Injuries to a 4-month-old baby boy in 2019 inflicted by his mother who was mentally unwell. Learning includes: there is some inconsistent understanding regarding statutory guidance in the child protection procedures about undertaking pre-birth assessments related to mental health risk factors; coordinated work, robust information sharing and effective strategic oversight will better ensure all children are safeguarded; children are best protected when the local system of management oversight in supervision and meetings is strong, resulting in well-coordinated risk assessments, interventions, and planning; professional curiosity is best supported when working with families and other professionals if there is a local culture of collaboration and professional challenge; confident and open practitioners work better with families if their professional views are challenged, and all practitioners at times struggle to communicate with some families; families do well when they have a good understanding of their rights and responsibilities, and can make informed choices. Recommendations include: ensure that all local multi-agency pre-birth risk assessment tools and protocols and information sharing comply with child protection procedures and local guidance, and that staff are aware of, and trained, in using these; seek assurance of the quality of individual agency supervision and management oversight; consider how empowering staff and supervisors in exhibiting professional curiosity can be encouraged in training and supervision, so that staff feel confident to have challenging conversations.
      
    Serious Case Review No:  2021/C9117  Published by the NSPCC On behalf of an unnamed local safeguarding children board      This report was written by an independent author and is owned by the commissioning LSCB.  This report is published by the NSPCC with the agreement of the National Panel of Independent Experts.  Publication of this report by the NSPCC does not constitute endorsement of the contents. Copyright of this report remains with the commissioning LSCB.    1  Official     Baby D Child Safeguarding Practice Review        2021   Executive Summary   1. This systems’ Child Safeguarding Practice Review considers a time period of 17 months in 2018-19 leading  to a serious incident involving Baby D, a White European 4-month-old baby boy. His mother became mentally unwell and consequently Baby D was injured by his mother. The family was a professional family, and the mother was a professional working with families.  This incident was raised by the Mental Health Trust, as a serious incident and they completed a Root Cause Analysis. However, despite the family being known to several other local agencies, none notified the LSCP of the serious incident.  This would have been expected, given the serious nature of the incident.   2. The family was firstly known  to agencies before pregnancy as the mother had a long history of significant mental health difficulties. They were living in County A.  They had regular support from Mental Health services, midwifery and GP during the pregnancy.  Shortly after discharge from the acute Hospital when Baby D was born, the mother became unwell and threatened to kill him. She was brought into A&E (Accident and Emergency) by  Ambulance to the same acute Hospital in County A; she was detained under the Mental Health Act and she and Baby D went to a Mother and Baby Unit over 100 miles away.   3. There were confusions over which county was responsible for the family as the family had been living temporarily in County B, a neighbouring county. County B Children’s Social Care carried out a Section 47 investigation and closed the case after several weeks; County A Children’s Social Care was informed of the open case but not of the threats to harm the baby, and was not included as part of that assessment. County A Children’s Social Care carried out a single assessment under Section 17 and closed the case  10 weeks later without meeting the family or meeting with most professionals, as the family did not wish to meet them.  Professional relationships working with the family were not always straightforward; the father did not feel he was informed of his parental rights and was told he could go to prison for being obstructive at one point.    4. Mental Health professionals working with the family, continued to have concerns regarding the mother’s deteriorating mental health in the community and the family agreed that she would not be left alone with the baby. Six weeks after the closure by   2  Official     County A CSC, the mother was alone with Baby D and dropped him on the floor. They were taken to the same acute Hospital  in County A and the mother was  again detained under the Mental Health Act. The baby was treated and discharged into the father’s care.   5. Professionals at times found it challenging to maintain a professional relationship with the father. It is hypothesised that he was trying to advocate for his wife. No professionals were able to have a conversation with the father regarding how his behaviours were impacting on their work.  6.  Now after considerable support and evaluation, Baby D is thriving in the care of his parents. After the period the review has examined in detail, there was stronger multi-agency involvement: for example a well-represented Strategy Meeting took place, leading to an Initial Child Protection Conference where Baby D was made subject to a Child Protection Plan, and joint supervision took place between the Health Visitor, Social Worker and their managers, which was good practice.  7. This report makes five findings and provides questions to our local Strategic Leadership Groups and Boards regarding supervision, pre-birth risk assessments, staff confidence in working with challenge from families, and information sharing.                           3  Official     Contents      Methodology          4 Baby D’s parents’ comments      4 Appraisal of Practice         7 Findings          18 Conclusion         28                                        4  Official  Methodology  8. This review uses a  SCIE (Social Care Institute of Excellence) systems’ methodology. A Review Team was made up of senior multi-agency professionals, who had no direct involvement with the family. The team met seven times virtually over a nine-month period, plus there were individual agency meetings to agree this report, which was drafted by the lead reviewer. A virtual practitioners’ day was held in October 20201  to go through chronological events, and individual meetings with those practitioners unable to attend also took place.  Some of the practitioners completed workbooks with their reflections. The family was invited to meet with members of the review group and met once with members of the Review Team. After collating and scrutinising the multi-agency chronology and practitioners’ feedback, this report consists of an appraisal of practice looking at four periods of time, ranging in total over seventeen months, findings, and questions to local senior leaders. Practitioners gave positive feedback in relation to their experience of the practitioners’ day.   9. The parents have suggested that this Review might have benefitted from having a perinatal psychiatrist as subject expert on our Review Team. This is accepted learning for us and this report has been considered in its sign-off process by a consultant perinatal psychiatrist, who had no involvement in the family’s story.   Baby D’s parents’ comments   10. Our local and national principle is that families should be involved in Child Safeguarding Practice Reviews and there should be a portrait of the child and a focus on his experiences at the centre of the Review.  We do know that Baby D is thriving in the care of his family. The parents met members of the Review Team in January 2021 and were given the draft report.  The parents gave their account of events before they read the report, and we are grateful for their time and insight-their words are in italics. The mother  said that she had felt let down from the perinatal appointment she attended before Baby D was born and considered that she should have been given anti-psychotic medication before the baby was born to mitigate against  any deterioration in her mental health.  The mother  felt that she had been given questionable medical advice. This is addressed in paragraph 22 below.  The parents said that the time since had been very traumatic, which affected them now.  The parents said that people did not seem to care, and it felt like professionals had run away when the family had wanted help. From the beginning, the mother said that she felt that she had had no continuity of care.                                                                 1  Police, County A and County B Children’s Social Care, Perinatal Mental Health Team, Acute Hospital Midwifery and Paediatrics Teams, County A Health Visitor, Separate contact was made with the GP, Mother and Baby Unit, GP Surgery Nurse.  5  Official  11. The parents told us that after Baby D was born,  the mother had needed to see the specialist team midwife as she was unwell- she was disappointed that her voice was not heard as she did not see this midwife. She said that she had struggled to sleep and to feed Baby D. The parents felt that the midwives should have kept a closer eye on her. She was discharged from the Maternity Ward at 9:30pm on a Friday evening and was visited the next afternoon at 5pm by a Midwife. The parents said that there was no contact from the mental health team. The parents told us that as they left hospital, they were given contraceptive advice, but instead they had needed someone to reach out to them, to care and coordinate.    12. The father said that he then called 999 on the Sunday as they had no other telephone number to call. He first called the Maternity Ward, but they said they did not have anything to do with this. The mother was then admitted to the Maternity Ward. The parents thought that professionals did not understand the mother’s history and would not give her any psychiatric medication. The parents felt that it all got out of hand, as the professionals did not understand the mother’s psychiatric history, even though she was treated at the same hospital. The mother said she was very stressed.   13. The parents said that no-one communicated to the family about the planned Mental Health Act Assessment. The parents said that the mother had not been subject to a Mental Health Section in the past. They said that there were five people in the room, it was a crisis and it was pointless and too late. The father said that he lost confidence and the situation was out of his hands. The parents said that they had a new baby, and this should have been the best time, but it was the worst time. The father said that he was not able to look after his wife, and she was not well enough to understand fully what was going on. The father said that common sense would have been to keep the family together – people were trying to tear them apart.   14. The mother remembered that an ambulance with a blue light took her and Baby D to the MBU (Mother and Baby Unit). The mother found this an awful experience.  She said that she was very confused and thought she was going to prison. The mother felt that there was a take it or leave it attitude that they had to go to the MBU- the father said that he did not know they had other options. The father thought that the transfer to the MBU was illegal;  he said that the mother was distressed, and two men moved her.  The father was also trying to work. The parents said that the family had offered to care for the baby at home so that the mother could go to a local psychiatric hospital and to bring Baby D in every day to see his mother. Things, the parents said,  were not managed by the NHS.   15. The discharge from the MBU seemed too early for the father. He said that he had lost confidence in professionals. The father said that the mother was determined to be discharged. The parents said that the Psychiatrist at the MBU had not understood the mother’s history or risks.       6  Official 16. The parents said that the support from the Home Treatment Teams had varied and they had not been supportive in the crisis before Baby D’s injury. The father said that he had not wished to consent to the 78 x-rays (the skeletal survey) prescribed for Baby D when he was injured, as he feared for his future health and development. To the father, that had seemed a reasonable response, but this had led to him being seen to be obstructive and CSC moving towards legal proceedings.   17. The parents said that after Baby D’s injury, they found that the Police had little knowledge of mental health issues. They said that the mother was arrested but she  had no capacity. It was obvious. The father said that he tried to plead that they go to Hospital, so that the mother could be assessed there. The parents said that the mother was in the Police station for 11 hours until 5am. For them, this did not seem to be the right place as the mother was no risk to anyone. No one explained the process to them, they told us. The mother said that she would not have tried to run away. She said that she was treated as a criminal and should not have gone to a medium secure forensic unit.   18. The parents said that the first time they met the social worker after Baby D was injured, the social worker said they had to comply, or the child would be taken away. The parents said that the social worker did not understand. They said that the professionals were more used to broken families and did not take it well when people questioned them. The family said that they had five different social workers. The father said that he stood up to professionals, but they lived in fear and had to sign up to agreements. They felt that if Baby D fell over, tripped, they would have to bring him to hospital. The parents now had a fear that Baby D would be taken away. They said that they had seen what had happened in the past.   19. The father said that he had found some professionals helpful and he would latch on to them. He said that he was looking for someone he could trust; someone patient and relate-able. He liked people to talk and listen to him.  The father said that he liked to understand the process of what was going on and to ensure his wife had the best treatment. He acknowledged that he was vocal about that and would try to decipher things in his head to make sense. It was better when they did not need to retell their story. The father said that he had been dealing with caring for his wife for 12 years, and they had friends and family who were always there. Some family members lived close by.  He said that he reached out to them. He said that he was high functioning and kept going. They both worked and played very hard. The father said that he would always challenge and ask questions to understand things.  They had never gone against consultant’s advice.   20. The parents told us that communication was key and there had seemed to be a lack of common sense. They felt that professionals were from so many different backgrounds; they could not work together collectively. The parents said that professionals did not understand or appreciate mental health issues. The parents hoped the conclusion of this report may help someone else.      7  Official  21. When we met them, the parents had not yet received the Root Cause Analysis Report from the Mental Health Trust, and this was sent to them shortly after the meeting. The parents said that they thought that there was a cover-up.     Appraisal of Practice    Pre-birth Planning   22. The family initiated and attended a mental health pre-conception meeting which lasted 30 minutes longer than usual, which was a positive. This meeting was very good practice. The consultant psychiatrist noted that the meeting was sensitive, and it  lasted nearly two hours.  The mother had impressive insight into the likelihood of her mental health deteriorating and accepted additional support would be likely when she was pregnant; the father had many questions. On reflection, the psychiatrist considered that the pre-conception counselling protocol could be improved to focus more on fathers - their hopes and fears, attitudes to services, treatment, and their own mental health.  The mother has expressed that she should have been given anti-psychotic medication in pregnancy. In hindsight, this is a valid point and maybe the outcome after Baby D was born could have been different, but this does not mean that the decision at the time was wrong. This was investigated in the Mental Health Trust Root Cause Analysis report and it was found that the mother’s care and treatment had been appropriate.   23.  Information was shared with the GP.  The mother  became pregnant swiftly after this meeting and was booked for her pregnancy very early and identified at booking with the maternity team as high risk due to her significant history of mental illness. She had the support of the same specialist midwife in the specialist team at the local acute Hospital throughout the pregnancy.  This was good practice.   24. The mother’s health was discussed monthly at the maternity concerns’ meetings at the local acute Hospital. A decision to refer to County A Children’s Social Care at the first meeting was not made after supervision. We have not been able to clarify the rationale for this.  This decision was not challenged or reconsidered by the maternity concerns multi-agency group. The lack of contingency planning and assessment before birth was a missed opportunity. This would have been a chance to plan for a safe delivery and after-birth care from a multi-agency perspective and work in partnership with the parents in a transparent way about strengths and risks. The father’s assistance, family and support network could have been clarified. A Mother and Baby Unit option could have been discussed at an early point, and maybe one closer to home identified, if needed.   25. There was good liaison between the midwife and GP- consistent parties throughout the pregnancy. The mother remained under the care of the Consultant from the     8  Official   Mental Health Team, who  was having 3 monthly reviews with the mother and sent  letters to the GP. GP Correspondence was  filed by an Administrator; Midwifery and Health Visiting also wrote to the GP.  Now safeguarding correspondence is read by a safeguarding lead in the GP practice and flagged.   26.  All midwives at the acute Hospital are trained to use the risk assessment tool and Whooley questions. The local  perinatal mental health guideline 2017 is available on the Hospital’s intranet but this was not followed.    27. All letters were received from Maternity by the Health Visiting team. In this case the mother was not contacted as usual at 28 weeks pregnancy by the Health Visitor. This is likely to have been an administrative error.   The local provider’s Standard was not met; this is discussed in paragraph 101 below. This was a missed opportunity.   28. At times during the pregnancy, “work stress” was noted for the mother by GP and midwives, which was seen as a potential trigger for exacerbation of mental health symptoms. At times, the mother had a sick note,  excusing her from work.  This was not escalated to the Mental Health teams by the GP or known by other professionals to be taken into account at the maternity concerns’ meetings.   29. The birth plan was made by the midwife in good time: it was about the birth itself, not mental health risks, and was not shared with other agencies. It would have been helpful for there to have been a mental health review after the birth. Now as the Perinatal Mental Health Team is well established with more staff, this would be considered. There was a collaborative mental health crisis plan made several months before birth with the mother by the Recovery  Team – this was standard good practice but this was not shared with the midwifery team, GP and family; this would now be shared with the Perinatal Mental Health team.   30. Above all, in this pre-birth period, despite good family and considerable professional engagement, the local  Child Protection Procedures, local  peri-natal mental health guidance and our local pre-birth protocol were not followed for a  mother with a history of psychotic episodes and more consideration could have been  given to assess risk and strengths.   Baby D’s Birth and Hospital Discharge   31. Baby D was born in the A County Acute Hospital where the pregnancy had been booked and monitored, a healthy boy, and the plan was for the mother to stay in the post-natal ward in hospital for several days, as she had some high-risk factors. In planning for the discharge, it seemed a surprise to practitioners that the family was     9  Official living temporarily in a neighbouring county in the grandmother’s home, County B, as their home was being renovated If it was known the mother would be going out of county postnatally, the midwives in County B would have been involved beforehand.   32. Whilst waiting for discharge, the mother asked three times to see the specialist midwifery team. Normally, the specialist  team can review cases as requested or a Consultant  from psychiatric liaison could have been involved.  It was recognised that the maternity specialist team was exceptionally busy  at the time, which included several high-risk safeguarding cases. Whilst the specialist team is not available out of hours, there is always a senior midwife on call. The psychiatrist had last seen the mother a week before hospital discharge, 2 days before the Baby’s birth. It is not known how the mother’s anxieties to see the specialist Team and worries about going home were viewed by staff in the context of her history, nor how the father was involved in being a protective factor, as this was not recorded. This was a missed opportunity and may have afforded the mother reassurance or delayed her discharge. There was a flag on the electronic record to remind staff to check the mother’s care plan and that she needed to be seen by the specialist team midwife prior to discharge. Specialist team records are now stored on the electronic record relating to safeguarding and mental health, so there is now greater access to records, and they are more up to date.   33. The mother and Baby D were discharged on a Friday to County B Community Midwives; information was sent by email by the acute Hospital Administration staff and was not received or confirmed by the sender. This discharge summary had scant mental health information.    34. Good practice when a mother has a history of mental illness, and is known to the specialist maternity team if they are moving out of county, would be for the Maternity Unit to telephone through to the Community Midwives in the other county  for a formal handover,  to confirm receipt of discharge, and to request an early visit which would have ensured a visit over the forthcoming  weekend by Midwives. There are no records of this in the Community Midwifery Team in County B but the parents have told us they were visited by a Community Midwife shortly after Baby D’s birth.     35. A  discharge planning meeting would have helped- this could have involved the  family, Health Visitor, GP, mental health team and midwives from both counties. Since January 2020,  there are now discharge planning meetings  involving post-natal midwives, if  there is high risk of deterioration in maternal mental health. A newly established  Perinatal Mental Health team was launched mid-January 2019 in  County A, and it works collaboratively with the specialist midwifery team to review mothers with a history of severe mental illness        10  Official  An electronic discharge summary was sent to the GP and Health Visitor, and the mother was given a discharge summary for the community midwife, GP and Health Visitor. Secure transfer was made of records to County B community midwives.   36. There was no communication with the Mental Health team that the mother had had  the baby and no perinatal mental health care plan; she could have been becoming unwell. Currently, there is joint work ongoing around discharge planning with Mental Health teams and midwifery. Ensuring this information is shared in accordance with NICE guidance will be part of this Review’s action plan.   37.  In this instance, Baby D was not registered with his GP until early March- no agency checked on this, including the Mother and Baby Unit, where a history was taken on admission.    Mother and Baby D returned to Hospital  38. There was no formal  professional contact at home, and two days after discharge, the father called 999 on the Sunday at 10:30pm, as the mother was threatening to kill the baby. We do not know how long the mother’s health had continued to decline, perhaps during that day, or why the Mental Health services or midwifery team were not contacted by the family. Mental health can decline very quickly.  39.  The Ambulance Service attended and conveyed the mother and Baby D to the local acute Hospital, where he was born, noting that the family was living in a temporary address, but not noting that address. The Ambulance Service made a safeguarding referral to County B  CSC, where the family was staying, as they should have. However, the  Ambulance Service Patient Report Form did have both addresses. This was a missed opportunity to share and clarify addresses.   40. County B Children’s Social Care (CSC) began a  Section 47 Child Protection Enquiry and did not ascertain this was a County A child or send any record of it to County A CSC at that time. This significant confusion about area responsibility began a long train of confusing events for the family and those working with them, which could easily have been remedied. County A CSC did not receive the Police notification and were  not aware of the threats to harm the baby. The Police notification only went to County B CSC as is practice, and it wrote of the mother wishing to smother the baby. Police was aware of the temporary nature of the address in County B, as the County A address was in their research.   41. In County B, there was a timely  telephone strategy meeting with Front Door Health in attendance, but no information was gained or shared regarding the mother’s mental health, nor was the family’s County A address known. This is a serious oversight.     11  Official   Now the picture is very different in County B as changes have been made at the front door to CSC, and Police are based in the team.    42. In County A, two days later, the acute Hospital referred to CSC and a single agency assessment  under Section 17 began;  there was no strategy meeting despite the mother having threatened to harm the baby, as Children’s Social Care was not made aware of this.  This would normally take place in County A,  if CSC were made aware of risks.  In County A CSC, the Head of Service contacted the safeguarding midwives querying why information was being sent to County B, concerned that key information was not being shared, that would impact their assessment. At the same time, the Health Visitor was trying to gain contact with midwifery to make a new birth visit and was not made aware of the incident- the Health Visitor had already contacted the parents about a new birth visit and had not heard back from them. It is not clear how the mental health team and GP were informed. Good practice would have seen a joint strategy meeting involving both counties and all other  agencies taking place, and ensuring key people were invited. This does take place in Counties A and B.  43. A Mental Health Assessment took place on Monday by County A Mental Health Social Care Team. The father felt strongly that he did not want his wife detained under the Mental Health Act; he did not want his wife to be interviewed by the Adult Mental Health Team and was observed by staff to be obstructive. The mother was not initially detained under the Mental Health Act and there was agreement for voluntary admission to a Mother and Baby Unit.   44.  The mother was subject to a further  Mental Health Assessment, the following day, which recorded the potential high risk to Baby D, including the mother talking of smothering the baby and being unresponsive to Baby D’s needs. It was agreed that the mother should be detained under the Mental Health Act. The family were against formal detention, the  father was articulate and persuasive with the psychiatrist during the first mental health assessment, presenting the counter argument that mother had the capacity to consent to voluntary admission. This led to a delay in formal detention, which the Hospital advised.  In hindsight, the Assessment could have been challenged as a day later, the same doctor reconsidered the decision and the mother was detained under Section 2, of the Mental Health Act.   45. County B CSC notes that the case was allocated for assessment in County A CSC. County  B CSC attempted to contact the father for 5 days to no success; they wrote about his confusion about consent and his parental rights. Medical staff found it hard to engage with the father and he talked of finding a private psychiatric unit for the mother, and caring for the baby himself, which would have been possible. County A contacted the father twice with no reply,  and a third time he contacted the social worker himself but the contact was limited as the social worker was not sure of his identity and the father shared limited information.      12  Official  There was very little consideration of  concerns about the father’s  anxieties and behaviour, despite many professionals finding the situation difficult. Professional curiosity did not extend to asking why the father was so surprised by the mother’s mental health presentation or what help he needed.   46. In the meantime, the mother and baby stayed on the maternity ward with nursing observations. There were conflicting professional  views of the mother’s ability to care for the child. The mother spoke of feeling abandoned by the specialist team midwife and wondered if she should have phoned the Team before. The Hospital contacted County  A CSC. And County A CSC tried to contact the Hospital in return, leaving six phone and email messages. A conversation would have led to a better understanding of matters for both sides and a sharing of strengths and risks.   47. County B CSC had 12 minutes’ notice from the Hospital maternity unit, before the mother and Baby D were transferred to the MBU (Mother and Baby Unit) out of the area, and County B CSC requested a discharge planning meeting.  This did not occur and would have presented another opportunity to clarify roles and responsibilities, not least addresses. That same day, County A CSC had contact with the maternity team in the Hospital to discuss the family’s address and plan to go to the MBU.   48. The GP practice were notified of mother’s attendance at A&E, including her detention under the Mental Health Act by a summary document. The summary did not include that mother had had thoughts of harming her baby. At this time there would have been no active role for the GP, as she was an inpatient on the Mother and Baby Unit.     The Mother and Baby Unit   49. The confusion of owning locations and areas spread to the  Mother and Baby Unit (MBU),  where it was recorded that “County A and B CSC” was carrying out an assessment. This added to the disadvantage of the MBU being approximately two hours away from home.    50. The MBU  assessed the situation, and considered that there was no impression there was a risk to Baby D. In the MBU, a history was taken from the father; he said how the mother had not wanted to have the baby and  said that the baby was better off dead. It was not clear if this information and stress for the father was shared with any party, and how it informed the MBU’s risk assessment and subsequent work with both parents.    51. The mother did not voice any threats towards the baby in the Unit and the Unit based the mother’s discharge on this. This would seem to be overly optimistic and not taking into account context, multi-agency involvement and history. This assessment seemed     13  Official  centred on the mother.  Children’s Services’ involvement  and future planning, including contingency plans should have been clarified whilst the mother and baby were safe, and good practice would have led to a  multi-agency meeting to achieve this.   52. The mother wanted to go home and was discharged from her Section after 6 days by a new doctor to the Unit. She requested discharge home a week later- in the meantime, the MBU and County B CSC had found it hard to contact the father, as he was working. He was concerned about the mother being discharged and becoming unwell again. Home leave then began.   53. Home leave was not ideal at this time in the MBU’s hindsight opinion,  due to the mother’s health, and the mother’s bed was left open in case it was needed again. It was hard for the Unit to liaise with local professionals in the home area. They routinely updated the Health Visitor but not the GP-this would only have happened on discharge. The Health Visitor, but not the GP are invited to CPAs (Care Programme Approach Meetings) and discharge meetings, which was what happened in this case. The Health Visitor did not attend the discharge meeting,  as it was out of county, and a significant distance, which was understandable.  The County A social worker was on the way to the discharge meeting and it took place without her; unfortunately, her train was delayed.  It would have been good practice for the Unit to  have updated the local GP and Mental Health Trust with details of any home leave, and for the discharge meeting to have waited for the social worker.   54. For local residents, MBU home leave is staged with short periods at home, Occupational Therapy visits and support from the Unit. This could not happen due to the distance for this family. The transfer to Mental Health services was not straightforward as the Home Treatment Team can only be referred on discharge and do not attend discharge meetings or CPAs. Shortly after this, there was a transfer between perinatal teams as the mother moved back from County B to County A.  55. There was a slight deterioration in the mother’s health before home leave, but the mother was an informal patient. The father was concerned regarding the deterioration. But the mother would not agree to stay. At this point, County B CSC closed the case. County A CSC met the MBU but not the family, as they would not agree to this. There was an MBU agreement that the father or maternal grandmother would always be with the mother and baby. There was no plan shared with the family or other agencies, with contingencies.   At Home  56. Following leave from the Mother and Baby Unit, the family lived at home, firstly with the maternal grandmother  in family accommodation in County B, and then back to the family home in County A for the next two months. Two weeks later, the mother      14  Official was discharged from the MBU by a series of telephone calls. Had she been a local resident, a lot more outreach would have taken place. Normal best practice  would have been a sit-down discharge meeting from the MBU involving the family and other agencies.    57.  During this time, many mental health professionals were involved: the MBU, the Perinatal Mental Health Team, the Recovery Team and the Home Treatment Team. This was confusing to professionals and family members and no lead Mental Health professional was identified.  Sometimes joint visits were carried out by the Perinatal Mental Health Team and the Home Treatment Team, which was good practice. The professionals did ask to see the mother alone, which was good practice, but both parents declined. In hindsight, this could have given another picture as to her wellbeing. Mental Health practice guidelines have been developed independently of this review by which practitioners are expected to try to see a client alone on at least one occasion, to allow for the use of routine enquiry about Domestic Abuse.  58. The family had found the Home Treatment Team visits disruptive due to different staff members attending; there were two occasions where the family cancelled visits – this was due to the Team being late for appointments and therefore was not unreasonable. On both occasions, the mother was seen the following day.    59. Risk was often assessed as low to moderate and included that Baby D should not be left alone with the mother. The family declined  informal re-admission to the MBU. There was reassessment under the Mental Health Act, and it was assessed that mother was not detainable. The Review Team could not identify if there was consideration or discussion with the family around the reasons for not wanting to return to the Mother and Baby Unit. We acknowledge that the Unit was a two-hour drive from the family home, and this could have been a substantial barrier. This potentially highlights the challenges of finding local MBU placements.   60. There was no evidence that the father was offered the option of a Carer’s Assessment by any agency,  to identify what support could have been available for him as he was in what could be imagined a stressful situation balancing the needs of caring for his new-born baby, unwell partner and juggling work commitments. Whilst consent would be required for this assessment, the local carers’ network would have carried this out in County A. This would be expected as good practice, so that the father  could engage in services in his own right. This is not always remembered by staff in general in our local safeguarding system. He could have been offered Carers’ support some years ago as well  before the baby was born, or he could have approached the network himself.   61. At times, it was noted that mother was trying to calm the father and grandmother at visits. This was not a matter for professional reflection.        15  Official  62. There was good communication between the Health Visitor  and the Perinatal Mental Health Team. The Perinatal Mental Health Team updated the GP after visits. Professionals found the father stressed  and at times challenging to work with. The Home Treatment Team   professionals visited in pairs following a decision they had made together regarding working with the father- there were no physical risks. They informed the Perinatal Team of this but did not inform other agencies of this decision. No agency or professional  thought of the effects of the father’s behaviour on the baby.  The Mental Health Home Treatment Team nurse thought that father was aware of any risks, due to mother’s previous relapses during their relationship.  63. The mother’s mental health fluctuated. The mother was seen three times by the Health Visitor, and the mother and baby were seen once by the GP at a 6-week check.  The mother was transparent at this meeting, informing the GP of her ill-health and admission to the MBU. The GP had not met the father. On reflection, following the  mother’s 6-week review, a case discussion between the Health Visitor  and GP would have been helpful; this would have enabled discussion about the potential impact of the mother’s mental health on Baby D.  64. During this period,  the Perinatal Mental Health Team’s concerns rose for the mother’s deterioration in mental health. County A CSC closed the case with the social worker on the manager’s direction, contacting the Mental Health Nurse, Health Visitor and Psychiatrist  in advance.  The CSC Team Manager completed the single assessment. A telephone call was made afterwards to the GP,   and  letters were  sent to the family, mental health nurse, Health Visitor and GP with the outcome of the single assessment.  Maybe there was a false sense of security that the family was engaging with the Mental Health Teams. At the time this was a  new Perinatal Mental Health Team. On reflection, the Team  was in its infancy and today this case would have been followed up with CSC by them, which could have potentially stopped case closure.   65. The CSC closure seems to stem  from the family declining to work with County A CSC and the involvement of mental health services. This should have been seen as a warning signal, and professionals should have been invited to a  meeting to share the full history- this would have been good practice. The mother’s thoughts of harming the baby when she was very unwell were not taken into consideration, as County A had not known of this.  The single assessment was completed and the recommendations with a letter were shared with other agencies. This is normal practice. The single assessment and a letter were  sent to the family.  There was no context or analysis around the mother’s fluctuating insight and mental health. The family had expressed, they did not need support.  66. Five weeks later, the baby was injured. It would seem professionals assumed CSC was involved- we do not know why professionals did not escalate this at the time nor challenge when the case was closed despite risks rising, as the Perinatal Mental Health Team informed the social worker regarding their concerns.  That Team spent     16  Official considerable time finding out how to contact the social worker and there was no feedback. The  Social Work Team manager completed the single assessment and closed the case, giving the management oversight of this decision in CSC, detailing mental health and Health Visitor support. The social worker had left. We question the effectiveness of supervision received at the time for all involved agencies. We ask if there was a false sense of security for professionals working with the mother.   67. We note the vulnerability of two different parties in the family dynamic and at risk at home, particularly at weekends.  There was a wish for the mother to continue life as normal and care for the baby. There was a focus on the mother, and not on Baby D.   Baby D was injured   68. The family did not initiate contact - it was always at the initiation of the Perinatal Mental Health Team. In the week before a bank holiday Monday, the Perinatal Mental Health Team noted a further decline in the mother’s wellbeing. The Perinatal Nurse had previously been on leave. The Health Visitor and Care Coordinator were informed. A safely plan was developed by the Perinatal Mental Health Team and revisited with the family; the Home Treatment Team could have been engaged over that weekend.  At every visit, the safety plan was updated with the family. The care coordinator  in the Recovery Team  and the consultant psychiatrist were informed. The Perinatal Mental Health Team brought the consultant’s appointment forward to see the mother. All agencies who were involved and the local  CSC should have been informed.     69. When the mother was alone with the baby in the family home in County A on a Friday of the forthcoming bank holiday weekend,  her mental state deteriorated and as a result she dropped Baby D deliberately. She subsequently informed the maternal grandmother of this, as she was in another part of the home, and the maternal grandmother called 999.   70. Ambulance attended the home and the mother, maternal grandmother and Baby D were brought to the A&E Department at the acute Hospital in County A  (the same hospital as noted above). The Ambulance Service called Police to assist.  The mother was subsequently arrested and taken to Police custody; she was not placed in a cell, but she was sat in the charge area with the father.  She was checked every 30 minutes.  This was evidence of compassionate policing.  In Hospital, the maternal grandmother remained with the baby. A Mental Health Act assessment was carried out  in police custody as is police policy, and the mother was detained at a psychiatric hospital in County A. This was appropriate practice in a crisis situation for the mother.   71. Baby D was admitted to a ward as a place of safety at the acute Hospital in County A. The father denied consent for additional photographs to be taken of the      17  Official  baby.  Hospital staff wanted to take photographs of a possible stork mark. A skeletal survey was carried out, which is standard procedure for an infant fracture according to NICE guidance in these circumstances, evidenced by the Royal College of Paediatrics and good practice. Professionals found the father’s behaviour challenging. He suggested involving a solicitor. This made professionals feel anxious when working with the family and medical staff told him that he could be imprisoned for being obstructive. This type of encounter would only raise anxieties for a parent and for staff members. On reflection, staff noted how this tension inhibited their practice and how fearful the father must have felt. Some spoke of how they felt controlled and unable to function; one person said that the father had berated them.  Some noted that the father seemed to prefer to work with more highly qualified professionals. This was seemingly not picked up in their professional supervision and addressed.    72. The strategy meeting four days later was tense, partly as the father was on the ward, although he was not involved in the strategy meeting itself.  The meeting was chaired by a County A CSC Team Manager, and ten professionals attended, which was appropriate. Police  attended the acute Hospital and assessed that the father was suitable to care for the baby, following Police intelligence checks. A discharge plan was made.   A LADO (Local Authority Designated Officer) referral was made by the Mental Health Trust Named Nurse three days later, due to the mother’s professional status. The father’s fear and  resistance were not discussed, which was a missed opportunity for both the family and professionals. There was no discussion of staff safety. Professionals were invested in  developing a good working relationship with the family, and so avoided addressing their concerns of safety and resistance. There was no sense of assessing the daily lived experience of a four-month-old baby with such relationship dynamics going on around him. The safety plan was discussed with the father at a subsequent home visit the following day by the social worker. There was also a discharge planning meeting.   73. Following examinations, Baby D was discharged into the care of his father four days after the incident,  that same day. Plans were also made for an Initial Child Protection Conference to take place. Debriefs were held for staff in the mental health teams. This was good practice.   74. The quality of information sharing could have been improved. There was no request for information from the GP by CSC until  over a week after the injury. The Hospital discharge letter was received by the GP surgery over a week after discharge, informing them that Baby D had been admitted following a Non-Accidental Injury.   75. No one informed the GP Surgery of the incident or discharge planning meeting- and Baby D attended the GP a couple of days afterwards for immunisations with the Practice Nurse. The Practice Nurse was not aware of the injury and as a result of learning, Practice Nurses at this surgery now note who brings a child in to appointments.       18  Official   76. The Mental Health Trust raised the incident as a serious incident within their own agency and carried out a Root Cause Analysis, raising this incident with the CCG in a timely manner.  Best practice would have been for each agency to have raised this as a serious incident immediately.  This was subsequently raised as a serious incident with the LSCP by the CCG - a significant delay of eight months.  Findings and Recommendations  77. We have outlined five  improvement recommendations for our local Partnerships to consider. We have identified several safeguarding contributory factors, which led to the serious incident in 2019 for Baby D using the themes of Tools, Information Sharing, Management Systems and Staff Interactions with Family Members. Rather than one cause or a concern for any one agency, these are system wide improvement issues. These issues for improvement take us beyond Baby D’s story to our local safeguarding systems.  Recommendations are made to both the Local Safeguarding Children and Adults Partnerships in the three local areas.    Tools  Pre-birth assessments and protocols  78. There are several local  tools to aid risk assessment and information sharing. The LSCP Pre-birth Protocol was first launched in 2015 and has been refreshed during this review period,  and the Think Family Protocol was updated in 2019. We have found that  many local practitioners are unaware of these documents, as well as the local  Child Protection Procedures or the local Perinatal Mental Health Guidance (2017) which outline pathways to assessment when there are pre-birth concerns.  The  Child Protection Procedures states  “ Or s/he could be an unborn child: Of a pregnant woman with any previous major mental disorder, including disorders of schizophrenic, any affective or schizo-affective type; also, severe personality disorders involving known risk of harm to self and / or others.” Our multi-agency local Threshold Document follows local guidance and outlines required action where there are pre-birth concerns of mental ill-health.  If these procedures had been followed, there potentially would have been adequate pre-birth planning for Baby D. Findings are in common with the Child O Serious Case Review, around a need to strengthen a coordinated multi-agency approach, and to include the voice of the child.   79. A pre-birth referral could have been made before 12 weeks’ pregnancy in this case, despite the mother being in good health, based on any single health agency assessment of risk. The  Child Protection Procedures advise that best practice is for a pre-birth assessment to be completed by 20 weeks pregnancy. In this situation, the clock would be ticking for CSC, but a decision could have justifiably been made to go over the 45-day single assessment timescale, thus not placing pressure on CSC to  19  Official close the case. Later, in the MBU, the threshold would have been made for a referral to CSC, if they had not been already involved.   80. Since this time, the acute Hospital’s maternity concerns meetings have been reviewed and their format changed, as at the time of our review, large numbers of pregnant women were discussed -  every woman  on the list.  Local guidance has been refreshed to triangulate with the Child Protection Procedures and local protocol. Now fewer vulnerable women are discussed each month  -  only new and high-risk women are discussed. This is a busy maternity unit serving  approx. 5,600 women per year and several  counties. Currently  not all other counties attend this meeting for their cases, but they receive lists.  The Perinatal Mental Health Team are planning to attend. The  County A  CSC Front Door Team, Drug and Alcohol and Health Visiting teams attend consistently. This meeting can now work effectively as a virtual and offline model to bring in other counties and services.  81.  Maternity concerns meetings’  minutes are now recorded on an Excel database, which ensures easier searching and reads more succinctly for everyone involved in the meetings.  All agencies who usually attend, are emailed prior to the monthly meeting to enable them to access any further updates to bring to the meeting. Rather than discussing every woman, only the recognised high-risk women are discussed or  if there have been any updates from any agencies or individuals.  The action tab, on the database, is updated after each meeting with the relevant information on what action is required, which individual or agency is actioning and the results of these actions.    82. We have found that the mental health risk assessment focussed on the adult not the child. The Mental HealthTrust’s risk assessment guidance is comprehensive and includes consideration of everyone in the household, children at risk, family support, guidance around carers, home leave, discharge, contingency planning, and an equality impact assessment tool.  Risk guidance should be clear on action and information sharing if the adult deteriorates in health or access cannot be undertaken to see the individual. A decline can happen very rapidly. As the social work team is now not part of the local mental health service in County A, a possible check and balance is missing. Local  CSC  Teams since this time has provided considerable staff development around pre-birth assessments.   83. Practitioner understanding of Baby D’s vulnerabilities pre-birth could have been stronger. The national picture 2supports our local analysis and search for improvement in working pre-birth and with infants. The Child Safeguarding Practice Review Panel has outlined that they have seen 137/500 cases for babies harmed or killed by non-accidental injury since its inception in June 2018 to December 2020. More than half appeared to have involved weak risk assessment and poor decision making. Between the beginning of the pandemic in March 2020 and October 2020,                                                            2 Child Safeguarding Practice Review Panel January 2020-Thematic review into non-accidental injury in children under one; Amanda Spielman 6th November 2020 speech at the NCASC 2020 (National Children & Adults’ Services Conference); Children’s Commissioner Lockdown Babies May 2020 https://www.childrenscommissioner.gov.uk/wp-content/uploads/2020/05/cco-lockdown-babies.pdf  20  Official Ofsted saw 40% of their serious incident notifications for babies; a fifth more than in the same period last year -  8 babies died.            Information Sharing in short and longer-term work  84. Information sharing is a local systemic issue for us to improve, as partners have told us of instances of not knowing information pre-birth, post-birth and regarding child protection enquiries and serious incidents.  In this case, not all key agencies knew most importantly that the mother had threatened to harm Baby D when first admitted to Hospital when he was 7 days old. Those agencies who were aware of this risk did not  reflect on this or share the information, ensuring partners were aware.   In this case, there are many other instances where important information was not shared or reflected on within or between agencies, such as the  mental health team visiting the family in pairs, when County A closed the case despite the Perinatal Mental Health Team raising concerns, or the GP noting the mother was suffering from work stress in pregnancy, which was a potential trigger for  a decline in mental health.  85. There needs to be consideration that when a child is discharged from Hospital, the ward telephones or emails involved agencies to inform of any Non-Accidental Injury, other serious issues, and discharge into the community, as appropriate. This will address the time lag between discharge and receipt of the discharge notification.  Baby D had attended the GP surgery for his third set of immunisations the day before the discharge notification arrived. Birth discharge notifications are also still handed to  mothers to give to the Health Visitor and GP; details of babies are not routinely taken by GP Practices when electronic notifications of births arrive from  hospitals. This is being addressed by ongoing strategic work between the CCG, GPs and Maternity Services.   86. The hospital or urgent care centre treating children for Non-Accidental Injuries or any other suspected abuse should make sure the  GP and other relevant professionals are aware of serious incident, and invited to  attend discharge planning meetings and receive any notes and safety plans immediately. GPs should be routinely invited to FINDING 1 There is some inconsistent understanding regarding statutory guidance in the Child Protection Procedures about undertaking pre-birth assessments related to mental health risk factors  QUESTION 1The Partnerships are asked if they are assured that all  local multi-agency pre-birth risk assessment tools  and protocols comply with  Child Protection Procedures and  local guidance, and if  staff are aware of, and trained, to use them.    21  Official attend strategy meetings by CSC and information requested if they are unable to attend.  They should not need to wait for the  normal discharge summary, as in this instance and in general, this can take some days to arrive.     87. GP surgeries have differing local practice in flagging records and sharing information regarding vulnerable patients. The GP Safeguarding Lead would have expected the records to be flagged and initiated discussion regarding next steps. The process outlined above whereby the safeguarding lead in each practice reviews all correspondence regarding safeguarding would have ensured a more robust response. A standard recording of who brings a child to appointments would also have been helpful and has been put in place at the GP surgery involved.  88.   Information was not clear to the family or professionals regarding the Mental Health lead for the mother, nor the rationale for staff visiting the home in pairs.  The Mental Health Teams seem to have asked family members to ensure that the mother was not alone with Baby D and to have informed them when her health declined.  This did not fully take place. The father seems to have been unaware of his rights as a parent, and as Nearest Relative to the mother as a mental health patient.   89.  It would seem that assumptions are made that information is known to other agencies, particularly when CSC is involved; agencies assumed County A knew about the mother wishing to harm the baby at the first Hospital admission. In some agencies, supervisors do not seem to systematically check the involvement of other partners. It could be pressure of work that prevents practitioners reflecting and thinking widely, but supervision should be a check on this. We address the issue of supervision below.  90. The need to strengthen information sharing from frontline to strategic levels was evident in our local counties. Strategic leads were not always identifying serious incidents within their agency, addressing this within their own system and alerting the Partnership to potential learning. Protocols in place were not being used.   County A  CSC  refreshed the serious incident guidance in June 2020 and the Partnership itself in October 2021.  In County B,  there have been improvements to the safeguarding front-door when cases are transferred to another county- this has been assured by a dip-sample audit of cases. “Think Family” has been disseminated as a concept for our working together since this review has begun, with a webcast being developed in February 2021 and plans being made for a summer  virtual Conference  with all the local Safeguarding Adults’ Boards.         FINDING 2 Coordinated work, robust information sharing and effective strategic oversight will better ensure all children are safeguarded. Our local information sharing within and between agencies can be further strengthened. QUESTION 2 The Partnerships are asked if they are assured that all  local multi-agency and single agency information sharing complies with the Child Protection Procedures and local guidance, and if staff are aware of  and comply with this.   22  Official         Expectations of families   91. We note that the father requested information about his parental rights to care for Baby D, as is understandable. Confusions about local area responsibility, would not have helped the family’s working relationships and we can imagine they will have sometimes felt very frustrated, alone, and afraid.  This may have led to them wishing to work with more senior professionals in the network.   Management systems  Staff oversight   92. Staff supervision is an extremely useful tool to help a practitioner reflect on their work with a family and other agencies and should provide an objective view to ensure any safeguarding issues have not been overlooked: it should be a system check. Supervision was taking place across all agencies in this review but was not  always effective. The Mental Health Teams had regular supervision including daily clinical supervision for the Home Treatment Team.  We wonder whether better staff oversight could have helped professionals to see the baby, and hear his voice, instead of focussing on the adults, with possible associated unconscious bias around the family’s professional status and ethnicity.   93. This review has found supervision at the acute Hospital led to a referral not going to CSC from the maternity concerns’ meeting. Subsequently there has been training of midwives in supervision and the process has been strengthened.  In the acute Hospital, there is a safeguarding supervision policy and a form is completed together in supervision for individual case holders, finalised by the Named Nurse or Named Midwife.  This is then put in the case records by the professional and a plan is agreed between the supervisor and supervisee. It is down to the professional to bring cases they wish to discuss. Best practice would be for previous actions to be discussed too, and clear documentation made of changes of plans.  94.  From summer 2019, there has been monthly open peer group or individual  supervision session for ward staff and A&E at the Hospital for anything they wish to discuss, undertaken by the Named Nurse or Named Doctor.   95. In County A, there were some changes in  CSC teams, and the social worker left, meaning the manager completed the  single assessment. It was a busy time in the  23  Official team due to staff turnover issues. Supervision would have noted that risks were rising as the case was being closed and multi-agency views were required.   96. The County A  CSC  Supervision Policy was updated in January 2021. A lot of work has gone on around supervision in CSC. Timescales are clear within the policy and included within the policy is joint supervision with other professionals, including Health and Education. Case discussions are held at least every eight weeks. There is a 10-day management oversight for all new assessments. In this instance, there was management oversight and case review three times in the first month. Reflective supervision applying the Signs of Safety approach is used.  After the Review period,  there was a joint supervision with CSC and Health Visiting, where they used a discrepancy matrix to reflect on the work with the family and consider next steps.  This was good practice.   Group / peer supervision happens between weekly to  monthly in CSC, and learning groups take place monthly. Practitioners are encouraged to have informal supervision whenever there are difficulties.   97.  In separating the Adult  mental health and social work teams in County A in 2017, the review has found that information sharing, and management oversight have fragmented in more than this one case. Good supervision would have helped staff develop relationships with other agencies working with this family and allowed for more professional challenge each agency’s decisions. It would have helped practitioners focus on the child and risk.   98. Supervision in Maternity at the acute Hospital in County A has changed over the last year. Originally, every member of staff in maternity would undertake a yearly inhouse update surrounding safeguarding and mental health.  They would also undertake an external multi-disciplinary update session every 3 years.  As well as this, the Band 7's in the specialist team would have a quarterly supervision with the Named Nurse for Safeguarding, who had the requisite Level 4 qualification. The Safeguarding Midwife and the Link Midwife for Domestic Violence also had this qualification. Last year the Safeguarding Midwife and the Deputy Director of Midwifery, undertook this Level 4 training.  The idea of extending this training was to be able to provide supervision to a recognised group of midwives who would benefit from this extra support.  This group of midwives were the Antenatal Clinic, Community and Examination of the Newborn Midwives.  Therefore, as from January 2020 quarterly supervision was started for these extra midwives alongside the previously mentioned updates for everyone else.  The aim is to provide supervision for 100% of these midwives every year.  99. The Health Visiting team has a standard  to ensure vulnerable women identified in pregnancy are followed up pre-birth- this did not happen for Baby D, and we do not know why. Baby D was not  identified as being in the higher tier (Universal Plus) for support.   100. The Health Visiting service in County A receives many specialist Hospital maternity team referrals with very few being opened to the specialist maternity team itself.  There is now a health visiting triage system as part of its Practice Standard to determine if the pregnant woman’s support should be opened or supported under the Universal offer. This Standard was introduced in January 2019.  The first audit of this  24  Official Standard was due in January 2021. There is currently no checking process to determine if the contact with the pregnant woman is undertaken following the triage.  Health Visiting is currently considering if a check could be implemented at 34-36 weeks pregnancy.   101. There should have been a strategy meeting at the first admission of the mother into hospital with significant mental health concerns,  and where, in addition,  the mother was threatening to harm the baby. County B had opened a Section 47 child protection enquiry but did not include any health professionals in the strategy meeting, save the front door health lead. Work has commenced by  County A CSC to improve the quality of referrals from other agencies.  Management oversight of professionals involved did not notice missing information, nor the confusions regarding addresses escalated to ensure this was resolved in a timely way. In comparison, the strategy meeting at the time of the baby’s injury was comprehensive three months later and shows good practice. We want to improve the identification of risks pre-birth and encourage professional curiosity to ask more questions.   102. One agency informed the LADO (Local Authority Designated Officer who oversees allegations made against staff and volunteers)  of the mother’s professional role, and before  Baby D’s birth, her anxiety was seen as “work stress”. We have asked ourselves if a non-professional or non-white family would have received the same response.   103. We are pleased that there is now as a result of this learning,  a process of identifying the lead Mental Health Professional in place. The Root Cause Analysis report was very good, and identified care and service delivery problems in its learning. It found that there was a lack of a  multi-agency approach in the working between the Recovery and Support Team, the Perinatal Community Team,  and Children’s Services; and that the Recovery  Team were delayed in providing a care coordinator, who would have been the lead mental health professional and a point of contact for the family and professionals.    104. One agency picked up the serious incident and non-accidental injury at a strategic level and ensured strategic oversight and learning. The reporting of serious incidents is a nation-wide matter of discussion at present. Locally, there has been a decrease in reporting over recent years in our sharing of serious incidents within the Partnership; the policy has been refreshed after our Independent Scrutineer reviewed the process in summer 2020, and more recently we have seen an increase in reporting. There is discussion in the  Designated Doctor network how the STEIS (Strategic Executive Information System) relates to the local reporting system as a national issue. Currently, supportive and reflective models of supervision are being considered to support local practitioners in understanding cases which seem “stuck” or challenging. Joint supervision took place between CSC and Health Visiting and their managers after this review time period, which was good practice. We will be ensuring single agency and our Partnership escalation and resolution policies are embedded further.    25  Official                    Practitioner interactions with family members  The family seems to have found some professionals hard to work with, and similarly, some professionals found it challenging to work with the family at times. Understanding was needed on both sides. This working situation was hampered by incomplete information sharing  and at times the confusions about lead professional and county. If professionals had communicated more effectively, the family would have had a better experience of professional support, and professionals would have been able to address any concerns of challenge in working with the parents more effectively.   105. Working with professional  and or affluent families sometimes requires practitioner confidence to face challenging conversations.  This has been evidenced in others of our local learning reviews over time,  and there have been multi-agency action learning sets to develop skills.     106. Practitioners sometimes find it hard to explain in words how they feel about the families they work with. In this case, practitioners’ assessments did not outline the difficulties they encountered in engaging with the family at times, and the effect of this FINDING 3 Children are best protected when the local system of management oversight in supervision and meetings is strong. This  leads to well coordinated risk assessments, interventions, and planning.  RECOMMENDATION 3 The Partnerships  are asked to assure themselves on the quality of individual agency supervision and management oversight.    FINDING 4  Professional curiosity is best supported when working with families and other professionals if there is a local culture of collaboration and professional challenge.  RECOMMENDATION 4  The Partnerships are asked to consider how empowering frontline staff and their supervisors in exhibiting professional curiosity can be encouraged in induction, training and supervision, so that staff feel confident to have challenging conversations, challenge their own stereotypes, and  reflect on their work. (Burnham Social Graces)     26  Official on the baby’s care, and safeguarding. This could stem from the impact of family’s ethnicity, culture and professional status on workers, and workers’ lack of confidence.   107. Local professionals often struggle to work with challenge- they modify their behaviour at times and are better equipped to deal with physical hostility instead. Professional supervision, and multi-agency supervision to reflect would help. Professional curiosity could have been strengthened in understanding the family, their ethnicity and culture, and to use the prompts in agency guidance and templates.  These gaps in knowledge were not always identified or addressed. This style of working meant that the baby’s experience and needs, and the support for the family  were not comprehensively considered. This is not new learning in our local learning reviews and multi-agency audits. Practitioners sometimes  find it hard to consider issues of ethnicity and culture, and perhaps find it uncomfortable to ask, maybe particularly so with professional families. County A CSC is doing work on identity and culturally sensitive practice.   108. Agencies had varying amounts of information about ethnic identity, religion, and its impact. In many cases,  family is a critical support to any new mother and support and its availability should be discussed. Assumptions were  made around the mother’s profession and education and working with professional parents. We have asked ourselves how  staff are prepared for  encounters  and manage possible challenge. Work around identity and support was work which could have been undertaken during the pregnancy without any sense of urgency yet was never fully completed in approximately 18 months of intervention. Only one lead in the network would have needed to ask the questions, so that there was no duplication of effort.  In County  A  CSC the front door teams now have packs for families with information about  consent, which is good practice.                     FINDING 5 Transparency is key when working with families. Confident and open practitioners work better with families if their professional views are challenged, and all practitioners at times struggle to communicate with some families.  Families do well when they have a good understanding of their rights and responsibilities, and can make informed choices.   RECOMMENDATION 5 The Partnerships are to assure themselves that local practitioners have sufficient understanding, supervision, resources, and training to engage with families with professional curiosity, and resilience.    27  Official    Conclusion  109. This report is presented to the LSCP in Counties A and B. It has been sent to the National Panel and the What Works Centre for Children’s Social Care.   110. We acknowledge some limitations in this Review as all meetings have all been virtual due to the ensuing COVID-19 pandemic. Our local learning has corresponded with national learning in terms of  risks of non-accidental head injury in babies 3, information sharing, the  importance of supervision and the need for thorough assessments for parents with mental health concerns.   111. The Review Team would wish to thank  the family and all practitioners who have taken part in this review and brought such helpful learning and reflection about our local systems, especially during a time of crisis working. We trust together with the parents that this report may make a difference to the safeguarding of  future local children and their families.                                                               3 https://learning.nspcc.org.uk/media/1351/learning-from-case-reviews_perinatal-healthcare-teams.pdf; https://learning.nspcc.org.uk/children-and-families-at-risk/parental-mental-health-problems#heading-top 