Death of a 6 month old boy on 22 December 2011 following complications from a head injury. The mother's partner was charged with Section 18 Assault (Causing Grievous Bodily Harm) and subsequently charged with Child A's murder. Child A's mother had routine contact with health services during her pregnancy and after Child A's birth and at no point were there any safeguarding concerns. Mother of Child A met her partner in October 2011 on the social networking site, Facebook. An allegation of sexual assault had been made against mother's partner in June 2011, leading to his dismissal from his role with a voluntary sector provider of services to adults with learning disabilities; this information had not been passed to the Independent Safeguarding Authority. Mother's partner was babysitting on 17 December 2011 when Child A was taken to hospital after suffering a head injury and cardiac arrest; it is not known whether mother's partner had moved into the family home at this time. Review considers issues of information sharing between agencies; systems designed to identify individuals who could provide a serious risk of harm to others, including the Multi Agency Public Protection Arrangements (MAPPA); and, use of social networking sites. Key recommendations include: development of the educational aspect of the Local Safeguarding Children Board's e-safety policy; development of greater understanding and communication of ideas and improvements between Adult and Children's safeguarding systems.
      
Title: The overview report of the serious case review in respect of Child A LSCB: North East Lincolnshire Local Safeguarding Children Board Author: Sian Griffiths Date of publication: 2012 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. 2 July 2012     The Overview Report of the Serious Case Review In respect of  Child A                         This report has been commissioned and prepared on behalf of North East Lincolnshire Safeguarding Children Board and is available for publication.     2     Contents                 Page   Glossary                             1:        Introduction   ................................................................................  4 1.1      The circumstances that led to this SCR  .............................. …….      4                               1.2      Terms of Reference ............................................................. ……. 5 1.3       Membership of the Serious Case Review Panel ................. ……. 7 1.4      Timescale for the Serious Case Review  ............................. ……. 8 1.5      Methodology  ........................................................................ …….      8 1.6      Parallel Processes ............................................................... ……. 11 1.7      Family Contribution to the Review  ...................................... ……. 11  2:       Factual information  2.1     Genogram  ........................................................................ ……. 14 2.2     Comprehensive Chronology  ................................................. ……. 15 2.3     Relevant ethnic, cultural or other equalities issues ............... …… 15  3:       Summary of information known to the agencies………………    15 3.1 Relevant Historical information known to agencies……………….. 16 3.2 Child A’s early life……………………………………………………..    16 3.3 Information regarding MP…………………………………………….    17 3.4 Weeks leading up to the death of Child A…………………………..   18  4:      Critical Analysis   ……………………………………………………     20 4.1 Introduction……………………………………………………………     20 4.2 Identification of Safeguarding Risks……………………………….      22 4.3 Other lessons identified……………………………………………….   27 4.4 Concluding comments……………………………………………….     27  5:      Individual Agency Reports and Recommendations ......... …….   29  6:      Multi Agency Recommendations ....................................... …        36     Bibliography  ........................................................................           37     3    GLOSSARY    FAMILY:  Child A:    Subject MA     Mother of Child A MP     Partner of Mother of Child A FA     Father of Child A   MPExP    MP’s ex-partner  CExP     Child  of MP     Acronyms:  A & E Accident and Emergency ACPO Association of Chief Police Officers CPS Crown Prosecution Service CRB Criminal Records Bureau EMAS East Midlands Ambulance Service GP General Practitioner IMR Individual Management Review ISA Independent Safeguarding Authority LSCB Local Safeguarding Children’s Board NLaG Northern Lincolnshire and Goole Hospitals NHS Foundation Trust OFSTED Office for Standards in Education OOH Out of Hours service for Children’s Social Care PCT Primary Care Trust PPU Police Public Protection Unit SCR Serious Case Review SCRP Serious Case Review Panel TOR Terms of Reference NELSCB North East Lincolnshire Safeguarding Children Board   4  1. INTRODUCTION  This Serious Case Review has been prepared in relation to the death of a 6 month old boy, known as Child A.  The purpose of a Serious Case Review is to identify whether agencies which provide services to children and families have acted appropriately and whether lessons can therefore be learned from Child A’s experience.  As a result the focus of the report is significantly on the activities of agencies.   Child A however is at the heart of this review.  The Review Panel offers its sincere condolences to Child A’s family.  1.1   Circumstances that led to this Review 1.1.1 Child A, a boy was born in North East Lincolnshire where he lived with his mother throughout his life.  It is understood that there was no contact between Child A and his father.   Child A was known only to universal services1  and had no involvement with Children’s Social Care or other specialist services prior to his admission to hospital in December 2011 at the age of 6 months. 1.1.2 On 17th December 2011, Child A’s mother (MA) went out for the evening leaving Child A at home in the care of her new partner (MP) Child A was 6 months old at this time.  During the course of the evening MA received a phone call from MP to tell her that Child A had stopped breathing.  MA told MP to call an ambulance which he did.  Paramedics and then an ambulance arrived at the house within minutes.   1.1.3 Child A was taken to hospital by ambulance where he was found to have suffered a cardiac arrest and where it was further identified that he had suffered a non-accidental head injury. 1.1.4 Later that day Child A was transferred via specialist paediatric transport to the Sheffield Children’s Hospital where he remained in intensive care until 22 December 2011.  At this point the decision was taken to remove the artificial life support on which he was reliant and he was pronounced dead. 1.1.5 MP was interviewed under caution by the police and subsequently charged with Section 18 Assault (Causing Grievous Bodily Harm) relating to Child A’s injury.   At a court appearance on 16th March 2012                                             1 Universal services are those services which are provided, or are routinely available to all children as families, including mainstream health and education.  This differentiates them from targeted services such as those provided by Children’s Social Care or other specialist support provided when a child is identified as having particular needs.  5 MP was charged with the murder of Child A.   MP was convicted of the manslaughter of Child A on 27th June 2012 following a trial at Hull Crown Court. 1.1.6 A Serious Case Review Group met on 9th January 2012 to consider whether a Serious Case Review should be undertaken.  In making its decision the meeting took into account the criteria outlined in Working Together 2010.  In particular the meeting identified the following criteria as having been met:   “a child sustains a potentially life-threatening injury or serious and permanent impairment of physical and/or mental health and development through abuse or neglect” 1.1.7 The meeting concluded that the criteria for undertaking a Serious Case Review had been met and made a recommendation to that effect.  This recommendation was endorsed by Martin Wright, the Independent Chair of NE Lincolnshire Safeguarding Children Board on 9th January 2012. 1.1.8 On  1st February 2012 OFSTED was informed of the decision to undertake a Serious Case Review 1.1.9 An Independent Chair and Independent Overview Author were appointed in February 2012 and a Serious Case Review Panel established to manage the process with representation from the relevant agencies invited. 1.1.10 During the time period of the review, Martin Wright the Independent Chair of the Safeguarding Children Board stepped down.  His successor, Sue Woolmore, took up post on 15th June 2012.  In the interim the Vice Chair of the Safeguarding Board, undertook the role of overseeing the Serious Case Review to completion with the agreement of the incoming Chair.   1.2   The Terms of Reference of the Review  1.2.1 The Terms of Reference for the Serious Case Review, which fully set out the scope and context of the Review are attached as Appendix A.  A summary of the Terms of Reference is as follows: 1.2.2  The Terms of Reference were established in line with the requirements of Working Together 20102, which states that a Serious Case Review must:  Establish what lessons are to be learned from the case about the way in which local professionals and organisations work                                             2 HM Government (2010) Working Together to Safeguard Children, Chapter 8  6 individually and together to safeguard and promote the welfare of children  Identify clearly what those lessons are, both within and between agencies, how and within what timescales they will be acted on, and what is expected to change as a result  Improve intra and inter agency working and better safeguard and promote the welfare of children  1.2.3 In addition the following Key Lines of Enquiry were identified:   Key Lines of Enquiry  TOR 1:  Did each agency have in place policies and procedures to safeguard the welfare of children and vulnerable adults, and were they applied appropriately in this case?  TOR 2:  Did agencies have the opportunity to work together to promote the welfare of Child A?    TOR 3:  To what extent did agencies communicate across sector and local authority boundaries in order to promote the welfare of children and vulnerable adults, and were there any barriers to achieving effective communication?  TOR 4:  What information was known to each agency regarding any aspect of safeguarding risk (relating to adults and children), and was this shared and managed responsibly?  TOR 5:  What was known about how well (or not) Child A’s family was supported or isolated?  TOR 6:  Did agencies respond to the known and presenting needs of Child A and the family?  TOR 7:  To what extent did services take account of issues such as: race & culture, language, age, disability, faith, gender, sexuality and economic status and how did this impact upon agencies assessment and service delivery in relation to their service user?  TOR 8:  How attuned are agencies to the risks that can be posed through use of social networking sites?  TOR 9:     To what extent did services have an understanding of the children and vulnerable adults that they were working with, their experiences and views, and how did this inform practice and progress?   7  TOR 10:  For IMR reports are there any common themes from previous SCR’s which your agency has acted on?      1.2.4 The Terms of Reference identified that the time period for consideration by the Serious Case Review should begin with the approximate date of  Child  A’s conception and conclude a week after the date that Child A died.  The end point was determined in order to capture the response of safeguarding agencies to Child A’s death. 1.2.5 The agreed timescale was therefore identified as:    1st September 2010 - 31st December 2011 1.2.6 This time period was identified in order to obtain a full understanding in relation to the significant events in relation to Child A, the significant adults in his life and the involvement of any relevant agencies.  Individual Management Review (IMR) authors were also required to consider any contextual historical information outside of the timescale which was available to their agencies and include this, where relevant, in summary form in order to contribute to an understanding of the family situation. 1.2.7 The Panel reviewed the time period during the SCR process to ensure that it was still considered fit for purpose in the light of emerging information.    1.3   Membership of the Review Panel The Serious Case Review Panel was made up as follows:  Role Agency/Organisation Colleen Murphy Independent Chair Head of Safeguarding and Youth Offending NE Lincolnshire Council Asst. Director of Assurance &  Adult Safeguarding NE Lincolnshire Care Trust Plus. Director Humberside Probation Trust Head of Integrated Family Services Integrated Family Services Designated Doctor, Child Protection/Consultant Paediatrician North Lincolnshire and Goole Hospitals NHS Foundation Trust  8 Detective Chief Inspector Humberside Police Designated Nurse NE Lincolnshire Care Trust Plus. Consultant, Lincolnshire Children's Services,  Lincolnshire County Council  Also in attendance at the Panel meetings were the following:  Helen Willis, LSCB Co-ordinator NE Lincolnshire  NE Lincolnshire SCB Administrator  Sian Griffiths, Independent Overview Author  Colleen Murphy is the Chair of the Serious Case Review Panel (SCRP). Ms Murphy works as an Independent Social Worker undertaking a range of work specifically in Children’s Services and quality assurance. Ms Murphy has been a qualified social worker for twenty three years, and has previously worked in social work and social work management positions in the Local Authority as well as the voluntary sector. Ms Murphy has undertaken previous Chair and authorship of many Serious Case Reviews.   Ms Murphy has no professional or personal connection with any of the agencies involved in this Serious Case Review.    Sian Griffiths is the Independent Author of the Overview Report.  Ms Griffiths works as an Independent Social Worker and is registered with the General Social Care Council.    Ms Griffiths has been a qualified social worker since 1987, working both in the Probation Service as a practitioner and manager and later as a Family Court Advisor in CAFCASS.  She has authored Serious Case Reviews for a number of other Safeguarding Boards. Ms Griffiths has no professional or personal connection with any of the agencies involved in this Serious Case Review.    1.4   Timescale for undertaking the Review 1.4.1  NE Lincolnshire Safeguarding Children Board, in line with Working Together 2010, required that the Overview Report be completed and submitted to OFSTED within 6 months, that is, by 09 July 2012. 1.4.2 The Review was completed within the required timescale.  1.5   Methodology of the Review 1.5.1 This Serious Case Review was conducted in line with the requirements of Working Together 2010.  The Review Panel was aware of the ongoing redrafting of Working Together and the development of a  9 systems model for SCRs.  Nevertheless, the Review was undertaken in line with the existing statutory requirements. 1.5.2 The Panel requested and received Individual Management Reviews from the following agencies:  Humberside Police  Lincolnshire Police  Northern Lincolnshire and Goole Hospitals NHS Foundation Trust  East Midlands Ambulance Service   North East Lincolnshire Council Children’s Centres  North East Lincolnshire General Practitioner Services  North East Lincolnshire Council Children’s Health Provision 1.5.3 The review identified 6 agencies which held relevant background information or had other brief involvement with the family but which was not of such significance or scope to justify the completion of an Individual Management Review.  These agencies were therefore asked to provide a brief report outlining their involvement with Child A, the mother of Child A or the mother’s partner.  These brief reports, for which a template was provided, were designed to identify any additional relevant information including any organisational learning which resulted from their enquiries. 1.5.4 The agencies who provided brief reports were:  NAVIGO (Provider of Mental Health Services in North East Lincolnshire)  North East Lincolnshire Children’s Services  Lincolnshire Children’s Services  Sheffield Children’s NHS Foundation Trust   The Armed Forces Welfare Service  Voluntary Sector Provider of services to adults in Lincolnshire 1.5.5 It was identified that MP had  previously been discharged from the army and also that he had been dismissed from employment with a Voluntary Sector Provider (VSP)3 in Lincolnshire  a result of a serious allegation which itself led to a criminal charge.  The criminal charge was outstanding at the time the SCR took place.  However, MP was subsequently found not guilty following a trial. The Army Welfare Service and the VSP were therefore asked to provide information regarding MP.  The Review made a conscious decision to seek information from the VSP which had employed MP prior to his relationship with the mother of Child A.  The VSP provides social care to adults. This was considered to be proportionate given that MP was                                             3 This provider is anonymised in order to protect the identity of the service user concerned, and other vulnerable service users.  10 subject to a criminal charge in relation to a service user of the VSP and the Review wished to satisfy itself regarding any safeguarding implications that arose as a result. 1.5.6 As it had been identified that MP had previously lived in Lincolnshire enquiries were made with the Lincolnshire Safeguarding Children Board as to any current or historical involvement with services in that area.  Brief factual information was provided arising out of the above allegation made against MP and consequent actions taken to ensure that this did not lead to any child safeguarding concerns. Lincolnshire County Council Safeguarding Adults Team confirmed that they were informed of the allegations made against MP and provided a short chronology outlining their involvement.  As a criminal investigation was taking place, the Lincolnshire County Council Safeguarding Adults team did not undertake a separate investigation as they were not required to do so.  It was therefore agreed that all relevant information  would be suitably covered within the IMR provided by Lincolnshire Police 1.5.7 Information was also sought from the following agencies who confirmed that they had no knowledge of the family:  CAFCASS  NSPCC  VANEL (Voluntary Action North East Lincolnshire)  Lincolnshire Probation Trust   North East Lincolnshire Youth Offending Service  Humberside Fire Service 1.5.8 A Health Overview report was commissioned from North East Lincolnshire NHS Care Trust Plus to encompass the IMRs of the NHS providers listed above. 1.5.9 The Serious Case Review Panel met on the following dates:  23rd April 2012(half  day meeting)  30th May 2012 (half day meeting)  13th June 2012 (half day meeting) 1.5.10 A structured meeting was also held on 5th March 2012 to brief IMR authors on their role.  All of the IMR authors were invited to the Panel meeting in April 2012 to take part in a discussion about the emerging themes and receive feedback in general terms.  IMR authors were also provided with individual feedback on their reports.   Authors had access to ongoing advice and support from Panel members and the Independent Chair and Author.  As a result all the IMRs were resubmitted following first drafts and were able to provide further information in line with the panel’s requirements.  11 1.5.11 Whilst not all panel members were able to attend all meetings due to staffing or other unavoidable commitments, the panel undertook its task with a constructive and questioning approach.  The final panel meeting was well attended with creating a positive opportunity to reflect on practice and ensure ownership of the learning.  1.5.12 The SCR Panel was explicit in directing agencies that any early lessons identified during the review should be responded to in practice without delay wherever this was possible.  It further asked to be informed during the process of any such early lessons and actions that arose. 1.5.13 The Overview Report was presented to the North East Lincolnshire Safeguarding Children Board at an extraordinary meeting on 25th June 2012.  Representatives of both Lincolnshire Safeguarding Children Board and Lincolnshire Safeguarding Adults Board also attended. The report was endorsed by the Board.  1.6  Parallel Processes 1.6.1 Following the injuries and subsequent death of Child A, a criminal investigation was initiated during which MP was interviewed and subsequently charged with murder. 1.6.2 Criminal court proceedings in relation to Child A’s death were ongoing throughout the undertaking of this review. On 27th June 2012 MP was found guilty of the manslaughter following a trial. He was sentenced to 8 years imprisonment.  1.6.3   MP was also charged with two offences under the Sexual Offences Act 2003 with regard to the allegations in Lincolnshire and criminal court proceedings were also ongoing.  1.6.4   On 28th February 2012 the coroner was informed that a Serious Case Review would be taking place.  The Inquest in relation to Child A was opened and adjourned pending the outcome of the criminal proceedings.   1.7  Family Contribution to the Review 1.7.1 In line with the expectations of Working Together (March 2010) early consideration was given by the panel to seeking a contribution to the Review by key family members.   1.7.2 Given the ongoing criminal investigation and in line with guidance provided by ACPO and the CPS in April 2011, the Chair of the SCR Panel sought the advice of the police Senior Investigating Officer with regard to meeting the family, so as to ensure that any subsequent proceedings would not be compromised  12 1.7.3 The mother of Child A and the man understood to be the father of Child A (FA) were both informed that a Serious Case Review was taking place.  The Panel particularly wished to meet with the mother of Child A but were aware of the potential difficulties arising out of the pending criminal proceedings. 1.7.4 The Police sought advice from the Crown Prosecution Service as to whether it would be appropriate for the Independent Chair and Author to meet with the mother.  The CPS advice was that there were no concerns about the mother being spoken to regarding the SCR process.  However, given that she would be a key witness in the criminal trial any information she provided would need to be considered for disclosure and questions that might relate to her evidence would need to be avoided.  As a result the panel concluded that to meet with the mother before the trial could potentially compromise the proceedings.  It was not considered appropriate to meet with other family members as an alternative.  1.7.5 The Panel therefore agreed that following the completion of the criminal court proceedings relating to Child A, further consideration would be given to contacting MA to see if she would be willing to make a contribution to the review.  It was agreed that if new information was consequently provided which could lead to further learning, the panel would reconvene to consider how to best ensure such learning was taken forward, including the possibility of an addendum to the Overview Report. 1.7.6 Following MP’s conviction on 27th June 2012, contact was made with the mother of Child A who confirmed that she would like to contribute to the Review, but would need some time to consider the verdict before doing so.  An arrangement was then made with the mother for her to meet with the  Independent Chair and Author of the review at the end of August 2012.  However, MA did not attend this meeting.  Further attempts were made to contact MA but without success.  This review has therefore not had the benefit of her involvement. 1.7.7 From an early stage the panel considered whether it was appropriate to contact MP after the trial in order to maximise the learning for this review.  Given the emerging information during the process of the review, the panel concluded that to do so would not provide added value. 1.7.8 Consideration was also given to involving MPExP.  However given her limited knowledge of the issues of significance to this review it was decided not to do so.  It was however agreed that she should be informed in advance of publication of the review given that the contents significantly related to CExP’s father and that it would then be in the public domain.     13 1.9 Geographical and Administrative boundaries   1.9.1 The historical county of Lincolnshire is divided into three administrative areas:  Lincolnshire County Council based on Lincoln.   North East Lincolnshire based around Grimsby.  North Lincolnshire based around Scunthorpe  North East Lincolnshire and North Lincolnshire are unitary authorities with responsibility for provision of their own local services, including children’s services.   1.9.2 Two police forces cover the geographical areas featuring in this Serious Case Review.  Lincolnshire Police covers Lincolnshire and Humberside Police covers the districts of North and North East Lincolnshire.   14 2 GENERAL FACTUAL INFORMATION  2.1         COMPOSITE GENOGRAM     Mother’s Partner Child A Died age 6 months 22.12.11 Father of Child A  Mother of  Child A MPExP: Ex-partner  CExP  Maternal Grandmother  Maternal Grandfather  15 2.2   COMPOSITE CHRONOLOGY OF SIGNIFICANT EVENTS  A full chronology of significant events was developed which fully informed the review.  The individual agency chronologies are reproduced in full within the IMRs, including information outside the timeline which has not been included in the composite chronology, but is covered where relevant in later sections of this report.   2.3 RELEVANT ETHNIC, CULTURAL OR OTHER EQUALITIES ISSUES  2.3.1 In line with the requirements of Working Together, IMR authors and the author of both the Health Overview and this Serious Case Review Overview report were directed specifically to consider any particular issues of race, culture, language, religious identity or disability of significance to the family.   2.3.2 MA identified both herself and Child A as white British to those agencies which sought this information.  Religion was not identified by any of the services as a particularly significant factor for the family.  However, arrangements were made whilst Child A was in hospital for him to be christened before he died.  2.3.3 MA’s status as a lone parent was noted by some agencies, but any potential vulnerability that this could suggest was balanced by the support she was seen to receive from her own mother with whom she lived when Child A was first born.  MA was known to be in employment as a support worker with vulnerable adults.  There were no indicators of significant economic or social disadvantage. 2.3.4 No other relevant issues, such as for example, disability or absence of community ties were identified as of significance to this family.  Limited information is available to the review about the family given the level of contact with services and the inability of the Review to contact the family directly. 2.3.5 MP was identified by health providers as white British. Very little other information is known about significant factors for MP.    3     INFORMATION KNOWN TO AGENCIES  The combined chronology which informs this report, detailed the relevant contact episodes between the child, his mother, his mother’s partner and each agency. Each IMR and the Health Overview Report includes a full detailed chronology and narrative containing all the information regarding the agencies’ involvement with the children. This section will therefore focus on  16 highlighting the key events and contacts with the family and agencies. Section 5 will critically analyse these events and contacts.  3.1 Relevant Historical Information known to agencies  3.1.1   Agencies were asked to provide any significant historical information regarding the Mother of Child A and MP in order to ensure that all relevant lines of enquiry had been fully considered.   3.1.2 MP joined the Army in October 2009 and married MPExP in February 2010.  The couple already had a child (CExP) born in 2008. 3.1.3 Whilst on leave in March 2010, MP contacted the army to tell them that his marriage was ending, and said that he wanted to leave the army.   He was instructed to return immediately, but did not do so. It was later identified that he had not in fact been at his marital home as he had said.  MP was therefore considered Absent Without Leave.  MP returned to camp in May 2010 and held in the Military Corrective Training Centre.  After serving his period of detention his army service terminated on 17th June 2010.    Whilst there were concerns about his suitability for the army, his family background and his temperament, nothing was identified that would have suggested the need for referral to external services.    3.2   Child A’s early life 3.2.1. Very limited information has been provided directly to this Review regarding Child A as he was only known to universal services prior to his death.   3.2.2. The first known contact with relevant agencies in relation to (unborn) Child A was on 3rd November 2010 when MA’s pregnancy was confirmed by her GP. 3.2.3. On 17th November 2010 MA told her GP that she had been hit by her partner, although the individual concerned is not identified in the records.  This information does not appear to have been shared with other health services who were involved with the family. 3.2.4. On 21st December 2010 MA and her mother registered with their local Children’s Centre which facilitated the family’s access to universal services in the area.  Maternity services, including midwifery and health visiting are provided from Children’s Centres and MA accessed routine ante natal support from the Centre regularly accompanied by her mother.  Following the birth of Child A, MA continued to access routine post natal appointments with the midwifery service at the children’s centre and registered Child A with the centre.  3.2.5. On 17th June 2011 Child A was born via normal delivery at the local hospital.   Child A and his mother were discharged home to her  17 parents later the same day and into the care of the community midwife. 3.2.6. On 20th June 2011 Child A was brought by his mother to the GP with a minor rash.  Routine post natal checks in relation to mother and baby followed in the subsequent days and weeks.  During one visit, MA told the health visitor that she did not want to disclose the name of Child A’s father as their relationship had ended while she was pregnant.  MA was living with her parents but had her own home and would be moving in with Child A shortly. She described a supportive family environment which was in line with the Health Visitor’s own observations. 3.2.7. MA’s ante-natal and post-natal care was unremarkable and MA engaged positively with the health visiting service.   MA regularly brought Child A to the Child Health Clinic for weighing and general advice. There was no information to suggest at any time that there were any concerns about the quality of Child A’s care.   On one occasion the Nursery Nurse had some concerns when a number of young females answered MA’s phone and on the 4th attempt it was answered by an unknown man.  The Nursery Nurse, who was persistent in her inquiries, was later provided with a reasonable explanation by the mother who had left her phone in someone else’s house by mistake and the Nursery Nurse had no reason for further concerns.  3.2.8. MA had various contacts with her GP practice and these were of the sort that would be expected for any mother with a new baby.  None of these contacts were of the nature to raise any safeguarding concerns.  3.3 Information re MP during April-October 2011  3.3.1. In April 2011 MP began employment in Lincolnshire with VSP as a member of their Bank Staff, which entailed him providing cover as and when required for staff absences.  VSP provides services to adults with learning disabilities and MP was employed to provide sessional cover as a Community Support Worker.  This involved providing support to learning disabled adults in their own homes.  His appointment was subject to an enhanced CRB check, a more comprehensive check which is required when employing someone to work with children or vulnerable adults.  This check was clear and VSP also obtained work and personal references all of which were satisfactory. 3.3.2. On 19th June 2011 a service user made a serious allegation of sexual assault against MP.  This was reported to the police and the Lincolnshire Safeguarding Adults team in line with established procedures.  MP was immediately suspended from his employment and later dismissed as a result of these allegations. 3.3.3. MP was interviewed in relation to this offence on 22nd June 2011 and bailed to his home address in Lincolnshire where he lived with MPExP  18 and CExp, their two year old son. On 22nd August 2011 MP’s wife informed the police that she and MP had separated and that he had moved to Grimsby to stay with his parents.  3.3.4. The allegation of sexual assault was investigated by the Lincolnshire Police Public Protection Unit (PPU).  At the completion of this investigation, which necessitated expert forensic and other reports, MP was charged with 2 counts of Sexual Activity with a Person with a Mental Disorder4.  3.3.5. On 11th October 2011 Lincolnshire police informed Lincolnshire Children’s Services that they had been contacted by MPExP telling them that MP had threatened to remove CExP.  She was given advice and no further action was required.  In December 2011 following the injury to Child A, Lincolnshire Children’s Services undertook an Initial Assessment in relation to CExP.  Children’s Services were fully satisfied with CExP’s care and his mother’s commitment with regard to safeguarding him.  3.4 Weeks leading up to the death of Child A  3.4.1. At some time during October 2011 MA is understood to have met MP via the social networking site Facebook.  MP was never known to any of the agencies involved with Child A and neither was it known when, or if, he became a part of the household. 3.4.2. MA informed the Children’s Centre on 7th October 2011 that she had moved house in August and that she was now in a relationship.  As her partner was not present to give his consent no further information was recorded about him at this point. 3.4.3. The last direct contact between the Health Visiting services and Child A took place on 25th October 2011, when all was well.  The next routine planned contact would have taken place in early 2012. 3.4.4. In November 2011 MA was informed by Children’s Health that she would be having a change of Health Visitor due to having moved address. 3.4.5. At just before 11pm on 17th December 2011 a 999 call was made by MP stating that his girlfriend’s baby was “barely breathing”. It was assessed by the call handler from the information provided that the child appeared to be unconscious. Instructions were given to MP regarding CPR.  A second 999 call was made by Child A’s mother a few minutes later stating that her partner had rung her informing her of her child’s condition and she was on her way home.  On her arrival home she told the operator that her baby was not breathing.                                             4 ‘Sexual Activity With A Person With A Mental Disorder Impeding Choice’ is an offence under the Sexual Offences Act 2003  19 3.4.6. A Fast Response Vehicle arrived at Child A’s home within 2 minutes of the initial 999 call.  An ambulance also attended Child A’s home within 8 minutes and delivered Child A to Diana Princess of Wales Hospital, Grimsby 10 minutes later. 3.4.7. Shortly after 01.00 on 18th December 2011 a staff nurse approached a Humberside Police officer who was in the hospital dealing with another incident.  She reported to the officer concerns about possible non-accidental injuries to Child A.  This police officer immediately contacted Humberside Police Command Centre and an investigation was initiated within the Major Incident Team.   3.4.8. The police officer had been informed by the staff nurse that the hospital had contacted the Lincolnshire Out of Hours (OOH) team for Children’s Services.  She told the police officer that she had been informed by OOH that another child of MP’s was ‘on the risk register’.  Two phone calls were made by Humberside Police to OOH in Lincolnshire who said that they held no information about the child of MP and had not raised any concerns about that child. They did however hold information regarding MP having involvement with Lincolnshire police.  3.4.9.  It has become apparent during the review that the hospital had misunderstood what the Out of Hours service had in fact said. The Out of Hours team had information about the allegations regarding MP, but could not disclose them because they were in relation to an adult, not a child.  They advised that the hospital call Lincolnshire Police for further information.  3.4.10.  An enquiry was then made to Lincolnshire Police who informed Humberside Police that MP was currently on Police bail for an allegation of sexual assault.  There had been an incident on 11th October 2011 between MP and his ex-partner in relation to ‘custody’ of their child.  They confirmed that Children’s Services had been informed of this incident. 3.4.11. During the early hours of 18th December 2011, MP was arrested on suspicion of causing Grievous Bodily harm and charged the following day. 3.4.12. During the night Child A was transferred via Embrace, a specialist paediatric ambulance service, to Sheffield Children’s Hospital, Paediatric Intensive Care Unit arriving there at 02.40 on 18th December 2011.   3.4.13. A telephone strategy discussion took place between the police and OOH on 18th December 2011.  This meeting identified that there were no immediate safeguarding concerns as Child A’s safety was assured in hospital.  3.4.14. Expert care was provided over the following days.  Medical staff were always in attendance, police officers were also present for much of the time and Child A’s mother remained with him throughout.  However, by 20th December 2011 the medical opinion was reached that Child A was unlikely to survive.   With the family’s agreement  20 active treatment was withdrawn and Child A died at 02.12 hours on 22nd December 2011. 3.4.15. A strategy meeting was held on 21st December 2011 chaired by a Principal Social Worker and attended by the Named Nurse for Safeguarding, a Detective Sergeant, Social Worker, and Health Visitor. 3.4.16. The Police notified the Local Safeguarding Board of Child A’s death as required by the procedures.  A decision was made by the Safeguarding Board Business Manager in consultation with the Safeguarding Lead for NLaG that a Strategy meeting would not be required under the LSCB’s Sudden Unexplained Death in Infancy protocol as although the injury was unexpected, the resulting death was not. The Business Manager later concluded that this had not been the correct decision.  4       CRITICAL ANALYSIS  4.1 Introduction 4.1.1. This analysis is based on the individual Agency contributions to the Review, discussions held within the SCR Panel and the author’s own contributions. The critical analysis has considered all of the Terms of Reference including the Key Lines of Enquiry which provided the working hypothesis for this review.  The combined conclusions arising out of the IMRs have been evaluated and this analysis constructed around the resulting key concerns in relation to individual agencies and from a multi-agency perspective.  Learning for the agencies will be considered and an evaluation of whether steps could have been taken to prevent Child A’s death will be presented. 4.1.2. The critical analysis has been undertaken with the conscious benefit of hindsight, which by definition, was not available to those involved with Child A at the time, neither agencies nor members of his family.  Notwithstanding the limited contact between Child A and agencies, the Review panel was determined,  to ensure that as well as considering  any direct lessons to be learned from such contact, this  review should also be used as an opportunity to reflect on any wider learning that might emerge.  4.1.3. Unlike the majority of children who are the subject of Serious Case Reviews5, it is evident from the history of Child A’s brief life, that he was a child who at no point gave cause for concern to agencies.  The services who were involved had no information that would lead them to be concerned about his care or that would have justified any intervention by safeguarding agencies.   4.1.4. There is no information to suggest that there were any concerns about Child A’s care or wellbeing prior to the catastrophic injury that resulted                                             5 OFSTED:  Learning Lessons from serious case reviews 2009-2010  21 in his death.  Post mortem information identified no evidence of any historical abuse to Child A.  He was seen regularly at the local children’s centre and by health services during his life time and was developing as would be expected for a child of his age.   Child A’s mother was fully engaged with services and there was no information to indicate that she was anything other than a capable and caring parent.  What is apparent is that prior to the events of 17th December 20011, Child A was a physically healthy child meeting all his developmental milestones and with nothing to suggest any concerns about his care.  4.1.5. Child A was of a white British background and was not known to have any special needs.  His mother had support from her extended family and the agencies took this into account when considering whether her status as a lone parent suggested any vulnerability.  The services provided appeared to be appropriate to his individual needs in this context. 4.1.6. Analysis provided within each of the IMRs confirms that suitable agency policies and procedures for safeguarding the welfare of children were in place. That they were not implemented was because there was no cause to do so.  Practice by professionals was largely of a good standard. 4.1.7. One issue for improvement has been identified within the GP IMR and the Health Overview report.  In November 2010 during the early stages of her pregnancy MA told her GP that she had been hit by her partner.  It is not clear from the records what advice or further discussion took place or to what degree ongoing risk to MA was considered.  In the absence of such discussions, this would represent a missed opportunity to provide support to MA and potential future safeguarding of her child. Good practice would also have been for the GP to have informed midwifery services of this disclosure.  4.1.8. Recommendations regarding the implications of domestic violence in regard to safeguarding have been made by both reports as a result.  At the same time both reports are quite clear that even had the midwife been informed, the outcome for MA or Child A would not have been affected as by  December 2010 MA was no longer in a relationship with this individual and there is no information to suggest she was at any risk from him subsequently.         4.2   Identification of safeguarding risks       4.2.1. This Review is confident that there was no information available to agencies within North East Lincolnshire during Child A’s lifetime, or with hindsight, to suggest that he could be at risk of harm from MA, his primary carer.   22 4.2.2. At the time of undertaking this Review MP was awaiting trial for the murder of Child A, the verdict being handed down after the Review was presented to the Safeguarding Board,  and as such care has been taken not to pre-judge whether MP was the perpetrator of the injuries to Child A.  However, irrespective of the outcome of the trial but given that MP was known to be caring for Child A on 17th December, the Review considered it  proper to evaluate whether or not any information regarding MP could or should have raised safeguarding concerns.    4.2.3. It is absolutely clear that none of the agencies within North East Lincolnshire had reason to know that MP was in a relationship with MA and therefore did not know whether he had any contact with Child A.  MA had told the Children’s Centre and health services, that she was in a new relationship in October 2011, but there was no requirement for her to provide information about her new partner.  Agencies must balance the need to safeguard children with the right of families to be protected from unjustifiable, intrusive interventions or inquiries.  Even had the Children’s Centre been provided with MP’s details they would have had no reason to make enquiries about his background.  4.2.4. It is fundamentally the responsibility of a child’s parent to make decisions about who is a suitable carer for their child. Without significant information to suggest that a parent could be recklessly putting their child at risk by their choice of babysitters or other carers, there would be no basis for agencies to intervene.  4.2.5. A number of services in Lincolnshire held some limited information about MP which has been provided to this Review and used to consider whether either at the time, or with the benefit of hindsight, this should or could have led to further action by those services.  This analysis will consider whether, irrespective of the services’ responses in this case, there may nevertheless still be lessons for the future with regard to managing risk.  4.2.6. It is now known that MP had been discharged from the army in 2010.  The Army Welfare Service provided proportionate information outlining the reasons that MP had been discharged.  MP had taken leave from the army without permission and subsequently served a period of detention as a result.  The Army identified personal attributes which they considered made MP unsuitable for service, but had no information that could have led them to conclude he could be a risk to either adults or children in the future.  4.2.7. The VPS which employed MP in Lincolnshire had done so after undertaking comprehensive reference checks and an enhanced criminal records check.  They had no information prior to the allegations of sexual assault to suggest that he was likely to be a risk to vulnerable people.  In the absence of historical information there is  23 no means by which an employer can identify the possibility of future risk.  The Independent Safeguarding Authority (ISA) in a commissioned research report6 recently acknowledged the difficulty in identifying any warning signs of risk where there was no previous pattern of concern.  4.2.8. Following the allegation, the VPS appropriately contacted the police and the Adult Safeguarding Team in Lincolnshire in order to trigger the necessary investigations.  The employer suspended MP from work immediately and dismissed him at the point they understood he was to be charged.  4.2.9. The VPS is required in these circumstances to make a referral to the ISA, which is the body responsible for making decisions about who should be barred from working with children or vulnerable adults.  The ISA does not have an investigatory function and therefore guidance to employers is that the referral should be made at the point when sufficient evidence has been gathered to reach a conclusion, in effect this is often at the point a person is dismissed or resigns.   4.2.10. During the course of this review it was identified that the VPS’s referral process had been initiated, but not completed, which represented a weakness in the organisation’s processes.    The failure to process the referral to the ISA on MP’s dismissal in November 2011 might have had serious consequences, had MP gained further employment with vulnerable people.  However, in practice, the outcome for Child A would not have been any different. The VPS fully accepts that this was a failing and confirms that it has now been rectified.  However, given the potential vulnerability that this could suggest for the future this report is making a recommendation to the VPS as follows:  The Voluntary Service Provider to review its procedures for referring to the Independent Safeguarding Authority, and its successor, in order to satisfy itself that the procedures are adequately robust.   The VSP accepted this recommendation and initiated the required actions immediately prior to the completion of this Review.  4.2.11. Lincolnshire Police working with the Lincolnshire Adult Safeguarding team, who provided support to the vulnerable adult, led the investigation into the allegation made in June 2011.  During the investigation MP was subject to police bail with conditions not to discuss the case with anyone involved, not to contact the victim or discuss the case on any social networking site. These are routine conditions in a case of this sort.  The condition regarding social networking sites being a reflection of police experience in other cases                                             6 McKenna and Day :  Safeguarding in the workplace.  ISA March 2012  24 rather than due to any particular concerns about MP’s use of such sites.  4.2.12. To impose bail conditions before a person has been charged with an offence the police must have grounds for doing so and the conditions must be proportionate7.  A remand to custody is not an option prior to someone having been charged with a criminal offence.  The police would not have been justified in applying more restrictive bail conditions to MP and given that the offence related to an adult, could not reasonably have been expected to consider bail conditions that related to safeguarding children.  4.2.13. Considerable thought was given during this Review as to whether further safeguards could, or should have been in place as a result of MP’s being investigated for these offences, and whether any recommendations should have arisen as a result.  In particular the Review Panel was concerned about the potential for MP finding alternative work with vulnerable adults.  4.2.14. The issue of managing the balance between the protection of children or vulnerable adults with the rights of individuals is a complex one and has been part of the recent Mason Review8 which considered the management of criminal records information in a report on behalf of the Home Office.   The Mason Review reflected that: “Any use of unproven, untried “evidence” against someone, from an employment perspective could seem to be a direct contravention of the fundamental principle that one is innocent until proven guilty.”9  However, it balanced this principle against the particular risks relating to sexual or violent behaviour and concluded therefore that it was: “right and proper that concerns such as those of violent or inappropriate sexual behaviour be taken into consideration when determining employment with children and vulnerable adults”.  The means to achieve this in practice is through the use of enhanced criminal records checks.  Had MP applied for work with vulnerable adults, this would have been the relevant safeguard.  In this context this Serious Case Review has concluded that no further recommendations would be warranted.  4.2.15. It was also a cause of some concern to this Review that there was a gap of 8 months between the date the alleged offences occurred and MP being charged with those offences.  Details provided to the Review however, identified that the time gap was a result of the requirement for specialist forensic reports and assessments and it was evidenced that the investigating officer pursued the case in a timely way.  No criticism can therefore reasonably be made of Lincolnshire Police for this delay.                                              7 Section 3, Bail Act 1976 8 Mason, S (2010): A Balanced Approach. Home Office   9 Mason, S, p26  25 4.2.16. In assessing what risks MP might potentially have presented and whether these could have been managed in any way, the author of this Review has reflected on other existing systems designed to protect children or adults from people who could be considered to pose a risk to them. The purpose in doing so being to consider whether any current or potential system might have provided a means to assess or manage risk in this case.   4.2.17. Where an individual is known to have a history of serious or dangerous behaviour, MAPPA, the Multi Agency Public Protection Arrangements is initiated to enable the relevant agencies to respond in a co-ordinated way.   MP had no criminal history and would not have been subject to this sort of approach.  4.2.18. Two disclosure schemes have been developed in recent years and these have been considered in order to identify whether similar schemes might have been of value in this case.  These schemes are: the Child Sex Offender Disclosure Scheme and the Domestic Violence Disclosure scheme.  The former is in operation across all the police forces in England and Wales, the latter is being piloted during the summer of 2012.  4.2.19. The purpose of both schemes is, in a carefully managed way, to provide   information to individual members of the public who have a concern about the safeguarding of a child or the potential risk of domestic violence to an adult.  Safeguards are in place to avoid the scheme being used maliciously.  These schemes cannot be viewed as a simple solution to the identified problems.  They require a very careful balance in relation to managing the competing human rights of those involved and there are also many informed commentators who have reservations about their likely effectiveness in protecting children.  Both schemes are triggered by individuals who have reason for concern, whereas, as in the case of Child A, there was no obvious reason for concern apparent.  4.2.20. The schemes are specifically targeted at the particular type of dangerous behaviour identified ie Child Sex Offending or Domestic Violence, rather than general concerns that someone may pose an unspecified risk. There is no research known to the author suggesting that someone who has sexually offended against an adult would be more likely than others to present a risk of physical abuse to a child.   The conclusion therefore must be reached that a scheme of this nature would not be relevant or feasible for the general identification of risk where there is no clear pattern of behaviour.  4.2.21. Having carefully considered with hindsight all the information available at this time regarding MP, it is the conclusion of this Review that there would be no possibility of identifying him as a person who might significantly harm a child.   26 4.2.22. The Review also paid particular attention to the relevance or otherwise of the use by the adults concerned of social networking sites, given the emerging recognition of some of the risks inherent with using such sites.  4.2.23.  MA and MP are believed to have met using the social networking site, Facebook.  There is no further information available, for example information that might suggest Facebook was consciously used by MP as a means to identify a vulnerable family.  In the absence of any such information, it would be dangerous to presume that the role of Facebook was in itself of significance.   4.2.24. There could potentially be considered to be a heightened level of risk in using Facebook as a means to meet a partner.  In particular, there is likely to be considerably less contextual information about the person concerned, than would probably be the case via more traditional means such as meeting someone through work or social settings.  There may be an illusory sense of transparency created by the process, in that individuals can post their own version of themselves, which may differ considerably from the reality.  As already noted, social networking can also be used to seek out and identify individuals for manipulative, even dangerous reasons.  4.2.25. However, no route to meeting a partner can be presumed to guarantee safety for the   individual or their children.  The degree to which an individual is alert to the potential risks of introducing another adult into their household is not something that agencies can control.  The Review has considered whether there is a role for the safeguarding board or individual agencies in raising awareness of such risks.  It has concluded that whilst there may be some scope for educative work, the likely impact of this should not be overstated.   4.2.26. One agency, the Children’s Centres has produced a recommendation to include this issue as an element in their educative work.  A supportive recommendation has also been made to the Lincolnshire Children’s Safeguarding Board in this regard. (Multi-Agency Recommendation 1)    4.3   Other lessons identified   4.3.1. The GP and Health Overview reports have appropriately identified recommendations regarding the effectiveness of the safeguarding role of GP practices as a result of learning from this report.     4.3.2. Following Child A’s admission to hospital a decision was sought by the police regarding the need or otherwise to instigate the Safeguarding Board’s procedures following the unexpected death of a  27 child.  The LSCB in line with Working Together  defines this as when the death:   was not anticipated as a significant possibility for example, 24 hours before the death; or  where there was a similarly unexpected collapse or incident leading to or precipitating the events which led to the death  4.3.3. The LSCB Business Manager in consultation with the Safeguarding Lead for NLaG at the time, concluded that Child A’s case did not meet these criteria as his death was anticipated more than 24 hours previously.  The Board Manager subsequently recognised that this was not the correct interpretation of the guidance and drew the Review’s attention to this issue.  4.3.4. In the case of Child A there was considerable multi-agency communication and the Serious Case Review procedures were immediately triggered, which meant that in practice this did not lead to any disadvantage to Child A or other children.  It has been recognised that in other circumstances this might not have been the case and there has been a clear acknowledgement that this was a misunderstanding of the guidance which will not be repeated.  4.4   Concluding comments  4.4.1.   From the outset of this Review the information available suggested that Child A’s death was the result of an individual and catastrophic incident rather than part of a pattern of events that could have been predicted. During the process of undertaking the Review the evidence has consistently reinforced this initial presentation.  However, this Serious Case Review has been undertaken comprehensively and with an open mind and in particular with a focus on understanding whether there may have been any indicators of what was to come. 4.4.2.   It is widely recognised that prediction of the risk of harm is a complex and imprecise activity with the most accurate results arising out of the use of complex assessment tools combining statistical calculations and detailed clinical assessment.10 and most  significantly that     “a history of violence is the best predictor of future violence”11 .                                              10 Kemshall, H. (2001) Risk assessment and management of known sexual and violent offenders: a review of current issues. Police Research Series, Paper 140. London: Home Office 11 Kemshall, H., (1999) 'The assessment and management of violent offenders', Kemshall, H., Good practice in working with violence, 50-73, London: Jessica Kingsley Publishers   28 4.4.3.   In the absence of any known risk in relation to any of the adults concerned there was neither the reason nor the practical means to assess the potential for such a catastrophic injury to Child A.    4.4.4. Child A’s death can be better understood as an unanticipated crime rather than as an unidentified safeguarding failure.  29  5   INDIVIDUAL AGENCY REPORTS AND   RECOMMENDATIONS   5.1     Humberside Police  5.1.1. Humberside Police have provided a chronology and Individual Management Review for this Serious Case Review.  5.1.2. The report has been prepared by a Detective Inspector from the Crime Management Branch of Humberside Police.  The author has had no operational responsibility in the case or any direct involvement with Child A and his family and as such met the criteria for independence.    5.1.3. The Report was countersigned by the Detective Superintendent, Unit Head of Major Crime and Crime Police.  The Countersigner had no direct knowledge or involvement of the services provided to Child A or his family.  5.1.4. Other than responding to a request for information from Lincolnshire police regarding the allegation made against MP in July 2011,  Humberside police’s first relevant contact with Child A was on 18th December 2011 when Child A was taking to hospital with the serious head injury that resulted in his death.  5.1.5. The report is comprehensive and detailed in its review of the actions of the police in response to Child A’s injury, the subsequent police investigation and involvement in statutory safeguarding processes that followed.  The author responded appropriately to requests by the review panel for further information  5.1.6. The IMR does raise a question about the interpretation of Working Together’s guidance regarding the definition of an unexpected death of a child12 and this has been addressed within the critical analysis of this Overview Report.   5.2     Lincolnshire Police  5.2.1. Lincolnshire Police have provided a chronology and Individual Management Review for this Serious Case Review.                                             12 HM Govt (2010) Working Together, par 7.21  30  5.2.2. The report has been prepared by a Detective Sergeant from Lincolnshire Police’s Public Protection Unit.  The author has had no operational responsibility in the case or any direct involvement with Child A and his family and as such met the criteria for independence.    5.2.3. The Report was countersigned by a Detective Superintendent, Head of the Public Protection Unit. The Countersigner had no direct knowledge or involvement of the services provided to Child A or his family.  5.2.4. Lincolnshire Police had no direct contact with either Child A or his mother, their only involvement arising out of the allegation made against MP.  The report therefore focuses purely on its management of this allegation.  The author of the IMR responded quickly and constructively to requests for further information.  In particular the author provided additional detailed information regarding the timetable of the investigation.  This information was requested by the panel to clarify any potential multi-agency learning regarding the way that offences against vulnerable adults are investigated and subsequent implications for safeguarding vulnerable adults and children.  5.2.5. No recommendations for action were identified for Lincolnshire Police.  Given their involvement and response, this position is a justifiable conclusion.   5.3     North East Lincolnshire Children’s Centres   5.3.1. North East Lincolnshire Council Children’s Centres Humberside Police have provided a chronology and Individual Management Review for this Serious Case Review  5.3.2. The report has been prepared by the Children’s Centre Development Officer.  The author has had no operational responsibility in the case or any direct involvement with Child A and his family and as such met the criteria for independence  5.3.3. The Report was countersigned by the Head of Service. The Countersigner had no direct knowledge or involvement of the services provided to Child A or his family.  5.3.4. Maternity and Health visiting services are delivered from Children’s Centres in North East Lincolnshire and as a result they had routine contact with the Mother of A from December 2010 and Child A from June 2011.  The report critically analyses the service provided and appropriately concludes that they were delivered to proper standards  31 and that there was no information available to the service to suggest that Child A or his mother was vulnerable or in need of specialist services.  5.3.5. The IMR has reasonably concluded that there were no gaps or failures in provision to Child A. Nevertheless, the author has pro-actively used the opportunity of this Review to identify recommendations for future improvements in practice. All recommendations were acted upon prior to the completion of this review.  5.3.6.  The recommendations for North East Lincolnshire Children’s   Centres  are:  1. Training needs assessment for front line children’s centre staff to be part of their annual appraisal, to include consideration of LSCB domestic violence and the impact on the child levels 1 and 2.  2. Continue to develop a multi-agency pre natal parent craft programme for all first time parents to be commencing September 2012  3. Include within home safety sessions advice on the use of social networking sites and keeping personal information safe.   5.4      Northern Lincolnshire and Goole Hospitals NHS Foundation Trust   5.4.1. Northern Lincolnshire and Goole Hospitals NHS Foundation Trust  (NLaG) have provided a chronology and Individual Management Review for this Serious Case Review  5.4.2. The report has been prepared by the Specialist Nurse Safeguarding.  The author has had no operational responsibility in the case or any direct involvement with Child A and his family and as such met the criteria for independence  5.4.3. The Report was countersigned by the Head of Safeguarding. The Countersigner had no direct knowledge or involvement of the services provided to Child A or his family.  5.4.4. NLaG had two periods of contact with Child A and his family.  The first contact was with MA in November 2011 when she attended the hospital for her first routine ante-natal appointment and the hospital continued to provide her with normal ante-natal and post natal care. The second involvement of NLaG was as a result of Child A being brought into the hospital following his injury.   32 5.4.5. The review is comprehensive and the author sought and included supplementary information at the request of the panel.  The Review appropriately notes the timely emergency care provided to Child A.  5.4.6. The review considers whether there are specific lessons arising out of this review.  Whilst not having any direct impact in relation to Child A, a technical change to ensure midwifery signatures on records are readable has been put into place.    5.4.7. No recommendations for the Trust have arisen out of this Review. Given their involvement and response, this position is a justifiable one.      5.5     East Midlands Ambulance Service (EMAS)  5.5.1. East Midlands Ambulance Service have provided a chronology and Individual Management Review for this Serious Case Review  5.5.2. The report has been prepared by the Lincolnshire Divisional Clinical Quality Manager.  The author has had no operational responsibility in the case or any direct involvement with Child A and his family and as such met the criteria for independence.  5.5.3. The Report was countersigned by the Head of Safeguarding for East Midlands Ambulance Service. The Countersigner had no direct knowledge or involvement of the services provided to Child A or his family.  5.5.4. The only episode of contact between the ambulance service and Child A was on 17th December when he received the injury that resulted in his death.  The review clearly and carefully analyses this episode and justifiably describes the response of the service as effective and efficient.  5.5.5. Whilst no lessons were identified which would have had an impact on the outcome for Child A, nevertheless the review identified three recommendations for future practice.  All recommendations were acted upon prior to the completion of this Review.  5.5.6. The recommendations for East Midlands Ambulance Service are:  1. Ensure a safeguarding referral is completed after child death or prognosis, where this is unexpected.  2. Emergency call taker to have refresher training regarding the importance of initiating bystander CPR as soon as possible within the cardiac arrest situation by using “repetitive persistence”.  3. Re-enforce the importance of managers to be present at Police interviews.   33  5.6    North East Lincolnshire General Practitioner Services  5.6.1. North East Lincolnshire  General Practitioner Services  have provided a chronology and Individual Management Review for this Serious Case Review  5.6.2. The report has been prepared by the Lead GP for Safeguarding Children in North East Lincolnshire.  The author has had no operational responsibility in the case or any direct involvement with Child A and his family and as such met the criteria for independence  5.6.3. The Report was countersigned by the Executive Lead for Safeguarding for NHS Humber Cluster. The Countersigner had no direct knowledge or involvement of the services provided to Child A or his family.  5.6.4. One GP practice had contact with Child A during his life and with the mother of Child A.  The report critically analyses the care provided to each and concludes there was nothing unusual or concerning about either their presentation or care.  5.6.5. The Review identifies some lessons for future practice, although reasonably concludes that these issues could not be judged to have had any impact on the outcome for Child A.  One recommendation is made as a result with a commencement date for action prior to the completion of this Review.  5.6.6. The recommendation for North East Lincolnshire General Practitioner Services is as follows:   The lead GP will work with Designated Professionals and other safeguarding children leads to ensure all GPs and primary care understand and act on the need to share information with relevant professionals where there are safeguarding concerns and in particular where there are concerns in respect to Domestic Violence.   5.7    North East Lincolnshire Council Children’s Health Provision  5.7.1. North East Lincolnshire Council Children’s Health Provision have provided a chronology and Individual Management Review for this Serious Case Review  5.7.2. The report has been prepared by the Head of Children’s Health Provision. The author has had no operational responsibility in the case or any direct involvement with Child A and his family and as such met the criteria for independence  34  5.7.3. The Report was countersigned by the Head of Children’s Health and Family Support. The Countersigner had no direct knowledge or involvement of the services provided to Child A or his family.  5.7.4. Children’s Health provided health visiting services to Child A throughout his life. The report considers the services in detail and reasonably concludes that they were provided appropriately and no safeguarding issues raised.  Whilst no specific gaps or failings in the service to Child A, are identified the author has used the opportunity to highlight learning and produced recommendations as a result.    5.7.5. The recommendations for North East Lincolnshire Council Children’s Health provision are:  1. Children’s Health Provision will review and develop new guidance for staff in respect of both clinical practice and safeguarding in order to improve and sustain the quality of services.  Safeguarding practice and supervision will be a focus for audit annually during the  2012/13 calendar year  2. Children’s Health Provision will work with midwifery leads to ensure that information sharing and the transition process between midwifery and health visiting is reviewed and recommendations made for a clear and robust process of transition and information sharing.  3. children’s Health Provision will work the CTP and Primary Care to strive towards all children having electronic SystmOne “shares” in place and where a practice uses EMIS, evidence of information sharing in line with the agreed process.  4. The community Children’s Safeguarding Team will raise awareness with staff through training about potential risks of social networking sites.   5.8    North East Lincolnshire NHS Care Trust Plus – NHS Commissioning Report  5.8.1. North East Lincolnshire NHS Care Trust Plus has produced a comprehensive chronology and Health Overview Report for this Review.  The author of the report is the Designated Nurse Safeguarding Children for Northern Lincolnshire.  The author had no direct knowledge of the services provided to the family or operational responsibility for those services.   35 5.8.2. The report was endorsed and countersigned by the Executive Lead for Safeguarding for NHS Humber Cluster.  The countersigner had no direct line management responsibilities for any of the services involved.  5.8.3. The Health Overview is of a high standard and proves a comprehensive review of the service from individual providers.  It contains a good level of critical analysis, provides clear judgements on whether different practice could have led to different outcomes and demonstrates a searching and professionally curious approach to learning.  5.8.4. The Health Overview has identified 5 consequential recommendations as a result:  1. North East Lincolnshire Care Trust Plus will through the Lead (Named) GP and Designated Professionals, and in collaboration with safeguarding children leads, ensure all GPs and primary care staff understand and act on the need to share information with relevant professionals where there are safeguarding concerns, and in particular where there are concerns in respect to Domestic Violence. This will be addressed through a review of accessibility of GP and primary care training which will be completed by September 2012with a roll out of training by March 2013.  2. North East Lincolnshire Care Trust Plus will ensure that robust processes are in place by September 2012 for a written report completed by midwifery service identifying issues of concern, in respect to the health and/or welfare of mother, baby and family, in all circumstances, on transfer from midwifery to health visiting care. This will include the completion of a “nil” report where there are no identified concerns  3. North East Lincolnshire Care Trust Plus will work with provider organisations/services using SystmOne, to ensure that by March 2013, all barriers are removed, to the creation of a single, accessible record which reflects all the patient’s needs, including the impact of parental and environmental issues on children, and provides a full account of all activity to promote the health, and welfare, of children  4. North East Lincolnshire Care Trust Plus, through the Designated Nurse and the Lead (Named) GP, will work to develop, by October 2012, a localised template for a practice specific safeguarding children policy, and encourage adoption by all general medical practices.  5. North East Lincolnshire Care Trust Plus, through the Lead (Named) GP, working in collaboration with other relevant practitioners will by October 2012, develop a template for practice based protocol for  36 the robust assessment and follow up of positive test results, and patient failure to attend appointments.   6  MULTI  AGENCY RECOMMENDATIONS  6.1. The individual management reviews for each of the agencies involved in providing services to Child A and his family and the NHS commissioning overview report have identified a limited number of recommendations.  Each of these recommendations has arisen as a result of agencies’ identifying areas of vulnerability or potential improvements to their services, rather than as a result of gaps or failings that had a direct impact on Child A.  6.2. What has become clear in undertaking this Review is that the service provided to Child A was appropriately provided predominantly on a single agency basis and there was no requirement for a complex multi-agency approach.   The only significant multi-agency working was in effect within the health service and where gaps have been identified here, they have been subject to recommendations by the Health Overview report.   6.3. In the context of the move towards GP Clinical Led Commissioning and the potential risks in regard to ensuring robust safeguarding during transitional periods and service reorganisation, this Review would wish to draw the Board’s particular attention to Recommendation 4 of the Health Overview Report. 6.4. During the course of this Review the emerging themes were shared with the North East Lincolnshire Safeguarding Adults Board in recognition of the potential for joint learning.  Arrangements were made for further discussion at the Adult Safeguarding Board’s meeting in July 2011.  In order to maximise the learning a recommendation has been made that this Serious Case Review should be shared with both Lincolnshire and North East Lincolnshire Safeguarding Adults Boards and Lincolnshire Safeguarding Children Board. (Multi-agency recommendation 2) 6.5. The SCR Panel has scrutinised this case with considerable care in order to be satisfied that any learning for the North East Lincolnshire Safeguarding Children Board is identified.  As a result two recommendations have been made to the Board: 1. The NELSCB to review its ‘e-Safety strategy’ to develop and include opportunities for awareness raising of the potential risks to adults and their children when initiating relationships as a result of  contact via social networking  sites.  2. The NEL SCB to share the Serious Case Review Overview report with the Lincolnshire and North East Lincolnshire Adult Safeguarding Boards and the Lincolnshire Safeguarding Children Board immediately, in order to share the learning.  37  Name of SCRP chair assuring quality of overview report Colleen Murphy Date 25.06.12    Signed on behalf of LSCB:           Craig Ferris Position:  Vice Chair of North East Lincolnshire SCB   Author:    Sian Griffiths      38 BIBLIOGRAPHY  Brandon, M et al ( 2008 ), A Biennial Analysis of Serious Case Reviews 2003-05, Department of Children Schools and Families. London. Brandon, M et al (2009), A Biennial Analysis of Serious Case Reviews 2005-07, Department of Children Schools and Families. London. Kemshall, H., (1999) 'The assessment and management of violent offenders', Kemshall, H., Good practice in working with violence, 50-73, London: Jessica Kingsley Publishers Kemshall, H. (2001) Risk assessment and management of known sexual and violent offenders: a review of current issues. Police Research Series, Paper 140. London: Home Office HM Government (2010) Working Together to Safeguard Children: A guide to inter-agency working to safeguard and promote the welfare of children. London  Mason, S (2010)  A Balanced Approach:  Safeguarding the public through the fair and proportionate use of accurate criminal record information.  Home Office McKenna, K and Day, L. Safeguarding in the Workplace: What are the lessons to be learned from cases referred to the Independent Safeguarding Authority? March 2012  ISA. Munro, E (2008):  Effective Child Protection Munro, E: (May 2011): The Munro Review of Child Protection: Final Report.  Department of Education. Ofsted (2010) Learning the lessons from serious case reviews: interim report 2009-10. April 2010. Ofsted.   