Death of a 15-week-old boy after feeding from a propped-up bottle sitting in a car seat in October 2015. Cause of death was unascertained. Mother (Child MF) was 15 years old when Child F was born. There was uncertainty as to who the father was. Child MF suffered from back pain, dizziness and lethargy when the baby was about 3 months old; she was struggling to cope with Child F and relied on her family for support. An adult was caring for Child F when he died. A post mortem discovered fractures to both legs which were non-accidental and occurred between 3 and 6 days before death. No person was identified as responsible for the injuries as it was impossible to conclude who was the carer at the time of the injuries. Key learning includes: recognition of underage sex; where the mother is a child, both her and the baby need to be treated as such; the quality of the Child in Need procedure and meetings needs improvement; professional curiosity was lacking and over optimism took place. Recommendations include: to ensure that the LSCB's Child in Need process is operating effectively; to ensure that all agencies working with a child or family record full details of all adults within the household; carry out and complete appropriate and relevant CSE risk assessments; highlight the importance of record keeping; professionals need to be able to recognise disguised compliance and dis-engagements; professional curiosity and healthy scepticism should be included in all levels of safeguarding.
      
 Title:  Serious case review concerning Child F. LSCB: Lincolnshire Safeguarding Children Board Author: Russell Wate Date of publication: 2018  This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC.  This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above.                           1 | P a g e         Serious Case Review concerning Child F                 Independent Author: Dr Russell Wate QPM  March 2018 v 2.0 2 | P a g e   1.0 Introduction 1.1 The key subject of this Serious Case Review is a baby boy (15 weeks at time of death) who will be referred to as Child F.  Child F is of a white British background.  At the time of his death Child F was living with his mother, who for the purpose of this review is called CHILD MF (also a key subject of this review). CHILD MF was 15 years old when Child F was born.   1.3        There was past involvement from Children's Services with CHILD MF. 1.4 On 3rd October 2015 Child F died.  Adult E who is described as Child F’s godmother and a family friend was caring for Child F overnight on the 2nd October 2015 and she stated that he had woken up at about 8 am on the 3rd October 2015 and Adult E gave him a bottle of milk which was propped up to his mouth with a rolled-up blanket. He was in a car seat at the time. She then fell asleep. Adult E further reported that she woke up later (it is not recorded how much later) and she found Child F to be unresponsive to anything she did to try and wake him. An ambulance was called. Child F was not breathing. 1.5       Child F arrived at hospital in cardiac arrest and died, he was pronounced dead at 10:57 am. The appropriate rapid response liaison processes were then followed. Early investigations centred on whether Child F had choked and a post mortem initially stated that there was no specific cause of death and so further tests were commenced.  A referral containing the information around the death of Child F was made to Lincolnshire Children's Services on 3rd October 2015.  This was closed as a referral, as is normal practice on the 5th October 2015. The case for CHILD MF was then re-opened to CSC. 1.6 A Police investigation commenced and as the circumstances of the death were suspicious Adult E was arrested.   1.7       A Post Mortem was carried out by a Forensic Pathologist and the cause of Child F’s death was deemed as unascertained. Injuries were found to his legs which were investigated the conclusions were, that there were fractures to both legs and that these injuries had occurred between 3 and 6 days prior to Child F’s death and were indicative of non-accidental injury. The Forensic Pathologist further concluded that though the fractures would have been very concerning for Child F’s well-being whilst alive and needed investigating, they were not the cause of his death. It must be noted here that Children’s Services were not told about these fractures until April 2016. The reason provided to the review author why this delay took place, is because the police needed clarification from the pathologist as to how the fractures could have occurred and this wasn’t received until March 2016. 1.8 The initial police investigation then became an assault (GBH) investigation and this was concluded with no person identified as being responsible for the injuries to Child F. As there was a large pool of carers it was impossible to conclude who could have been the carer at the time of the injuries. 1.9 As the family were residing in Lincolnshire during Child F’s life Lincolnshire Safeguarding Children Board (LSCB) have completed this Serious Case review.  1.10 The period under review was agreed as around the date of July 2014 (As it was at this time that it was first discovered CHILD MF was having under age sex) to the date of Child F’s death on 3rd October 2015.  Other information outside of the defined period was to be considered and included if identified as relevant or significant to any learning.   The review centres on the following family members. Child F. Referred to only by this name in this review.  3 | P a g e   Relationship to Child F       Name Age at time of the death  Mother of Child F  CHILD MF 15yrs  Assumed father of Child F and previous partner of CHILD MF Young Person A 18yrs  Mother of CHILD MF and maternal grandmother to Child F Adult B 34yrs  Partner of Adult B making him step father of CHILD MF and step grandfather of Child F Adult C 38yrs  Friend of family and son of Adult F and possible father of Child F Adult D 20yrs Family friend and carer of Child F when he died Adult E 39yrs Family friend and mother of Adult D Adult F 49yrs  2.0 Terms of Reference, Contributions and Methodology 2.1 The purpose of this review is to:  Identify improvements which are needed and to consolidate good practice  Translate the findings into a programme of action which leads to sustainable improvements and the prevention of death, serious injury or harm to children.                Agencies were asked to consider the events that occurred, the decisions made and the   actions that were taken or not taken. Where judgements were made or actions taken which indicate that practice or management could be improved, the analysis should aim to provide an understanding of what happened and why.    2.2    The review author and panel asked some specific questions of the agency authors to focus on. These are the key issues that form the specific Terms of Reference for the review.   Was there a Pre-Birth assessment undertaken and was the Pre-Birth protocol followed.  Did all agencies contribute effectively and was the information collated and analysed to identify risk and need?  Was there an effective Pre-birth Plan and was it delivered?  Did the CIN process recognise the separate and individual risk and needs for both children, CHILD MF and Child F? Did the CIN process collate and analyse risk and needs and review them appropriately?  Did agencies have a clear picture of who was supporting and caring for CHILD MF and Child F? 4 | P a g e    How did agencies support CHILD MF in managing her physical health needs whilst she was caring for Child F and meeting his needs?  On the information available to Agencies at the time of closure of the case(s) did agencies have a clear knowledge of the family's vulnerabilities and was the decision to close appropriate?                                 Contributors to the review 2.3       A number of agencies have contributed to this review as follows:  Lincolnshire Partnership NHS Foundation Trust (LPFT)  United Lincolnshire Hospital NHS Trust (ULHT)  Lincolnshire Community Health Services (LCHS)  Lincolnshire Youth Offending Team (YOT)  GP Surgery Lincolnshire  Lincolnshire County Council Children’s Services (CSC)  Schools – Lincolnshire  East Midlands Ambulance Service(EMAS)  Lincolnshire Police                Independent author 2.4 Lincolnshire Safeguarding Children Board commissioned an independent author to carry out the review. The review is supplied by RJW Associates and the lead reviewer is Dr Russell Wate QPM. He is independent of any agency within Lincolnshire.  2.5       The review panel was of great assistance to the review process and the review author in the compiling of this report. The panel was chaired by an independent chair that has had no involvement with this case.               Methodology             2.6        Agencies with any relevant information were asked to provide an Agency Narrative Report (ANR) using a suggested template and including a chronology of significant events. Analysis then took place of the findings and after requests for further information following an ANR presentation day; the report was completed for sharing and presenting to the Lincolnshire Safeguarding Children Board. 3.0 Summary of the case 3.1 This section aims to provide a picture of the lives of Child F and his mother CHILD MF as seen through their interactions with services and professionals from the various agencies.                  Significant Background information 3.2 CHILD MF was known to the Local Authority and other agencies throughout her early years. CHILD MF went missing from home on occasions and was displaying vulnerabilities that raised her risk and was believed to be having underage sex.  3.3         Young Person A spent a number of years as a Looked after Child, with foster parents and went missing on occasions. At the time of Child F’s death, he was in a Youth Offender Institute serving a sentence for an unprovoked knife attack on an innocent person. He played no part in the care of Child F. 5 | P a g e                   Pre-pregnancy information 3.4      On 29th June 2014 Lincolnshire Police were informed anonymously that Young Person A had two young girls in his room. One of the girls was named as CHILD MF. The Police attended the location which was Young Person A’s lodgings but there was no evidence found of the girls having been there. This unconfirmed information was the first connection between Young Person A and CHILD MF.    3.5      On this date it was discovered that CHILD MF had been taken to hospital by her mother Adult B with stomach pains. CHILD MF thought she was pregnant as she had had unprotected sex. due to inconsistencies in the information provided, the Nurse became concerned and made a referral to the customer service centre in CS and informed her school. This information was also shared by the school nurse with CS on 17th July 2014. Child MF had an allocated targeted youth worker due to concerns about her risk-taking behaviour and there was put in place a multi-agency TAC (team around the child) process. 3.6         On 15th July 2014 CHILD MF and her mother Adult B met with a Targeted Youth Worker to discuss problems at home and school.  3.7       On 16th July 2014 CHILD MF attended the Out of Hours Department which is part of Lincolnshire Community Health Services (LCHS) with abdominal pain, thinking she may be pregnant. No questions were asked about the identity or age of CHILD MF’s partner which would have further informed their risk assessment. The School Nursing team were advised and a Nurse from this team followed this up but identified no further action was required. The case was open at this time to Children’s Services. 3.8        On 12th August 2014 a joint home visit was completed by the Family Worker (FWT) and the Targeted Youth Worker (TYW) from Children’s Services and CHILD MF was seen with her mother Adult B. They discussed the behaviour of Adult C and his alleged assaults on CHILD MF.  3.9          CHILD MF attended the Out of Hours Department on 31st August 2014 as she was vomiting and a further pregnancy test carried out, which was negative. The School Nurse was again informed and planned to see CHILD MF at school to offer support and sexual health advice. 3.11     In supervision on 1st September 2014 the Children’s Services Targeted Youth Worker requested an escalation in the level of intervention/service offered to the family due to the increasing risks for CHILD MF. The worker’s supervisor advised that there needed to be a review of the concerns, strengths and what gaps there may be before escalating to Social Care, this occurred on the 8th September using signs of safety mapping.  3.12      On 8th September 2014 CHILD MF disclosed at school, that during an argument, Adult C had put his hands around her throat and shaken her causing her to hit her head against a door frame. This information was then reported to the Police central referral unit (CRU) and a decision was made for a CSC single agency enquiry and the circumstances assessed by an allocated Social Worker. The Police were informed by the Social Worker that an assault had taken place but CHILD MF would not engage with them or make any complaint. There were no visible injuries. A common assault investigation was commenced but was filed with NFA.   3.13 Also on the 8th September 2014 a school visit was completed by a School Nurse following CHILD MF’s recent visits to the Out of Hours Department. CHILD MF stated that she had a 16-year-old boyfriend (Young Person A), he lived in Nottingham and that she saw him at weekends. She went on the train which he paid for and that they did have a sexual relationship which was consensual and they did not use contraception as Young Person A 6 | P a g e   did not like to use condoms. She was referred to the Community Sexual Health Advisor and her GP.  3.14 On 9th September 2014 a Social Worker made a home visit and CHILD MF was not at school and was in bed unwell. The discussion was about the allegation she had made against her step father Adult C. She said she wasn’t in fear of him nor did she want to take it any further but that he had assaulted her as she didn’t want to go to school. The case was allocated for a full Social Care Assessment.  3.15 On 10th September 2014 the School Nurse followed up the school visit with a home visit. The family were seen and no concerns were raised in relation to them. At this visit the School Nurse was not aware of CHILD MF’s disclosure that Adult C had assaulted her so it led to in the view of the LCHS ANR author a missed opportunity for her to have a safeguarding discussion, with Children Service’s. A further visit was arranged and Children’s Services were already doing a section 47 enquiry.   3.16 It was confirmed that CHILD MF and her family had moved home and a new Social Worker was allocated and a transfer summary completed. This highlighted that further work needed completing around school attendance, potential sexual exploitation and relationship building with her mother, also work around her drug use and CHILD MF’s vulnerabilities. This work was carried out by her early help worker. 3.17 On 6th October 2014 the school that CHILD MF was expected to attend in her new area was contacted by LCHS and were told that CHILD MF had not yet enrolled. CHILD MF was no longer at her previous school so had not been in education for a number of weeks.                 Ante natal period 3.18 On 7th October 2014 Children’s Services received information that CHILD MF (14yrs) had had a positive pregnancy test and the father was said to be Young Person A. A CIN meeting was already scheduled. 3.19 Children’s Services completed a home visit on 9th October 2014 and saw CHILD MF with Adults B and C. The pregnancy was discussed and Adult C became aggressive claiming he was going to “kick off” and he was blaming professionals for the situation. He stated he did not want to bring up someone else’s baby. A Family Plan was completed.        3.20 The same day, on 9th October 2014 East Midlands Ambulance Service (EMAS) received an emergency 999 call from CHILD MF reporting that she was 14 weeks pregnant and had been kicked in the stomach. Adult B took over the call and voiced that she was fearful that if the police were called she “would lose all her children”. EMAS dispatched a solo responder to the address who arrived at 9.41 pm. The EMAS control room notified the police due to the concerns around the alleged assault of a child.   3.21       CHILD MF advised the crew that she was pregnant but that she was unsure for how long. Adult B was present and said that she was aware of the pregnancy and the alleged assault. CHILD MF said that she had been pushed in the stomach by her step father which unbalanced her but didn’t cause her to fall. A full clinical assessment was carried out and no injuries were noted. CHILD MF reported that she didn’t have any pain and all tests were normal.   7 | P a g e   3.22     As mentioned the Police were informed via EMAS that CHILD MF had been assaulted by her step father Adult C and that tensions were high at home. Officers attended and it was revealed that CHILD MF was pregnant after completing a positive home test. The attending police officers believed that Children Services were aware and dealing with the family and so did nothing further. (This was an error of judgement and the attending officers have since been interviewed and accept their mistake and learned from it via managerial advice and correct awareness of compliance with policies).                    3.23 On 13th October 2014 CHILD MF was seen by a midwife. CHILD MF was still not at school. Her pregnancy was confirmed on 17th October 2014. On the same day a School Nurse recorded a notification of the 9th October incident. The School Nurse demonstrated persistence in following up concerns by contacting CSC to establish what the outcome of this referral made by EMAS was. The CSC Customer Service Centre are not authorised to share this information, the process is that it would be the SW who would do it, and so contact was made directly with EMAS who communicated the outcome to the School Nurse.  3.24 On 30th October 2014 the respective Social Worker’s for CHILD MF and Young Person A met, and it was revealed that it was not known that Young Person A had visited CHILD MF’s home.  3.25     On 3rd November 2014 it is recorded by Children’s Services that the Social Care Assessment was nearly finished and there was already a plan to move from Team Around the Child (TAC) to CIN. The CIN meeting was set for 13th November 2014. 3.26 On 12th November 2014 CHILD MF told her Social Worker in a meeting regarding the CIN that her relationship with Young Person A was over. She was worried about attending a new school and agreed to a Young Expectant Parents (YEP) group. The Social Care assessment was completed, it included looking at the vulnerabilities listed earlier in this report and concluded that CHILD MF had a difficult relationship with her mother and stepfather.   3.27 On 13th November 2014 the CIN meeting was held. The outcome was that a School Nurse would complete a health assessment of CHILD MF. CHILD MF was due to start her new school on 24th November 2014. A further CIN was set for 2nd December 2014 for a handover to the new Children’s Social Care team. 3.28 On 19th November 2014 a health assessment was completed with CHILD MF by a School Nurse at the school attended by her siblings. CHILD MF was worried about starting at her new school and feared what people would say when they found out she was pregnant. She discussed her new boyfriend who apparently lived across the road but no details of him were obtained. She was assessed as well and healthy. Her home life was more settled.  3.29 On 28th November 2014 CHILD MF attended her first (booking) appointment at the antenatal clinic and was thought to be approximately 14 weeks pregnant. CHILD MF stated there were two potential fathers but the names are not recorded. Child MF was identified as being involved with Social Care at this point. 3.30 On 2nd December 2014 a CIN meeting took place, which was well attended by all agencies. CHILD MF had not been attending school and she was encouraged to do so and also attend the YEP class.  8 | P a g e   3.31 On 5th December 2014 Children’s Services record the information about CHILD MF’s confirmed gestation time and that a family friend who is 19 years old must be the father. It does not state why this is known. 3.32 On 11th December 2014 a Families Working Together (FWT) worker saw CHILD MF and her family at home, as did a Social Worker. All was recorded as well and a note on the file is made that “it has been proven / agreed that Young Person A is not the father of the baby “. 3.33 On 17th December 2014 Children’s Services record that CHILD MF is attending school and making friends. A later note says the opposite as she is seen at home the same day and is off school and feeling down about school. 3.34      On 12th January 2015 a CIN meeting was held. CHILD MF attended and said she was ill and not at school. It was established that her school attendance was only 44% which gave concern. It was felt that CHILD MF was using her pregnancy as an illness to avoid school.   3.35      On 21st January 2015 in supervision the Social Worker was tasked to complete a pre-birth assessment as part of the pre-birth protocol and developing the CIN plan. A Social Worker saw CHILD MF and took her to the YEP class where she completed the second stage of the process. CHILD MF now stated that she wanted home education and she discussed her relationship with this unknown man which was going well.  3.36     On 23rd January 2015 CHILD MF attended hospital with Adult B and an unknown friend for an Ultrasound Scan (USS). The unknown friend is also recorded as an unnamed partner. He was not asked his name.  3.37        On 9th February 2015 a CIN meeting took place and it focussed on CHILD MF not attending school and what was now in place for her education. As she could not develop routines it was of concern that she may not cope when the baby was born and had little comprehension of what life will be like when this happens.   3.38      In mid-February 2015 CHILD MF attended the antenatal assessment centre three times due to abdominal pain and reduced foetal movements. Concerns were raised to the Community Midwifery Manager regarding the Community Midwife’s not referring to Children’s Services at 20 weeks gestation. No clarification could be found that an early help assessment had been undertaken or a referral made for the unborn (it was known that CHILD MF was already involved with Social Care, so rather than an EHA the information should have been passed to Child MF’s SW). (It appeared to have not occurred due to a combination of sick leave and annual leave.) A safeguarding alert was requested to be added to CHILD MF’s patient’s electronic admission system. Also, in mid-February 2015 it was established that CHILD MF was not attending her Young Expectant Parents (YEP) groups and that she was not committed to it.   3.39     On 11th March 2015 a CIN meeting took place. No Health Visitor was present and there were no apologies sent for this. The Midwife attempted to contact the SW to clarify the date of next CIN meeting (as the MW had been informed by the School Nurse that meeting was scheduled for 11/3/15.) The MW received no direct communication from the Social Worker. A Pre-Birth plan WAS to be drawn up with Children’s Services, Health and Midwifery by 24th March 2015. 3.40     On 24th March 2015 Children’s Services completed a pre-birth assessment visit where CHILD MF was present with Adults A and B. A further CIN meeting was planned for 5th May 2015. 9 | P a g e   3.41    On 9th April 2015 the Pre-Birth assessment was completed and it did not identify any safeguarding issues of sufficient concern to move the unborn Child F into Child Protection planning, so it led to a CIN plan 3.42     On 5th May 2015 a CIN meeting was abandoned as the Social Worker failed to attend with no reason given. This was being held at CHILD MF’s school and CHILD MF was seen by the community midwife and was now 34 weeks pregnant. The Midwife was still, at this point, awaiting contact from the SW in relation to the previous CIN meeting, and also confirmation of date for next meeting.  On 14th May 2015 a new Social Worker completed a home visit and CHILD MF was reported as tired and fed up and wanted her baby to be born. 3.43      The CIN meeting was reconvened on 18th May 2015. The meeting attendees had received no updates from the previously held meeting and so were not able to provide any updates to the plan at this meeting. It was agreed that the case would remain at CIN for CHILD MF and Child F (when born) and be reviewed at the next meeting in July. 3.44       On 6th June 2015 Children’s Services were informed that CHILD MF was in labour. The birth plan or written agreement stating Young Person A was not allowed on the ward could not be located by ward staff. CHILD MF was at the maternity ward and was accompanied by her mother Adult B and friend Adult F and Adult F’s son Adult D.  CHILD MF was told she could only have two visitors and Adult D stayed rather than Adult B. It was documented that it appeared that Adult D was in a relationship with CHILD MF but this was denied by Adult D and CHILD MF, both saying they were just good friends. Adult D was recorded as being 20 years old.  CHILD MF gave birth in June 2015. Social Care was informed.               Post-natal period 3.45     On 8th June 2015 CHILD MF was transferred to the postnatal ward and she then informed staff on the ward that Adult D was her partner and CS was informed of this disclosure. There was some confusion in relation to written agreements. Adult B also told the midwife that the Social Worker had said CHILD MF could be discharged without a written agreement being in place. Due to this conflicting information clarification was sought. A member of CS when contacted agreed that CHILD MF and her baby could be discharged without the written agreement (It is disputed by CS that this advice was given and is discussed further in this review). CHILD MF and Child F were discharged. The plan didn’t include a discharge planning meeting so one didn’t take place. (The ULHT ANR author however believes it would have been helpful for one to have taken place, due to the conflicting information. The review author supports that consideration for this should have happened, to ensure all agencies were aware of the CIN plan). 3.46    A CIN meeting was held on 10th June 2015 and it was decided that no further support was required for CHILD MF and the case could be closed but not for another month. It was discussed whether a TAC was needed and the decision was that it wasn’t required, and the family did not want this either, and as in CIN cases, it also needs to be voluntary. 3.47     A postnatal visit was completed by the Community Midwife on 11th June 2015 and CHILD MF and Child F were seen. Child F was feeding and a significant tongue tie was recorded. (There appeared to be no suggestion that the tongue tie was having an adverse impact upon Child F as he was gaining weight appropriately).  Although the midwife undertook a post-natal home visit on the morning of the 11th, she was not made aware of the CIN 10 | P a g e   meeting being held on the afternoon of the 11th (according to their records) and therefore was not in attendance at the meeting. CHILD MF and Child F were seen again on 12th June 2015 by the Community Midwife and no concerns were identified. 3.48      A CIN home visit was completed on 15th June 2015 by a social worker. The SW describes the interaction CHILD MF has with CHILD F as being very positive.  3.49   On 16th June 2015 a further postnatal visit was completed by the Community Midwife and no concerns were identified. CHILD MF was discharged from Midwifery care. 3.50      On 17th June 2015 a Health Visitor made a home visit and CHILD MF and Child F were seen. Contraception was discussed and her emotional well-being showed no concerns. Support was being provided by CHILD MF’s parents.  3.51      CHILD MF attended a Health Visitor appointment with Child F on 22nd June 2015 and he was recorded as progressing appropriately. CHILD MF was accompanied by Adult D whom she described as her partner. Adult D is 20 years old. The Health Visitor did not inform the social worker of this development. 3.52      Child F was taken to the GP surgery on 25th June 2015 and seen by a Nurse Practitioner. He was accompanied by as referred to in the notes mum and nana. The GP Practice document the relationship of the attending adults but not the names (the review author questions how they actually know who is present or able to carry out further checks without the names of people.)  It was a normal examination after Child F had recently been unsettled and was vomiting after feeds.  3.53     A planned closure visit by a Family Support Worker took place on 1st July 2015 and the analysis was that all was really positive and they appeared to be a family unit. CHILD MF was thankful for the support she had received and now wanted to do it on her own. Her siblings however mentioned that CHILD MF and Child F did not live at home but stayed with Adult F across the road.  3.54    There were some continued ongoing issues with Child F’s feeding which involved visits to the GP surgery and on 9th July 2015 Child F was taken there by a male recorded as being Child F’s dad. No detail of him are asked or known. (The review author questions this practice and the assumptions made that this male person had parental responsibility.)  3.55     A CIN meeting took place on 13th July 2015. It was reported that there had been no contact with Young Person A and he had not tried to make any contact with CHILD MF. His name was not on Child F’s birth certificate as father. CHILD MF stated that she wanted to resume her education and Adult B would look after Child F when she went to school. CHILD MF was now taking the pill and she denied that Adult D was her boyfriend. She claimed they were just good friends and Adult B stated she had no concerns about Adult D. It was agreed that Children’s Services would undertake an assessment of Adult D to see if he posed any risk to CHILD MF. If no concerns were raised then the case was to be closed. 3.56      On 29th July 2015 a social worker completed a home visit and recorded all was well with CHILD MF and Child F. CHILD MF again denied that Adult D was her boyfriend. The following day Children’s Services looked to close all of their services to CHILD MF and her family. Universal services were of course still in place. 11 | P a g e   3.57     On 4th August 2015 CHILD MF failed to attend her 8-week post-natal appointment and did not take Child F for his first vaccinations. A further appointment was made. It is not known why she did not attend or whether it was ever questioned with her. 3.58      Children’s Services closed the case on 14th August 2015. It was considered that CHILD MF was positive and caring for Child F and did not need support. CHILD MF however was still a 15-year-old mother who could be seen as vulnerable; accepting the fact that age alone may not be a sole reason for her being vulnerable no assessment had taken place of her new boyfriend which had been an agreed action at the last CIN meeting. 3.59     On 3rd September 2015 CHILD MF failed to attend her post-natal appointment. She attended the GP surgery the following day feeling dizzy and lethargic.  3.60    Throughout September and early October 2015 CHILD MF attended her GP surgery a number of times suffering with back pains, dizziness and feeling lethargic. She was prescribed medication and a course of physiotherapy. Due to the pain she was in she was now finding it difficult to look after Child F and various family members were now looking after him. This information was not known at the time to agencies.               Period at death 3.61    CHILD MF was struggling to cope with Child F and feeling that she had relied on her family too much for support (it is fully accepted by the review author that agencies were not made aware of this struggling to cope by CHILD MF) on 2nd October 2015 she asked Adult E to look after Child F through to 7th October 2015. Child F was taken to Adult E’s address and left in her care with his car seat/travel system combo. Adult E put Child F to sleep in the reclined car seat and woke in the night to feed him. She propped a bottle of milk up with a blanket so that she did not need to hold it whilst he fed. She then fell back to sleep and woke up, now 3rd October 2015 to find that Child F wasn’t breathing. An ambulance was called. On its arrival, the crew found Child F was not breathing and had no respirations, nor pulse. Cardiac monitoring was applied which read asystole (the absence of any heartbeat). CPR was taken over by the paramedics and Child F left in the ambulance and was taken to Lincoln County Hospital who had been pre-alerted. 3.62    Child F arrived at hospital in cardiac arrest. Further resuscitation was attempted; however, the decision was taken to discontinue resuscitation and he was pronounced dead at 10.57 am. The appropriate liaison processes were then followed. Early investigations centred on whether Child F had choked and a post mortem initially said there was no specific cause of death and so further tests were commenced. Adult E was arrested for the murder of Child F. 3.63   A post Mortem was carried out by a Forensic Pathologist and Child F’s death was still deemed as unascertained. Injuries were found to his legs, with the conclusion that there were fractures to both femoral condyles, and that these injuries had occurred between 3 and 6 days prior to Child F’s death. They were also indicative of being caused by non-accidental injury. The Forensic Pathologist further concluded that though the fractures were concerning for Child F’s well-being whilst he was alive and needed investigating as to who caused the injuries, they were not the cause of his death. 3.64    A referral containing the information around the death of Child F was made to Lincolnshire Children's Services on 3rd October 2015.  This was noted to have been closed as a referral on 5th October 2015 (In line with policy). The case for CHILD MF was then re-opened to Children Services. 12 | P a g e   3.65      As already mentioned earlier the police investigation moved from a murder investigation to one of serious assault after the results of the post mortem, and as a result Adult E was not investigated further for blame around Child F’s death. It was eventually concluded with no person identified (due to a wide pool of possible carers) as being responsible for the injuries to Child F’s legs and the case has been filed pending any fresh information.               Period post death       3.66      Information that has transpired now is that CHILD MF and Adult D had lived together during her pregnancy with Child F and Adult D was claiming to be the father of Child F.   Adult D states that he, CHILD MF and Child F moved into his mother's home straight from hospital after Child F's birth and so he was clearly involved more than professionals knew. Both CHILD MF and Adult B misled the Social Worker and Early Help Worker regarding where CHILD MF and Child F were living at the time of the closure in August 15.   4.0    Analysis of significant safeguarding events             This analysis includes where possible the response to the challenges and questions that the SCR panel and review author set for the ANR authors.                Pre-pregnancy information  4.1        There was no recognised assessment in relation to CHILD MF having underage sex. The first information existed in June 2014 when the police were notified that Child MF was one of the girls visiting Young Person A, and then through health visits later that summer.  A later opportunity is where intelligence was received by the Police Divisional Intelligence Unit (DIU) on the 4th February 2015 about CHILD MF who was 15 years old, being pregnant and this was passed through to the CRU, who correctly forwards it on to CS. Unfortunately, it was not picked up that this was information which may have resulted in a crime. It appears that both the staff members in the DIU and the CRU thought the other was assessing the information. It has been accepted that this information was missed and so a crime report was never raised. A dip sample of submissions and referrals has taken place and Lincolnshire Police are confident that the CRU team are now more proficient and accurate in this area of assessment and that this was a one off.   4.2       There is record of consideration by professionals that CHILD MF maybe vulnerable to, or at risk, of child sexual exploitation (CSE). On the 22nd September 2014 in planned Supervision between Deputy Named Nurse and School Nurse, the School Nurse was advised to complete work regarding the risks of child sexual exploitation and ensure this was handed over to the new school nurse team. So, consideration was given but not executed. (This reflects the recommendation from the LCHS ANR for follow up of all staff to have completed the LSCB CSE training). The Signs of Safety mapping identified vulnerabilities and risks. The LSCB CSE risk assessment was completed by a Children’s Services worker in November 2014, this scored as medium risk.   4.3        A TAC meeting was arranged for early September 2014 by the school due to mounting concerns that they had and invites were made to the appropriate professionals. CHILD MF had moved schools after difficulties at her previous school. She failed to attend on a number of occasions and Adult B would contact the school to inform them, the school felt that CHILD MF’s truancy was a result of unclear boundaries and Adult B’s inability to apply appropriate sanctions. A date of 24th September was eventually agreed upon but this never occurred as the family had moved and CHILD MF would no longer be attending that 13 | P a g e   school. This information was sent to the TAC administration team and it would appear that no TAC meeting ever took place as CHILD MF started at her new school on 24th November 2014 (CHILD MF had been seen by the School Nurse at the school attended by her siblings on 19th November 2014 for a health assessment) and they had no record that she was at TAC status. This information should have been shared by the schools.  4.4       The communication of the discussion (which took place by LCHS’s Deputy Named Nurse for safeguarding (DNN) following CHILD MF’s disclosure of an assault by Adult C) was not seen by the School Nurse until after a home visit had been made on 10th September 2014. After a review of the records it shows that the DNN sent a task to the School Nurse informing her of the incident and the decision to proceed with a Section 47 investigation. Due to the School Nurse not seeing this task until completing the records after the home visit to the family on 10th September 2014, the School Nurse was not able to discuss any concerns with the family or liaise with the Social Worker prior to contact. Due to this above information not being known, it is clear to the review author that the School Nurse had a missed opportunity to discuss with CHILD MF and Adult B the risk posed by Adult C at the time of the home visit.  The review author has been made aware that actions have since been adopted by the LCHS to send all such tasks to the LCHS 0 -19 Team task message box with an urgent red flag attached. It has been agreed that the Team task boxes are checked daily to ensure urgent tasks are responded to in a timely manner and named professionals notified. This will ensure that this doesn’t happen in the future.  4.5        During CHILD MF’s two attendances to the Accident and Emergency Department it is noted that there was a lack of documentation to suggest further exploration of the reason(s) for presenting. It is expected that there would be documentation pertaining to this within the attendance records and that safeguarding of CHILD MF should have been considered. There is no documented evidence of any liaison with Social Care following either attendance or any enquiries relating to whether CHILD MF was known to Social Care at that time.                Ante natal period 4.6 There were concerns highlighted about possible contact from Young Person A, the possible father of Child F. The family were aware that he was not to be in contact, Young Person A made limited contact prior to the birth. He was at the family home on one occasion during the Social Care Assessment of CHILD MF’s pregnancy.  CHILD MF initially said that Young Person A was the father, but when the pregnancy was properly dated she said that these dates confirmed that he could not be the father.   4.7 CHILD MF’s pregnancy and her vulnerability further came to light on 9th October 2014 when Lincolnshire Police attended the incident after a notification by EMAS. It has been recognised by the Lincolnshire Police that they did not address issues relating to CHILD MF’s pregnancy and situation and this was a missed opportunity.  (In 2014 a system called Stop Abuse was introduced within Lincolnshire Police which allows any officer or staff member who, for whatever reason, has any concerns or doubts about children or adult safeguarding or domestic abuse to press a button and activate a simple form. This form once completed is automatically sent to the Central Referral Unit for assessment and onward referral. This has given staff more confidence in referring incidents which they otherwise may not have. On 9th October 2014, the system was not fully embedded and there was still a need for professional judgement to be made at the time by the officers attending and not all of them used the Stop Abuse system. Now it is wholly embedded and 14 | P a g e   used as a natural process of the officer’s assessments at relevant incidents. This is a system that Lincolnshire police have adopted to try and prevent any missed opportunities in relation to safeguarding.)  4.8      CHILD MF was supported in education by her school when she did attend. Families Working Together and Early Help worked closely with CHILD MF and her family. CHILD MF attended the Young Expectant Parents Group (attendance though was very variable) and the issues of unassessed risk from Young Person A were noted.  CHILD MF and the wider family appeared to accept and work with these workers generally well, and at the closure expressed particular appreciation to the Families Working Together and Early Help worker. The review author feels the actions taken are a demonstration of good practice.  CHILD MF did not attend all the Young Expectant Parents Group on all occasions but was assisted to work through the material in different ways, to the point where it is described as completed by the point of closure by Early Help. CHILD MF, it was hoped, would return to education in September 2015 and Adult B made it clear that she would care for Child F whilst this happened.    4.9     The rest of the Pre-birth protocol was not used as it was felt by CS that it was not needed from the indications from the Social Care Assessment. There were however, many vulnerabilities that would indicate consideration for pre-birth protocol to be followed by professionals from the different agencies (young age of CHILD MF, her poor childhood experiences, long history of CS involvement, CHILD MF vulnerable to CSA, chaotic household: domestic abuse, criminality, mental health concerns etc). There was never a suggestion that CHILD MF would not care for her own son and needed some support for her and the family over the next few months as the pregnancy came to an end and her baby was born.   This assessment though was not complete as there was no information from CHILD MF’s GP surgery in this assessment, as no request for information had been made (it is accepted that CS do not always seek information from GP’s in relation to Social Care Assessments but might have been useful in this case). Neither was any information recorded from other health agencies or education so a complete account was not obtained. There was no assessment of Adult B and whether she would be able to cope with another child in the household. Bearing in mind her own children were at this time being supported by CS.   4.10    CHILD MF attended her routine antenatal care appointments as expected and only failed to attend one appointment with the Community Midwife, claiming that she had forgotten. This was rearranged and CHILD MF subsequently attended. There were some inconsistencies noted from the documentation in CHILD MF’s maternity records with regard to who accompanied CHILD MF to her appointments. At some appointments, the names of who accompanied CHILD MF was documented, however, at other appointments it was documented that CHILD MF was accompanied by a ‘family friend’, ‘cousin’ or ‘partner’ and there is no evidence that the Midwife used professional curiosity to ascertain the identity of these people. Local learning implemented from reviews recently undertaken, requires midwifery staff to document the identities of adults accompanying children and young people to their health appointments. CHILD MF’s attendances occurred at the time that this new process was being implemented and therefore would not have been fully embedded; however, should CHILD MF attend in similar circumstances today, one would expect the documentation to more fully reflect those in attendance.   4.11 CHILD MF sought appropriate care from the Antenatal Assessment Unit on several occasions during February 2015. There is documented evidence of effective liaison 15 | P a g e   between hospital-based Midwives, Community Midwives and Social Care at this time. Although the majority of the documentation does evidence effective liaison, challenges relating to communication were noted on one occasion due to a change in CHILD MF’s Social Worker and the allocated Community Midwife being on long term sick leave. This resulted in a lack of clarity regarding whether a referral for CHILD MF’s unborn child had been made to Children’s Services at 20 weeks’ gestation as would have been expected. Appropriate escalation to the Community Midwifery Manager was noted in order to address these challenges. The review author has been told that such information is now held centrally within a Safeguarding Database, which is accessible to all Midwifery and Neonatal staff.  4.12      At the booking appointment it was documented CHILD MF had disclosed that there were two potential fathers to her unborn child, however, no details were recorded in respect of this in CHILD MF’s maternity records. It would be expected that the midwife would use professional curiosity to ascertain details regarding both males which would include their name, age and their history, including any potential substance misuse, criminal history and Social Care history and communicate this information to the relevant agencies.  4.13       CHILD MF failed to attend a number of appointments at the GP surgery and these are referred to as DNAs (did not attend). The practice “did not attend” policy states, “Where a child repeatedly DNAs this should be considered under child protection procedures as it may be a sign of neglect”.  CHILD MF did have several DNA’s recorded on her notes however the GP felt that as CHILD MF was almost 16 she was aware of the consequences of her actions and so they took action to address this directly with her. (Child F only missed one appointment, for his 8-week check and this was followed up).  At no time did any clinicians at the surgery feel there were any safeguarding concerns regarding Child F or CHILD MF. The review author fully accepts that CHILD MF was from the information he has been given, Gillick competent and the surgery carried out the Fraser guidelines1 in relation to her sexual health, however he does feel that CHILD MF was still a child and at times extremely vulnerable.   4.14 When a child transfers to another service or area, all safeguarding concerns including plans should be discussed and relevant information shared appropriately. There is some evidence of this with the schools. There was also a handover in Children Services and the social worker in the previous team kept the case for a while after the family had moved.                 4.15 The contacts made to some of the agencies did not identify who some of CHILD MF’s male partners were. The Biennial Analysis Report of Serious Case Reviews (Brandon et al 2009) highlighted this as a theme:                   “The failure to know about or take account of men in the household was a theme in a number of serious case reviews. Assessments and support plans tended to focus on the mother’s problems in caring for her children and paid little attention to the men in the household and the risks of harm they might pose to the children given histories of domestic violence or allegations of or convictions for sexual abuse.2” (Brandon et al, 2009). This is clearly relevant in CHILD F & MF’s case. Various professionals never asked or enquired who                                                            1 Gillick competency and Fraser guidelines refer to a legal case which looked specifically at whether doctors should be able to give contraceptive advice or treatment to under 16-year-olds without parental consent. But since then, they have been more widely used to help assess whether a child has the maturity to make their own decisions and to understand the implications of those decisions. 2 Brandon M et al (2009), ‘Analysing serious case reviews and their impact’. A biennial analysis of serious case reviews 2005-2007’. Nottingham, DCSF publications. 16 | P a g e   the male partners were and assumptions were made that they were the father or other person with care responsibility.     4.16 As already highlighted a recommendation from other Serious Case Reviews in the area, is that the names and relationships of all adults attending medical appointments with children should be sought and documented. This did not occur on various occasions. Emergency Departments and GP and Health systems should require these details to be inputted as a mandatory field. It is recognised as vital and particular good practice for Health Visitors to obtain the name and date of birth of any new partners who play a significant role in a child’s life. There is already a section within the Emergency Department record system that is involved in this SCR that highlights for staff to identify who a patient is accompanied by. The requirement to add names of those in attendance is also written into this Trusts policy. The use of this facility is audited on a quarterly basis. Consideration should be made for this audit at times being shared with the LSCB.   4.17   During the time that CHILD MF attended hospital for the induction of labour, it was documented that CHILD MF was accompanied by her Mother, a family friend (Adult F) and Adult D. Adult D supported CHILD MF throughout her labour and the nature of their relationship was questioned by Midwives in view of him being 20 years of age. Any intimate relationship was denied between CHILD MF and Adult D which has transpired to be untrue. Again, there should have been further professional curiosity as to why CHILD MF chose Adult D to accompany her through her labour.               Post-natal period 4.18 Initially, Social Care were requesting that CHILD MF and Child F remained in hospital overnight to allow for Written Agreements to be created with CHILD MF and her family, however the nature of the Written Agreements is not clarified in any documentation. A decision was made for CHILD MF to be discharged home without any Written Agreements in place or a discharge planning meeting being held. Discharge planning meetings would not routinely be convened for cases managed at Child in Need unless there were any identified complicating factors, but in view of the information known regarding CHILD MF’s relationship with Adult D, the Midwife should have given consideration to discussing with Social Care whether a discharge planning meeting would be justified in this instance.  4.19    CHILD MF and Child F have been allocated the same Social Worker which is believed not to be common practice when both children are open to Social Care. This can impact on safeguarding each child as individuals, with the needs in particular of the mother outweighing the looking at their child’s individual safeguarding needs. However, there is no evidence that there were any conflicts with only having one social worker in this case actually having a detrimental impact.  4.20      At a Child in Need meeting on 13th July 2015 the attendees heard that CHILD MF was doing well in caring for Child F and there was agreement that the Child in Need Plans were no longer needed. There is however, no evidence in either CHILD MF’s or in fact Child F’s GP record that any members of the GP practice team were notified about CIN meetings or any CIN plan. As a result, there was never any GP information at the CIN meetings. The family declined a TAC. The attendees at this meeting are recorded as the family with only two professionals, being an Advanced Practitioner for Social Care on behalf of the Social Worker and a Health Visitor, who was not Child F’s Health Visitor. The Social Worker for the case was not present. These two professionals had limited knowledge of the case yet still made the decision to close it down. The review author questions whether this was an 17 | P a g e   appropriate action, although does accept that there was further supervision between the social worker and their supervisor on the 30th July that reinforced that the closure was appropriate.    4.21 At the point of the closure CHILD MF was reporting that she is at home with her family, that she is managing well and enjoying being a mum, that her mother was available for support (albeit that CHILD MF said she did not need this support from her mother).  The stepfather Adult C had been witnessed as interacting well with Child F and no longer said that CHILD MF and her baby would need to leave.  As such, Children’s Services believed that they did have a clear picture of who was supporting and caring for CHILD MF and Child F but the review process has revealed a different picture as the information they had was not accurate. Given the information available to Children's Services at the time of closure, it can be seen as safe practice, but it is arguable that there were no outstanding identified needs for either CHILD MF or her baby.  However, the quality of this decision could be open to question given the family history and CHILD MF's young age as a new parent, leaving the case open for a longer period of time and supporting CHILD MF to access community resources may have been better practice, and also ensuring that an assessment of the new partner was completed.  The review author would like to stress that this view is purely specific to this case. The closure of cases in general is a lot more sophisticated than taking this case as an indication of what should happen in all cases. This must be left to the judgement of the social worker in the case, their supervisor and their partners working on the case.  4.22      The information regarding CHILD MF and Child F having moved across the road to Adult D and F’s house was mentioned to the Families Working Together (FWT) worker by CHILD MF's siblings at their closure visit on 1st July 2015, CS were also aware by the information passed to them from the midwife that CHILD MF was in a relationship with Adult D. It is recorded that this information was emailed to the Social Worker. There is no corresponding record in CHILD MF or Child F's CS records. The Social Worker has reported that this information was followed up during a further visit by the advanced practitioner (not Child F or CHILD MF’s SW) and was denied by Adult B and CHILD MF but there is no record made of the visit. The question also wasn’t asked of why Adult D was present at the birth of Child F. The siblings were never spoken to further about this information which may have been beneficial to do so, notwithstanding that CHILD MF and Adult B denied this information and this was accepted on face value. It is now clear this was CHILD MF and Adult B showing disguised compliance. This action by CHILD MF and Adult B fit what Brandon (2008) describes in her research as “Apparent or disguised cooperation from parents often prevented or delayed understanding of the severity of harm to the child and cases drifted. Where parents ...engineered the focus away from allegations of harm, children went unseen and unheard.” (Brandon et al, 2008)3.  If it had been confirmed, the new situation would have been considered and may have led to the case remaining open for longer. Analysis of this therefore is that whilst not recorded, the SW did follow up this information and as it was denied it went no further. The SW has retrospectively reported to the review that the matter was followed up appropriately.  Although the review author fully understands the thoughts of the SW, it is definitely poor record keeping and showed an apparent lack of professional curiosity as it would appear that the information provided by the children was correct, as was discovered later. It was an opportunity missed by CS to                                                            3 Brandon, M. et al. (2008a) Analysing child deaths and serious injury through abuse and neglect: what can we learn? A biennial analysis of serious case reviews 2003-2005. Research Brief DCSF-RB023 London: Department for Education and Skills (DfES). 18 | P a g e   look at the implications of the move and assess why CHILD MF and the adults were covering it up. This shows a lack of professional curiosity to this disguised compliance. Lord Laming (2003) suggested social workers needed to practice “respectful uncertainty”, applying critical evaluation to any information they receive and maintaining an open mind.4 4.23      At a closure visit on 29th July 2015 CHILD MF is recorded as saying to the Social Worker that she has no boyfriend at present. The Social Worker asked who "the male" was that attended CHILD MF's health appointment and if she was involved with him. CHILD MF stated that he was a friend and that was all. Professional curiosity should have taken place and this would probably have established that he was Adult D (who was 20yrs old), and whom we now know CHILD MF was living with. 4.24      Looking at the Child in Need (CIN) plans that were in place for CHILD MF and Child F.  There were gaps in the timely running of Child in Need meetings and the recording of these and poor distribution of the minutes. Meetings did not take place when they should have done and there were breakdowns in communication such as the Community Midwife not being aware of nor invited to certain meetings. One such meeting had to be abandoned because of non-attendance of the social worker. It is not right to say on the strength of looking at this one case that improvement in the CIN process is required, however it is important that LSCB seek assurance that it is working effectively via for example an audit.  4.25 Health Visitors completed the primary birth and 6-week assessment within the timescales expected. The 3 to 4-month Health Visitor contact did not take place and no additional contacts made which would be expected for a family with these identified vulnerabilities.  However, the HV responsibilities though were not fully completed or multi-agency working not fully carried out for example by attendance at meetings and liaison with other health and/or outside agencies. It is believed by the ANR author and the review author that an enhanced level of contact was not provided to an identified vulnerable mother (a child herself) with a young baby in order to enable her to make the required assessments and analyse and act upon concerns identified. Records do not reflect an assimilation of the history of concerns regarding CHILD MF, to inform the risk assessment following any visits for either the primary birth contact or 6-week assessment.         4.26       The Health Visitor team leader did not allocate CHILD MF and her unborn baby a named Health Visitor and complete their part of the pre-birth assessments however the review author has been informed that this has been addressed. All referrals for antenatal care requiring an appointment by the Health Visitor are recorded within the patient’s electronic record following midwifery referral via Child Health. All referrals are screened by the Team Manager to ensure even where staffing capacity issues are present pregnant women with identified vulnerabilities received antenatal assessment from a named Health Visitor. This ensures the required responsibilities to LSCB Pre-Birth protocol are identified and completed. Whilst acknowledgement in this case is that the LSCB Pre-Birth protocol was not followed as a result of the incomplete pre-birth assessment by the SW, LCHS has ensured that this is embedded in practice within the organisation and would be able to demonstrate this via internal audit. This demonstrates really good and prompt learning from this SCR process.              Period at death                                                            4 Laming, Lord, (2003) The Victoria Climbie inquiry: report of an inquiry by Lord Laming (PDF). Norwich: TSO P205. 19 | P a g e     4.27    With regard to the carer at the time of Child F’s death, Adult E, there is nothing in the records to suggest that she was actively involved in caring for Child F until a description of this arrangement is provided at the time of his death.  At such there was no opportunity to analyse if there were risks inherent in such arrangements.           5.0  Family perspective.              5.1    Neither CHILD MF nor her mother Adult B have taken up the review authors offer during the writing of the review to speak to them and hear their views. There are other parallel processes taking place that make this understandable.  At the inquest they did speak to him.  They had seen the draft SCR and had a chance to read it extensively. They were pleased that the review highlighted the risk factors with bottle prop feeding and being put to sleep in a car seat. They also wanted included the risk factor of sleeping with a baby on a sofa (This was information given by Adult E when giving evidence at the inquest but was unknown to the review) in particular whilst under the influence of drink or drugs that included prescription drugs. They felt that fact the Child F could have had his own SW and separate CIN plan wasn’t explained and in hindsight may have wanted this but still didn’t want it for CHILD MF. The review author has contacted CHILD MF further but no further information has been forthcoming.        6.0     Conclusion         6.1    The above commentary and analysis shows what happened during the period set for the review and at previous significant times.  Conclusions have been made and there are some lessons to be learned in relation to the way safeguarding and promoting the welfare of children could improve. Instances of good practice have been highlighted in the report.          6.2    The review has recognised a number of themes for learning that have arisen from the analysis, and where possible answering the questions posed to the ANR authors. These were: following the Pre-Birth assessment being undertaken was the Pre-Birth protocol followed?  Did all agencies contribute effectively and was the information collated and analysed to identify risk and need?  Was there an effective Pre-birth Plan and was it delivered?  Did the CIN process recognise the separate and individual risk and needs for both children, CHILD MF and Child F? Did the CIN process collate and analyse risk and needs and review them appropriately? Did agencies have a clear picture of who was supporting and caring for CHILD MF and Child F? How did agencies support CHILD MF in managing her physical Health needs whilst she was caring for Child F and meeting his needs?       6.3          Looking at the above questions and taking account of the analysis the following themes for learning are as follows:  Key Learning Themes   Recognition of underage sex;   Where the mother is a child both her and the baby need to be treated as such;   The Pre-birth assessment was not to the appropriate depth required;   The quality of the CIN procedure and meetings in this case needs improvement;  Professional curiosity was lacking and over optimism took place;  The lack of assessments of known males;   Poor record keeping at times was revealed.  20 | P a g e    6.4 During the summer of 2014, when CHILD MF was 14yrs old, it was clear that she was engaging in underage sex.  There was no real exploration provided to the review of who this was with, and whether CHILD MF maybe subject to child sexual abuse or sexual exploitation. It is fully accepted by the review author that the FWT and targeted youth worker did as is mentioned earlier some good work with CHILD MF and believe some of this would have taken place during this time. The Family Education Trust have published a book ‘Unprotected’ by Norman Wells (20175) which strongly suggests that agencies and professionals are normalising underage sex and undermining the age of consent. The learning from this publication is in particular important learning for this review and should be acted on by all agencies.  6.5        There are a number of examples when CHILD MF was not treated as a child; an example of this is the sexual activity as described in this review. There was no real examination of her as a vulnerable 15yrs old, the Social work assessment which closed at the beginning of April does however look at how she will cope as a mother. There was also some work done with her relating to risks and impact. It was not known by most if not all agencies at the time of how she was really struggling as a child mother, in the months after birth and in particular the period before Child F dies. During this period family members and friends were looking after Child F as CHILD MF was struggling so much, this though was not shared with agencies that had made it clear to CHILD MF that they were there to support her. This seems to demonstrate how life was like for this child at this time, albeit agency records portray a different picture to what reality was really like. The GP records do show how much in pain she was and as a result struggling to cope. 6.6       CHILD MF had become more vulnerable during the period from leaving the home family unit to living with Adult D and Child F at a separate address (which the siblings had already told a worker, and we now know in hindsight both CHILD MF and Adult B agree this happened). It was clearly during that period that she found it so difficult to cope she asked Adult E, for her help. It was agreed that Adult E would take care of Child F for that five-day period to give CHILD MF a break and it was during that time that Child F tragically died. This highlights how difficult CHILD MF was finding coping as a mother. There appeared to be a lack of consideration of the fact she was likely to be struggling given the quality of her own parenting and her environment and no attempt to analyse reality as opposed to what was being said by CHILD MF and her mother, who clearly were showing disguised compliance. 6.7       As already stated in the review, the author’s view is that Child F should have stayed on a CIN plan. The review author has also already stated that this is his view specific to this case and not CIN plan closure in general. There is little separation from activity with his mother to treating him as an individual child. Both having the same SW is an indication of this. What was life like for Child F during this period; although not a causation of his death he suffered broken legs which due to his age were highly likely to be non-accidental injury. The moving around all of these friends and family members could not be settling for him, hence him not sleeping at night. The bottle prop feeding and sleeping in a car seat (albeit reclining) is not recommended by research. 6.8       A Pre-Birth assessment took place and was completed on 9th April 2015. This covered the period from 5th February 2015 to 2nd April 2015. The review author considers this assessment to be incomplete. There was information available about risks and vulnerabilities retained in other agencies in particular education, health agencies and for example the GP, which had not been sought or included.  There is no assessment of Adult B                                                            5 Wells N (2017) ‘Unprotected’ ‘How the normalisation of underage sex is exposing children and young people to the risk of sexual exploitation’ Family Education Trust, Middlesex. 21 | P a g e   and the fact that all of her children had been subject to CIN and CPP plans in the past. No assessment of the males involved. The LSCB pre-birth protocol wasn’t followed to the depth required as further information seeking in particular from health agencies should have taken place.  6.9  When CHILD MF was pregnant with Child F the agencies mainly knew where she was and that her mother was the support for her. After Child F’s birth some agencies, such as the police, attended no further incidents (Child F’s death aside) and thus had no cause to monitor their whereabouts. However, what came to light through the subsequent investigations (albeit looking back in hindsight) was that the family was anything but supported and CHILD MF and Adult D were finding it very difficult to understand and deal with their roles as parents. The review author feels the multi-agency partnership lost close contact with CHILD MF, Adult B and Child F and did not identify the risks at the very time when they were at their most vulnerable. The CIN plan is what could have done this. Agencies at the time of Child F’s death did not have a clear picture and possession of all the information some which was available to some agencies and some information that was concealed by the family.  6.10      During the CIN process, there were five different Social Workers identified to have been allocated and present at the meetings. Once the family moved, there was a lack of continuity of care by the School Nursing team with two different nurses being involved, neither of whom received the transfer information from the previous team. This information was present in Child MF’s record and could have been reviewed by the new area SN team.    6.11   There was also a lack of professional curiosity demonstrated by professionals across the agencies, on numerous occasions, whether it was finding out who the males were that were in contact and close to the family or earlier on who CHILD MF was having underage sex with. There was a shortfall in this professional curiosity around this family when the Social Worker did not record the visit where the information was checked regarding whether CHILD MF and Child F had moved to a neighbour’s house across the road. They did not further check with the siblings who had given the information in the first place or pursue the matter further. Another example is following the receipt of the Child in Need documentation at the GP’s practice which gave a different surname and date of birth for CHILD MF, should have prompted the GP practice to follow up with the issuing agency to clarify the information is correct.  6.12   This review has highlighted numerous occasions when recording of information or the sharing of information was not completed correctly: for example, the visit as mentioned by the SW in the previous paragraph or the information not passed to the School Nurse when she has done her home visit about the assault on CHILD MF. (As already mentioned earlier in the review action has already been taken that has resolved this as an issue). Information should also have been shared when the radiologist and pathologist first suspected (October 2015) there was a possibility of fractures to Child F’s legs rather than when confirmed in March/April 2016. 6.13    The review has found nothing to suggest that any agency or professional could have predicted the death of Child F. 6.14   An inquest was held into the death of Child F and on the 9th of February the Coroner made the following judgement. He concluded that:           "On the 3rd October 2015 Child F, age 4 months, was being cared for at the home of Adult E. At around 8.00am Child F was placed in a car seat at the property and bottle feed some milk. 22 | P a g e   His bottle was propped on a blanket. At some time between 8.00am and 10.00am he died from choking on that milk."  7.0      Recommendations               Each individual agency has identified its own learning and made recommendations to improve services and outcomes for children. The Lincolnshire LSCB will monitor these to ensure that the recommendations are fully implemented. This Serious Case Review has also identified learning and made some recommendations as detailed below and the implementation of these will assist the partnership to deal more effectively with similar circumstances in the future resulting in the improved safety and welfare of children.                         Recommendation 1             It is recommended that assurance is provided by the Local Authority and their partners that the Lincolnshire LSCB’s Child in Need process is operating effectively.   Recommendation 2             The LSCB should make it a requirement that all agencies working with a child or family, record the full details of all adults within the household as well as those who have significant contact with the child. (It is accepted by the review author that some agencies already have this mechanism in place). They should also ensure that is incorporated in all relevant multi-agency training.  (This requirement is already in some agencies policies and should be monitored through audits.)            Recommendation 3            The LSCB should seek assurance from its partners that the quality of assessment for the pre-birth protocol is of the right standard on all occasions where vulnerable mothers who are children themselves are pregnant. This is a multi-agency requirement.           Recommendation 4           I) Assurance to be provided by all partner agencies to the LSCB that the application of the 'Sexually Active Young People Policy' and 'Harmful Sexual Behaviour Policy' is happening.            ii) The LSCB should continue to seek assurance from all in their partnership that they are carrying out and completing appropriate and relevant CSE risk assessments, and appropriate staff have completed the LSCB CSE training.          Recommendation 5 The LSCB’s should issue a practice note to all agencies using this case to highlight the   importance of recording information and sharing this where and when appropriate. Recommendation 6  The LSCB should review its training to ensure: a) That professionals are able to recognise disguised compliance and dis-engagements and know what to do in order to able to work these circumstances. 23 | P a g e   b) That professional curiosity and healthy scepticism is included in all levels of safeguarding training to give staff confidence and skills to challenge and check service user’s information (this requirement is already in some agencies policies and checked happening through audit.) The understanding of ‘what life would be like for the child’ in that family will assist this process. Recommendation 7 The LSCB should ask its Child Death Overview panel to consider  i) Research and producing information in relation to the dangers of bottle prop feeding and babies sleeping in car seats. ii) Re-issue guidance on safer sleeping in particular guidance about the high risk to a baby of sleeping on a sofa or in an armchair, which is an even further risk if drink or drugs are being used (this includes drugs that may make a person drowsy). Recommendation 8 Review the information sharing meetings (in particular the one after post mortem to ensure all information is being shared). Recommendation 9         I) The LSCB should seek assurance from children's services as part of the social care assessment process, that all agencies are contacted for information.            ii) The LSCB should seek assurance that all universal services can do this, and will respond in 10 working days, unless it is an urgent safeguarding under section 47.  