreed as: • Children's Social Care  • Hospital • Clinical Commissioning Group   • Community Health Services • Police • Public Health • CAFCASS What else is happening? • Any disciplinary proceedings on going for staff? • Any parallel proceedings?  • Any known conflict between agencies/staff related to this case? • Any vulnerabilities or concerns? A criminal investigation was undertaken but was subsequently ceased and no further action taken.  No other parallel proceedings/investigations were undertaken. Are you asking for IMRs/agency chronologies? Do you have a template? An integrated chronology compiled.  Discussions held agreed that IMRs would not be required but case summaries of any relevant information prior to the timeframe for the SCR. A Practitioners event held. Any follow up information from the Practitioners event was sought from the SCR Panel members.  Informing and involving family members (This needs to be discussed in more depth once lead Meetings held with John’s mother.  Meeting with the father was offered but not taken up.  23  Scoping Question Scoping Response  reviewers have been commissioned.)  How are family going to be informed about the SCR? Who will provide support to the Review? Who will be the main senior manager contact? Who will provide admin support to the review? How will documents etc. be assessed? The LSCB Business Unit will support the Review and provide administration and be the contact for the Review. Documents will be sent either via the Council’s own secure system GCSx or standard email password protected or by recorded delivery. Final Report Are you clear in what format and style, tone, length you want this to be?  What is the process for sign off? This review will be short, concise and focused and the report will provide the reader with a clear understanding of the learning from this case and how practice can be improved and impactful. The report should explore and answer ‘the why’ of how this serious incident happened.   The report will be signed off by the LSCB. Accountability, Quality Assurance and Governance What process is in place to address the above? The Lead Reviewer and SCR Panel members will be responsible for ensuring that there is appropriate accountability within the review. This will include that where agencies identify any areas for improvement that this is translated into a single agency improvement plan at the earliest opportunity using the standard template and impact measures are agreed.  The Lead Reviewer and/or LSCB Business Manager will provide regular updates to the Serious Case Review Group who will in turn hold the SCR Panel to account for quality and report progress with the Review to the LSCB.   The Independent Chair will hold agencies to account where there are any concerns about accountability, engagement or governance arrangements. The LSCB will sign off the final Overview Report, Action Plan and Communications Plan. Who will lead on the Project Plan for the Review? What are the key dates, meetings, milestones?  Do you have a contingency plan?  Do you have a communications/media plan? The LSCB Business Manager and the Lead Reviewer will be responsible for the Project Plan going forward.   The SCR Panel will agree the key dates and milestones.    The requirement for a contingency plan was discussed at the Scoping meeting in June 2017.    Communications and media plan will be determined as appropriate prior to the publication of the Review,      24   Appendix 2 - Factual Queries from John’s mother.  Following a meeting with the mother and her sister to share the report she raised the following queries;  Section 3.3, 3.4 and 3.5 page 7 and 8 of the SCR report   1. Query from the Mother   Mother states that on all admissions to hospital she did tell hospital staff that Children’s services were involved with John as she knew they would find out so there was no reason to lie. John had had social work involvement nearly all his life. Mother said she remembers on the 3rd presentation she mentioned to hospital staff her Social Workers name.    Response from the Hospital;   3.3 The Hospital Emergency Department did not gather the information that would have prompted a question to be asked of mother as to whether John had a social worker.   3.4 It is recorded that John had no Social Worker indicating that the question had been asked of mother who presented with him.   3.5 As 3.4 however Mother then shared the name of Social Worker with ward staff when John was admitted to the Children’s ward.    2. Query from the Mother   In regards to 3.5.4 and the issues of going home mother does remember challenging the Consultant Paediatrician about why because some of the tests had not been completed so her rationale was if the hospital were that concerned why there was a delay.  Mother remembers apologising to the Consultant Paediatrician for her reaction to be told that John needed to stay in hospital, she said that she felt overwhelmed by the situation and having been at the hospital for a number of days.     2.1 Response from the Hospital;   3.5.4 The information shared within the chronology and then subsequently within the report is as it reads and was shared at the practitioner’s event by the Consultant Paediatrician. 25     3. Query from the Mother   Mother also states that her partner attended the hospital on all 3 presentations with John    3.1 Response from the Hospital;   The information shared for this review reflects that which is recorded in the notes.    4. Query from the Mother   John’s mother queried the following;   3.16.4  The second domestic abuse incident on the 23/10/15 Mother said this should read 23/08/15, when John was 18 months old (two months prior to the first head injury presentation) was between mother and father, after the couple had separated. The Police referred the incident to CSC for domestic abuse as mother 'attacked' father mother denies attacking the father and there is nothing in the Police or Children’s Services chronologies that state there was an attack only a verbal argument . Mother would have been five eight months gestation with her second third pregnancy at the time of this incident. John and his siblings continued to be managed with CIN support package at this time.       4.1 Response from Police;   Police checked their records and the paragraph on page 14 has been amended accordingly  3.16.4 The second domestic abuse incident on the 23/08/15, when John was 18 months old (two months prior to the first head injury presentation) was between mother and father, after the couple had separated. The Police referred the incident to CSC for domestic abuse due to a verbal argument. Mother would have been eight months gestation with her third pregnancy at the time of this incident. John and his siblings continued to be managed with CIN support package at this time.      5. Query from the Mother  Sections  3.16.6 to 3.16.7 - Mother states that the neighbour who made the 2 calls to the Police about the DA incident on the 20.8.16 could not have seen into the flat as the curtains 26  were closed and there were alleged ongoing disputes with this neighbour. The info to the Police below there is no contact made with the alleged witness/caller and no recording of any injuries were noted on the mother, she denies an assault took place.   5.1 Response from Police;   As above no contact was made with the referrer to establish their account, and no recording of any injuries were noted on the mother and she denied an assault took place.   