Death of a baby within a week of birth. Both parents concealed the birth, death and burial of Baby C. No agencies were involved until after Baby C's death when mother disclosed to her mother (maternal grandmother), prompting a police investigation. Older sibling had been removed from parents care and adopted. Father was violent and controlling of mother in their relationship. Mother claimed that Baby C had been born with a deformity and would not take breast milk. Mother and father were charged with murder but the judge ruled that a murder conviction would not be safe, as cause of death was unascertained. Parents pleaded guilty to concealment of birth and were sentenced. Baby C was White British. As the deliberate concealment from all agencies of the pregnancy and subsequent death of Baby C could neither have been predicted nor prevented, this review only looks at potential interventions which could support practice and lessen the likelihood of similar events happening in the future. Recommendations include: consider developing a system of notification letters to the GPs of parents who have experienced the traumatic loss of a child through adoption; explore the possibility of whether, under the General Data Protection Regulation (GDPR), notification outlining the information the GPs will need to know could be legitimately sent, in the interests of the parents, when consent cannot be obtained; seek reassurance that suitable provision is available to support women who want to break the cycle of repeat pregnancy and care proceedings.
      
 Title:  Baby C: serious case review. LSCB: Bolton Safeguarding Children Board Author: Anthony Hayley Date of publication: 2019  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.                             Baby C  Serious Case Review                  Anthony Haley Independent Reviewer  Published  August 2019   1  Abbreviations   MC Mother of Baby C FC Father of Baby C SC Male sibling of Baby C MG Maternal grandmother of Baby C PG Paternal Grandmother of Baby C BSCB Bolton Safeguarding Children Board SCR Serious Case Review GMP Greater Manchester Police NPS National Probation Service NHS National Health Service FNP Family Nurse Partnership CCG Clinical Commissioning Group GDPR General Data Protection Regulations GP General Practitioner CPP Child Protection Plan MARAC Multi-Agency Risk Assessment Conference IRO Independent Reviewing Officer IDVA Independent Domestic Violence Advisor   2  Table of Contents Abbreviations ........................................................................................................................ 1 Summary of Events ........................................................................................................... 3 The Review Process .......................................................................................................... 3 Criminal proceedings and coroner’s inquest ...................................................................... 4 Family participation in the review ....................................................................................... 4 Summary of findings .......................................................................................................... 4 NARRATIVE OF EVENTS .................................................................................................... 5 Background of parents ...................................................................................................... 5 Events surrounding the adoption of SC ............................................................................. 5 Events leading up to the birth and death of Baby C ........................................................... 7 The police investigation ..................................................................................................... 7 LEARNING FROM PRACTICE ............................................................................................. 8 The learning event ............................................................................................................. 8 Analysis and research ........................................................................................................... 8 The parents’ relationship ................................................................................................... 8 Coercive control ................................................................................................................ 9 Concealed pregnancy ........................................................................................................ 9 What might make a difference? ........................................................................................... 10 Early intervention ............................................................................................................. 10 Post adoption support ...................................................................................................... 10 General practitioner services ........................................................................................... 11 RECOMMENDATIONS ....................................................................................................... 12 Recommendation 1 ......................................................................................................... 12 Recommendation 2 ......................................................................................................... 12 Recommendation 3 ......................................................................................................... 12 AGENCY RESPONSE TO RECOMMENDATIONS……………………………………………..13   3  INTRODUCTION Summary of Events This Serious Case Review (SCR) relates to the death of Baby C, a white British child, who died within a week of birth.  The pregnancy, birth, death and burial had been concealed by both parents.    Due to the concealment, no agency was involved until after the death, when a police investigation was prompted by Baby C’s mother (MC) disclosing the birth and death to her mother, the maternal grandmother (MG). MG told a support worker, who passed the information to the police.  The police investigation led to Baby C’s body being found.  MC and Baby C’s father (FC) were charged with murder.    At their trial, after the prosecution case had been put, the judge ruled that a conviction for murder would not be safe, as the cause of death was unascertained.   The parents pleaded guilty to concealment of birth and were sentenced accordingly.  The Review Process The Bolton Safeguarding Children Board (BSCB) Learning and Improvement Group met and had access to agency summary reports for the period which covered the pregnancy, birth and subsequent burial.  These informed the recommendation to the Chair of the BSCB.  The group concluded that the case met the threshold for a Serious Case Review (SCR) in accordance with Working Together 20151, but that this would not take place until the criminal proceedings had been concluded.    The BSCB commissioned an SCR using a systems approach and incorporating elements of the ‘Welsh Model’ for Serious Case Reviews2 which would ensure that practice learning informed the process.     An initial meeting of the SCR panel determined that, as during the period prior to the pregnancy, birth, death and burial of Baby C, no agencies were involved with the parents and child, the review was to include consideration of the last period of engagement with services, which was within three years of Baby C’s birth.   The Independent Lead Reviewer chaired the serious case review panel which presided over the process.   In addition, the panel was comprised of:  Designation Agency Designated Nurse Children Looked After Bolton CCG Detective Sergeant, Serious Case Review Team Greater Manchester Police Named Midwife Bolton NHS Foundation Trust Head of Service Child Protection and Child Sexual Exploitation Children’s Services, Bolton Council Probation Operations Manager National Probation Service (NPS) BSCB Officer Bolton Safeguarding Children Board   1 https://www.gov.uk/government/publications/working-together-to-safeguard-children--2 2http://www.sewsc.org.uk/fileadmin/sewsc/documents/Published_SCR_CPR/Child_Practice_Review_Guidance _-_Welsh_Government.pdf  4  A practice learning event was held and involved many practitioners who had direct experience of engagement with the parents, either in relation to the adoption of SC (their previous child) or following their arrest.  Lines of enquiry Two themes were identified as lines of enquiry by the Learning and Improvement Group.    These were: • To understand what support is available to parents whose birth child is adopted; in particular services or interventions provided to resolve the emotional trauma experienced by parents as a consequence of losing a child to adoption and to what extent preventative work is undertaken to reduce the likelihood of further pregnancies leading to adoption • To understand what led to this couple being so disengaged from universal services and under the radar; to identify any preventative measures that can be taken to reduce the likelihood of future concealed pregnancies  Criminal proceedings and coroner’s inquest It is beyond the scope of his review to examine the circumstances around the court process that led to a lesser charge of concealment of birth.  The coroner has decided that an inquest will not take place.   Family participation in the review The review would have welcomed the participation of family members.  FC, MC and PG were separately invited to contribute to the review process, but they either did not respond or chose not to take part.  MG was unwell and was unable to contribute.  Prior to publication contact was made with FC, MC and PG.  PG and MC responded and a copy of the SCR was shared just prior to publication.    Summary of findings The death of Baby C could not have been predicted.  Concealed pregnancy is rare.  The concealment of a pregnancy, birth and burial by a couple is exceptionally rare but there is a well-established connection between concealment of pregnancy and infant mortality.  During the period of conception, pregnancy, birth and burial the review established that no professionals were actively involved or providing services to this couple.  Therefore, there were no opportunities for practitioners to influence or change the outcome.   The only opportunities that services potentially had to influence later events were in the parents’ earlier interactions in connection with Baby C’s older sibling (SC).  For this reason, and in the commitment to learning lessons from this tragic death, the review panel agreed that there was value in reflecting on practice, systems and processes during care proceedings and adoption planning.  The aim of the review was to consider and identify what services could do now and, in the future, to improve outcomes for children whose parents have previously had children removed.     5  NARRATIVE OF EVENTS Background of parents Both parents have stated to agencies that they had difficult childhoods and experienced inconsistencies in being parented.  Specialist assessments indicated that, since leaving home, MC had been in a violent and controlling relationship with FC.  FC was brought up by his mother, who had periods of ill health.  FC has described periods of foster care and shared his experiences while in care with agencies working with him.  He attended a special school and states he has of a diagnosis of attention deficit hyperactivity disorder.  FC was diagnosed with an emotionally unstable personality disorder when he displayed a clinical risk due to his suicidal ideation and history of self-harm.  Post diagnosis, FC failed to engage with the psychological therapy services offered. He had had no further contact with mental health services until his arrest in respect of Baby C.   MC was brought up by both parents.   Her mother had significant health issues and has lived in a care home for some years. MC was assessed, after arrest, as having a borderline personality disorder.  MC has, over time, made several allegations of abuse, during her childhood and adulthood, to the police. Her changing stories made investigation very difficult and consequently no prosecutions have occurred.    At the time of Baby C’s birth, MC and FC had been in a relationship for a number of years.  At the start of the relationship she was around 18 years old and FC was 28 years old. Agencies viewed FC as violent and emotionally controlling and MC reported incidents of domestic violence to the police. MC’s wider family had no contact with her due to her relationship with FC.  He did not and does not accept that his relationship with MC was abusive.    As in many cases where violence and domestic abuse is present, in this case there were several elements suggestive of coercive and controlling behaviour from FC.  For example, FC controlled the finances and MC was not working or in receipt of benefits.  She had stopped claiming Job Seekers Allowance several months before her pregnancy with Baby C.  MC said that she was not able to go out without FC by her side.    Events surrounding the adoption of SC During her pregnancy with SC, MC booked in and attended routine ante-natal appointments appropriately. She reported suffering from depression but declined any counselling.   It was discovered that she was Rhesus Negative and that this could adversely affect any subsequent pregnancies without preventative treatment. She agreed to this but missed appointments despite contact by letter and several messages being left for her.  She was, however, visited by an outreach midwife and did receive a good level of service.    MC and FC were living between temporary homeless accommodation and the paternal grandmother (PG)’s home at the time of SC’s birth. The midwife was concerned about the lack of care and safety for the child as the parents were sleeping on a sofa at PG’s home and SC was sleeping in a car seat or with them on the sofa. The midwife challenged the appropriateness of the child’s sleeping arrangements and she obtained a Moses basket for him.   The relationship between MC and FC was volatile.  MC reported two incidents of domestic violence to the police, with FC as the perpetrator and she was referred for a Multi-Agency Risk Assessment Conference (MARAC). SC became the subject of a Child Protection Plan (CPP) as he had been injured by FC.  Following the incidents, MC moved into supported housing with SC.  It is improbable that MC truly detached herself from FC.  He was texting her, despite her having been given a new sim 6  card for her mobile phone so that she could avoid contact with him.  Accommodation was sought for her outside Bolton, but she was reluctant to leave the area. FC was hanging around her supported housing, threatening MC and staff.  MC told different stories to different people and stayed away with SC overnight on several occasions, giving unlikely excuses or offering no explanation.  This did not comply with the requirements of her supported housing agreement and was also in breach of the CPP. As a result, SC was placed in foster care.  Following the removal of SC, both parents had contact with him at a contact centre.  The contact officer remembered them as parents who were difficult to engage and whose contact was inconsistent. They were observed as having an air of detachment from SC.  FC disengaged from the assessment process after a few months and had no further contact with SC or services supporting the child.   A few days after FC’s disengagement, MC reported that she and FC had split up after another violent incident and that she had begun a relationship with another male. This new relationship only lasted a few weeks and ended in an incident involving the other male and FC.  SC’s social worker recorded that MC was ambivalent about contact with SC.  She did not always go willingly to contact, and sometimes social workers had to work to persuade her to go.  The social worker, contact workers, housing staff and independent domestic violence workers (IDVA) worked hard to engage with and support MC.  MC’s attachment to SC continued to be poor.    MC was told that the plan for SC would be for adoption.  The same day, she gave away SC’s clothes and toys and left the supported accommodation, telling the social worker not to contact her again. She returned to live with FC and neither then responded to phone calls, texts or letters from the social worker or to communication from the courts. Letters to MC and FC were returned, marked that they had gone away.  Court proceedings continued, and SC was adopted.    The procedures at the time required the social worker to refer birth parents to post adoption services at a later point during the court process, but this was not possible because of their early disengagement.    Consideration was given to the setting up of the letterbox contact service3 which provides a mechanism of communication between birth parents, adoptive parents and children, in the child’s interests.  The way this service is delivered can be seen as offering a degree of support to birth parents, in coming to terms with their new situation.  In this case, early disengagement and lack of response to letters and phone calls meant that it was not possible to set this up.  MC was offered a good level of service by the partner agencies.  They worked together and communicated well to give an appropriate response.    Practitioners at the learning event identified that there was an assumption, from all those working with MC, that she wanted to be a mother and a desire on the part of professionals to see MC succeed as a parent. This is not a unique feature of this case.    On reflection, practitioners identified that MC was ambivalent in her attachment to SC. The learning identified that practitioners should always be open to the possibility that a parent may need permission to verbalise a desire to relinquish their parental responsibilities. It was thought that existing procedures, and the legal process, do not readily support this practice.   3 Letterbox contact is a formal arrangement for birth parents, relatives and the adoptive parents to share information about the child(ren) when and if appropriate. This is a confidential and agreed process made through the court process. 7   The system worked effectively in relation to SC.  The social worker and partners made every effort to support MC to parent SC and to enable her to separate from FC.  The lack of interaction between MC and SC was observed and some acknowledgement from MC, that she was not committed to keeping SC, was obtained at the case conference.  The independent scrutiny of IRO, and the challenge provided, served to ensure that there were no unnecessary delays in making appropriate plans.  Events leading up to the birth and death of Baby C As the parents avoided contact with services during this pregnancy, the information on what happened during this period comes, principally, from the police investigation. It is known that MC was not working or claiming benefits. Records indicate that she was also not registered with a GP practice, only being re-registered after her arrest in respect of Baby C.  FC, however, was claiming benefits throughout the period.   Notes by MC recovered later by the police, detailed significant events and emotions. One of the pages contained a summary of a seven-day period at the time of Baby C’s birth describing how Baby C had been born, then died days later and was buried.  The notes described negative feelings towards the pregnancy. MC stated that the baby had been born with a deformity and would not take breast milk.  MC said, to a witness, that the baby was not fed with formula baby milk because FC would not give her any money.  As part of the investigation, police uncovered CCTV footage which showed MC waiting alone in a public area with Baby C, while FC went into a building. There was a health centre opposite the building, but neither parent sought help for the baby.  CCTV also showed the couple shopping for food and alcohol for themselves but buying nothing for the baby.  When later asked for the name of the baby, MC said that it did not need a name.  She stated that there had been no provision for the baby, and it was ‘just left’.   Some days later FC and MC buried the body and then went shopping.  It was not until about 6 weeks after the death that Baby C’s body was discovered by the police. Expert examination of Baby C showed the baby was small, but well into the third trimester (at approximately 36 to 38 weeks gestation).  Baby C was emaciated and there was a likelihood that death was a result of dehydration after 3 to 4 days of life.  Baby C showed no evidence of injuries or deformities which might have caused death.  Baby C had no stomach contents.   It is difficult to imagine how much Baby C must have suffered during such a short and tragic life. Baby C was unwanted, neglected and left to die by both parents.  The police investigation Some weeks after the death of Baby C, police received a telephone call from a carer for MG. The carer reported that MG had been upset by a telephone call from her daughter, MC.  MC had called to ask for some money.  She had told MG that the reason she had not been in touch for a year was because she had been on drugs and had had a baby who was born at home.  She said that she had given birth and described the baby as deformed.  MC also told MG that she hadn't fed the baby, as it wouldn't take breast milk, and that it had died.  She said that she had buried the baby in a shoebox.   As a result of this information, officers spoke to both MC and FC separately regarding the allegation.  Each expressed surprise, with MC stating that MG was lying and confused. FC stated that he had no idea what the police were talking about and that MC had not recently been pregnant.   8  Police conducted house to house enquiries in the area and spoke with a neighbour.  He had been visited by both MC and FC, who asked him to be quieter as MC was pregnant and needed to sleep. They told the neighbour that they had not told anyone about the pregnancy.   The couple were arrested. After a thorough investigation, FC and MC eventually gave information which led to the discovery of Baby C’s body. Baby C had been buried in a shoebox, in a cemetery near established graves. A search of FC and MC’s home address uncovered handwritten A4 papers and notebooks, which appeared to be written from MC to FC and gave an account of Baby C’s birth and tragically short life.   GMP had conducted a persistent and tenacious investigation.  Without this, the circumstances of the life of Baby C might have never been discovered.  After an initial investigation, where the parents denied that the baby had existed, it was the actions of the supervising officer which led to the discovery of a neighbour who was able to confirm that there had been a pregnancy.  It is to the credit of the police that MG’s allegation prompted a thorough investigation, despite the initial contact being the third-party sharing of a report from a vulnerable adult.    LEARNING FROM PRACTICE  The learning event As part of the SCR process, a practice learning event was held.  The participants included practitioners who either had a history of involvement with the parents in relation to the events leading up to the adoption of SC, or had recent involvement with the parents following their arrest or were able to contribute knowledge about current and past standards of practice and procedures.  The involvement of practitioners at the event proved invaluable in informing the analysis and conclusions that have been arrived at in this review.  The participants were both open and insightful in their contributions.  Analysis and research As MC and FC had disengaged from services prior to the adoption of SC there were no opportunities for services to influence the course of events in the months leading up to the conception of Baby C.  The key issue has, therefore, to be whether anything could have been done to prevent FC and MC’s disengagement or to prevent the pregnancy.  It is not known whether MC’s pregnancy with SC was a wanted pregnancy, or a consequence of the couple’s chaotic lifestyle.  They may have succumbed to societal norms in starting a family.  What is clear is that MC was observed to have a degree of ambivalence to parenthood during the pregnancy and after the birth of SC.     Irrespective of this, the choice of continuing to parent SC was taken out of their hands and this would have prompted an emotional response.  It is likely that they felt embarrassed and hurt and experienced a level of trauma. They were recorded as angry and focused their anger on Children’s Services.   The parents’ relationship Practitioners who worked with MC and FC believe that they had a complex relationship.  Notwithstanding the considerable efforts of all agencies to support MC in separating from FC, she prioritised her relationship with him above her own safety and that of SC. 9   Coercive control  Legislation on coercive control4 was not enacted until after FC and MC had disengaged from services. It is clear that both the police and partner agencies had a good understanding of the nature of this relationship. Partners provided a range of opportunities for MC to be supported, including support for a prosecution for domestic abuse and violence, access to safe accommodation and professional support to separate from FC. The unreliability of MC’s changing accounts, and her leaving the refuge for long periods to be with FC, was indicative of a high level of enmeshment.  An article by Torna Pitman, ‘Living with Coercive Control: Trapped within a Complex Web of Double Standards, Double Binds and Boundary Violations’5, explores the effects on a woman’s behaviour of a coercive relationship and may give some insight into why MC chose to be an active participant in such terrible events,   ‘The effects of coercive control allow an understanding of why women may appear to behave in ways that are unattractive or destructive to herself or others. Although this does not imply that it is acceptable, in the context of her entrapment, it is simply more understandable.’  ‘Why I Stayed/Left – An analysis of Intimate Partner Violence on Social Media’ by Jaclyn Cravens et al6, outlines the conditions which might enable women to leave controlling and abusive relationships.   The first is the woman facing the reality of the abuse, the second is seeking or being offered support, the third is the motivation of protecting children and the fourth is fear of violence.    During the course of the proceedings for SC, and during the pregnancy with Baby C, MC demonstrated a desire to continue and prioritise a relationship with FC.  She did not see his anger, control and violence as an inevitable part of their being together.  She did not present as a person able to face the reality of the abuse she lived with. MC was not ready to accept support to separate.  MC did not form an attachment to SC or Baby C which could have enabled her to prioritise their needs above her need to remain in the relationship. Although FC was violent towards MC, and she did report two incidents to the police, she has said that she is now not afraid of him.  Fear of violence may not have been the primary form of control which he exerted within the relationship.  In his book, ‘Coercive Control’7, Evan Stark outlines strategies other than violence that controlling partners use to maintain control, e.g. threats of self-harm are explored.  Some of these strategies feature in MC’s descriptions of FC’s behaviour.  Concealed pregnancy Research on concealed pregnancy leading to a child death is scant. In a related area, there is research by Vellut et al (2012)8 who looked at child death by neonaticide9 including concealed pregnancy.  The research identified the characteristics of women whose pregnancy resulted in a neonaticide.  Concealment of pregnancy is rare but when it occurs, it is associated with an increased likelihood of infant death.    4 https://www.gov.uk/government/publications/statutory-guidance-framework-controlling-or-coercive-behaviour-in-an-intimate-or-family-relationship 5 https://academic.oup.com/bjsw/article/47/1/143/2622273 6https://www.researchgate.net/publication/283193192_Why_I_StayedLeft_An_Analysis_of_Voices_of_Intimate_Partner_Violence_on_Social_Media 7 Coercive Control: How Men Entrap Women in Personal Life. Evan Stark 2007 8 https://www.ncbi.nlm.nih.gov/pubmed/22858094 9 Neonaticide is the deliberate act of a parent murdering their own child during the first 24 hours of life. 10  ‘Psychopathology was rare, but mothers shared a personality profile marked by immaturity, dependency, weak self-esteem, absence of affective support, psychological isolation and poor communication with partners. No pregnancy was registered, nor prenatal care followed.  Pregnancies were experienced in secrecy, with conflicting feelings of desire and rejection of the infant and an inability to ask for help. Those around the mothers, often aware of the pregnancy offered none.’  This description offers a possible insight into MC’s situation.    What might make a difference?  The deliberate concealment of the pregnancy from all agencies and the subsequent death of Baby C could neither have been predicted nor prevented.  It is therefore only possible for this review to look at potential interventions which would support practice and lessen the likelihood of a similar course of events in the future.   Early intervention MC was identified as a vulnerable first-time parent and considerable effort was made to engage with her, despite difficulties in maintaining contact.  While at the time this represented a good level of service, Bolton, alongside many other local authorities, has adopted the Family Nurse Partnership (FNP) model.  This is an evidence based10 approach to improving the life chances of first-time mothers aged under 20 and their babies, which takes place during pregnancy and up to the child’s second birthday.   It uses an intensive program of visits to promote attachment, health and development, as well as referral to other services as appropriate.    If it had been available at the time, MC would have been eligible, and it is possible that this mentoring could have identified and addressed her attachment issues.  This had the potential to lead to either, an improvement in her care of SC, or discussions leading to an acknowledgment that her relationship with FC was not positive, or that there was no space in their relationship for prioritising a child.  It is possible that skilled work by a Family Nurse, might have been able to build MC’s self-esteem to the extent that she would have been able to see her relationship with FC differently.    However, in this case, it is probable that FC would have presented obstacles to MC’s engagement with this type of service, as it would have undermined his attempts to exert control.    Post adoption support At the time of SC’s adoption, the post adoption counselling service for birth parents in Bolton was provided by Caritas.  This would be offered 5 weeks before the finalising of the proceedings and could be taken up at any point by the birth parents, irrespective of their location.  Birth parents could also self-refer at any time. Although few birth parents take up the offer, some might engage later. If this happened a service would be provided. The services offered are outlined in Bolton’s childcare procedures online11.  Adoption Now, which works across six local authorities, has recently replaced Bolton’s in house, adoption service.  After Adoption are the new providers of post-adoption counselling services.    10 https://www.nice.org.uk/guidance/ph40/documents/social-and-emotional-wellbeing-early-years-expert-report-42  11http://boltonchildcare.proceduresonline.com/chapters/p_adopt_support.html?zoom_highlight=post+adoption+support+for+bith+parents 11  It would seem very unlikely that MC or FC would have been part of the small group who take up this support if the information had reached them, so it is unlikely that this would have made a difference to subsequent events.   The offers that are available nationally to birth parents, mainly focus on helping them through the trauma of losing a child.  Few work with parents specifically to improve their chances of avoiding future pregnancies, which might result in a repeating cycle of removal and the associated trauma.  Those that do this work, for example, the Pause Project12, offer an intensive programme of support for mothers which aims to break this cycle and give women the opportunity to reflect, address destructive patterns of behaviour and develop new skills and responses that could help them to create a more positive future.  It aims to reduce the number of children needing to go into care.  Pause has been independently evaluated by Opcit Research13 who found it to be extremely effective in reducing the number of pregnancies.   Research by Pamela Cox saw the same features in the work of Mpower and Positive Choices14.  These were independent organisations mentoring birth parents, who had already had a child adopted, to encourage better choices in contraception and improve their life circumstances. They work to help birth parents to avoid another pregnancy which may ultimately lead to care proceedings.  This often also involves referral to other agencies, e.g. mental health services.  Not all birth parents would engage. For those that did, the rate of pregnancies leading to care proceedings was substantially reduced. In many cases the desire to parent a child in future was the primary driver.  Work by Karen Broadhurst et al15 found that, if women are prepared to engage with support, resilience can be fostered and functioning improved.  A high level of motivation in wishing for change was evident in successful individuals. Support from a service independent of the local authority that had made a decision to remove a previous child was an essential element.  However, MC did not fit the profile of the women who have successfully engaged with services as she showed an inability to detach from FC. If Pause, or any similar intervention, had been available prior to the conception of Baby C, it is unlikely that it would have been effective in changing the course of events. Nevertheless, the Pause or a similar model, has great potential to change lives and implementing such approaches are an important step towards breaking the cycle for many women who are at risk of repeated pregnancies and removals.   A critical moment in the sequence of events that led to the tragic death of Baby C was his conception by parents who were not ready to have a child.  Pro-active support for these parents in making informed choices about family planning, might have made a difference.  This would have required a proactive approach to them by services that had not been involved in the removal of the previous child.  Neither MC nor FC was in a mindset that would have led them to seek support.   General practitioner services Whether the conception of Baby C was a positive choice, or a consequence of the chaotic lifestyle that MC and FC were living, it was not in MC’s interests to be pregnant at the time. The lack of change in her circumstances meant that it was probable that any child would be removed.     12 http://www.pause.org.uk 13 https://www.gov.uk/government/publications/social-care-pause-programme 14 https://www.essex.ac.uk/research/showcase/can-we-do-more-to-support-birth-mothers-after-their-child-is-taken-into-care 15 https://www.familylaw.co.uk/news_and_comment/recurrent-care-proceedings-part-3-birth-mothers-against-the-odds-turning-points-for-women-who-have-lost-children-to-public-care#.W3xBiuhKhPZ/ 12  Because she had not seen a GP in the months leading up to the conception, she would have received no specific advice.  While there would have been a flag on SC’s GP file indicating his care status, this would have been sent on to a new GP when he went into foster care.  There would therefore have been no indication of MC’s vulnerability to further trauma in the case of a further pregnancy on her GP record.    At the time and currently, there is no automatic system for informing health services about the vulnerability of birth parents to trauma subsequent to the loss of a child through adoption. GPs and other health agencies can remain unaware that birth parents have been through such a difficult process and therefore would potentially be traumatised by a further similar experience.  At the learning event practitioners expressed a view that it was likely that a letter to the GP, highlighting the trauma experienced by the parents and their vulnerability in the event of a repeating cycle, would be responded to pro-actively.  This might have made a difference to the contraceptive advice MC received, and to her subsequent choices, as she was registered with a GP up to the period of the conception of Baby C.   As the GP record is the only one that transfers when a patient moves to another area, this would also address the issue of parents who move from area to area whose new GP would otherwise not be aware of their circumstances and vulnerabilities.    RECOMMENDATIONS The panel makes the following recommendations to the BSCB.  Recommendation 1 The local authority and CCG should consider developing a system of notification letters to the GPs of parents who have experienced the traumatic loss of a child through adoption.  The notification letter should highlight the vulnerability of these parents and invite consideration of appropriate health responses.   Recommendation 2  The local authority should explore the possibility of whether, under the General Data Protection Regulations (GDPR), notification outlining the information the GPs will need to know could be legitimately sent, in the interests of the parents, when consent cannot be obtained.    Recommendation 3  Bolton LSCB should seek re-assurance from the Local Authority that suitable provision is available in the local area to support women who want to break the cycle of repeat pregnancy and care proceedings, and that the provision is evidence-based and of a good standard.    13  AGENCY RESPONSE TO RECOMMENDATIONS RECOMMENDATION RESPONSE Recommendation 1 The local authority and CCG should consider developing a system of notification letters to the GPs of parents who have experienced the traumatic loss of a child through adoption.  The notification letter should highlight the vulnerability of these parents and invite consideration of appropriate health responses.   There are many different reasons why a child may be adopted, and not all are a consequence of parental abuse or neglect.  Bolton Local Authority and Bolton Clinical Commissioning Group have considered this recommendation and agreed a balanced response would be to notify GP’s of parents on occasions where there is a risk of significant harm to a child, for example, where there is a subsequent pregnancy or the parents are regularly caring for a child.     Recommendation 2  The local authority should explore the possibility of whether, under the General Data Protection Regulations (GDPR), notification outlining the information the GPs will need to know could be legitimately sent, in the interests of the parents, when consent cannot be obtained.    Bolton Local Authority have considered this recommendation; however, it would not be proportionate for the GPs of all parents to be routinely notified where a child has been adopted.  The only occasions notification would take place is where parents have consented to information sharing or parental consent is overridden as there is a risk of significant harm to a child or unborn child as recommendation one.   Recommendation 3  Bolton LSCB should seek re-assurance from the Local Authority that suitable provision is available in the local area to support women who want to break the cycle of repeat pregnancy and care proceedings, and that the provision is evidence-based and of a good standard.  The LA have commissioned Family Action PACuk to work with families who lose their children through adoption. This service will be operational as of the 1st October 2019. The services main focus is around coping with the loss of a child; however, this work would also explore the cycle of repeat pregnancy.   The Local Authority holds regular ‘Practice Weeks’ to promote good practice across Children Social Care services.  The learning from this review, the services available and good practice points will be included in the next scheduled session.    Bolton Safeguarding Children Board will write to Family Action PACuk with a copy of the report requesting they ensure the leaning from this review informs the work of the service.    