Serious injury of a 32-day-old baby boy. Antonio was taken into the care of the local authority; his father was found guilty of causing grievous bodily harm (with intent) and jailed. The case did not meet the criteria for a serious case review (SCR) however Kent safeguarding children board decided to conduct a review, largely following the SCR process. Family were known only to universal services and the review did not find any significant weaknesses in the services provided before or after the incident. At the time of the incident, detailed information about the case was published in the national and local press, which led to a public disturbance at the family home and the home of maternal grandparents. Identifies key learning points and missed opportunities, including: a lack of coordination in the arrangements for setting up the review process; leak of confidential information regarding the case, which led to significant public disorder.
      
 Title:  'Antonio': a case review LSCB: Kent Safeguarding Children Board Author: Kevin Harrington 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.                        This report is the property of the Kent Safeguarding Children Board. It is confidential and is not to be disclosed without the permission of that Board Page 1 of 19 Kevin Harrington Associates Limited           “ANTONIO”  A CASE REVIEW         Kevin Harrington JP, BA, MSc, CQSW  On behalf of the Kent Safeguarding Children Board  Completed in October 2012             This report is the property of the Kent Safeguarding Children Board. It is confidential and is not to be disclosed without the permission of that Board Page 2 of 19 TABLE OF CONTENTS   TABLE OF CONTENTS ............................................................................... 2 1. INTRODUCTION ...................................................................................... 3 2. CASE REVIEW PROCESS ...................................................................... 3 3. BACKGROUND INFORMATION ............................................................. 5 4. NARRATIVE CHRONOLOGY ................................................................. 5 5. THE AGENCIES ...................................................................................... 8 5.1 Darent Valley Hospital ............................................................................. 8 5.2 Kent Community Health NHS Trust ........................................................ 8 5.3 Kent Police ............................................................................................... 9 5.4 Kent County Council Children’s Services ........................................... 10 5.5 Kings College Hospital .......................................................................... 11 5.6 General Practitioners ............................................................................. 11 6. SPECIFIC ISSUES IDENTIFIED IN THE TERMS OF REFERENCE FOR THIS REVIEW ............................................................................................ 11 6.1 Introduction ............................................................................................ 11 6.2 What was your agency’s involvement with Antonio and his family from January 2011 until this review was initiated? ................................... 11 6.3 Did your agency hold any significant history of any member of this family  prior to this time? ............................................................................ 12 6.4 Evaluate the nature of support provided within the Maternity Unit including preparation and support arrangements in relation to discharge, and transition from midwifery to health visiting services. .... 12 6.5 How did your agency take into account parents’ previous history, family and social relationships when assessing their parental capacity prior to the incident? ................................................................................... 14 6.6  If predictive risk factors were known, were they acted on appropriately and shared across all agencies? ........................................ 14 6. 7 What lessons can be learned from this case in relation to the way local professionals and agencies worked together to safeguard and promote the welfare of the child? ............................................................... 15 6. 8 What was the quality of work undertaken by each agency and how did it contribute to the wider multi agency response? ............................. 15 6.9 Is there evidence of good practice illustrated by this case? ............. 16 7. CONCLUSIONS: KEY LEARNING POINTS AND MISSED OPPORTUNITIES ...................................................................................... 17 8. RECOMMENDATIONS .......................................................................... 18 8.1 Introduction ............................................................................................ 18 8.2 Recommendations to Kent Safeguarding Children Board ................. 18 APPENDIX A: Biographical details of report author ............................. 19 This report is the property of the Kent Safeguarding Children Board. It is confidential and is not to be disclosed without the permission of that Board Page 3 of 19 1. INTRODUCTION  1.1 Antonio was 32 days old when he was brought to Darent Valley Hospital (DVH) by his parents, Mr and Mrs B. He had very serious injuries which were believed to have been inflicted. He was taken into the care of the local authority. His father faces criminal charges in relation to his injuries.  1.2 These incidents were considered by the Kent Safeguarding Children Board (KSCB) to determine whether a Serious Case Review (SCR) should be carried out. Regulation 5 of the Local Safeguarding Children Boards Regulations 2006 requires Safeguarding Boards to undertake reviews of serious cases. The Regulation defines a serious case as one where (a) abuse or neglect of a child is known or suspected; and (b) either – (i) the child has died; or (ii) the child has been seriously harmed and there is cause for concern as to the way in which the authority, their Board partners or other relevant persons have worked together to safeguard the child.  1.3 It was decided that the criteria for conducting a SCR were not met. This decision was based on the fact that there had been very little contact between the family and any police, health or social care agencies. There was no history suggesting any child protection issues in relation to this family. There were no social concerns and they were not known for any reason to police or social workers. Their contact with NHS agencies during Mrs B’s pregnancy had not raised any concerns. There was therefore no indication of cause for concern about the ways in which agencies had worked, separately or together, to safeguard Antonio. It was decided that there was insufficient evidence to indicate that it was appropriate to carry out a Serious Case Review.  1.4 However the injuries to such a young child were very serious. It was decided that, while the statutory criteria for a SCR were not met, it would still be right to examine what agency involvement there had been. This is the Overview Report from that exercise.   1.5 There are some learning points arising from the review but it is right to emphasise that the injuries inflicted on Antonio could not have been predicted or, consequently, prevented by the agencies contributing to this Review.  2. CASE REVIEW PROCESS   2.1 The process for conducting SCRs was largely followed. Chronologies of agency involvement with the family were drawn up. That involvement was analysed by agencies in Individual Management Reviews (IMR). The information contained in those reports has been drawn together and further analysed in this report, which has been prepared by an independent person1                                            1 See Appendix A  with experience of such reviews. This report is the property of the Kent Safeguarding Children Board. It is confidential and is not to be disclosed without the permission of that Board Page 4 of 19  2.2 The organisations contributing to the Review were • Kent Community Health NHS Trust: this Trust provided the health visiting service to the family. • Kent Police:  Kent Police investigated the injuries to Antonio • Kent County Council, Specialist Children’s Services (KCS):  KCS investigated the injuries with police and made arrangements for the care of Antonio after he had been injured • Maidstone and Tunbridge Wells NHS Trust:  this Trust had no direct involvement in this case but contributed to Review Panel discussions. • Dartford and Gravesham NHS Trust: this Trust, via Darent Valley Hospital (DVH), provided midwifery services to the mother, and care to the baby immediately after the incident. • Kent & Medway NHS and Social Care Partnership Trust:  this Trust had no direct involvement in this case but contributed to Review Panel discussions. • NHS Kent and Medway:  this agency provided an overview of health service provision to the family • Kings College Hospital: this agency provided specialist medical care to Antonio after his injuries  2.3 There was some confusion in the original arrangements for this Review. The report from Kent & Medway NHS Trust states that it includes a review of Primary Care records carried out by the Named GP2 , but contains no analysis of GP involvement against the Terms of Reference. The GPs were able to contribute as the review came to completion but should have been more fully involved.  2.4 The participating agencies were asked to draw up a detailed chronology of their contact with family members between April 2011, when Mrs B first made contact with ante-natal services, and 22/1/12, when this review was initiated. They were further asked to evaluate their involvement with the family generally and with specific reference to the following questions: 1. What was your agency’s involvement with Antonio and his family from January 2011 to the present day? 2. Did your agency hold any significant history of any member of this family prior to this time? 3. Evaluate the nature of support provided within the Maternity Unit including preparation and support arrangements in relation to discharge, and transition from midwifery to health visiting services. 4. How did your agency take into account the parents’ previous history, family and social relationships when assessing their parental capacity prior to the incident? 5. If predictive risk factors were known, were they acted on appropriately and shared across all agencies? 6. What lessons can be learned from this case in relation to the way local professionals and agencies worked together to safeguard and promote the welfare of the child?                                             2 Each locality has a “Named GP” to provide a General Practice lead role in child protection. This report is the property of the Kent Safeguarding Children Board. It is confidential and is not to be disclosed without the permission of that Board Page 5 of 19 7. What was the quality of work undertaken by your agency and how did it contribute to the wider multi agency response? 8. Is there evidence of good practice illustrated by this case?  3. BACKGROUND INFORMATION  3.1 Mr & Mrs B, a white British couple in their thirties, married some five years ago and Antonio is their first child. Their housing, employment and general social circumstances seem to have been stable. Mr B has suffered from a chronic health condition which has required frequent contact with medical services. Mrs B has had a series of illnesses since her late teenage years.  4. NARRATIVE CHRONOLOGY  4.1 Mrs B commenced her ante-natal care in 2011, advising hospital staff that this was a planned pregnancy. She also told staff that she had previously suffered from a medical condition and that treatment for this had ceased some three years previously. This information was checked against GP records and highlighted as a possible risk factor in the pregnancy but it was decided by maternity services that referral to specialist medical services would not be necessary.  4.2 Mrs B was entirely compliant with ante-natal care which raised no matters of concern. Throughout her pregnancy and subsequently Mrs B also saw a student midwife as part of the midwife’s training.  4.3 The birth of Antonio was straightforward. He had a minor physical condition which made feeding difficult. This was identified at an early stage and specialist midwifery advice was given. The feeding problem was notified to community midwives when mother and child left hospital, on the second day after Antonio’s birth.  4.4 Midwives visited more frequently than usual to monitor the feeding problem. After a check at DVH, five days after Antonio was born, a referral was made to a specialist clinic at Kings College Hospital (KCH). After four home visits by midwives care was transferred appropriately to Health Visiting services.  4.5 Prior to her first booked visit the Health Visitor happened to meet Mr B in the course of her duties. She has subsequently reported that he seemed relaxed and happy about the birth of his first child. The Health Visitor called at the home two days later. Antonio was now two weeks old. Mrs B talked about the medical condition she had previously suffered from and also told the Health Visitor about some other difficulties she had experienced as a younger woman. Mrs B’s mother was present during the visit. The Health Visitor undressed Antonio as part of her routine checks, noted no cause for concern and planned her next visit in three months’ time.   4.6 There was no contact with any services during the next two weeks, until Mrs B contacted her GP, as she was concerned that Antonio had “chesty” This report is the property of the Kent Safeguarding Children Board. It is confidential and is not to be disclosed without the permission of that Board Page 6 of 19 symptoms. A GP appointment was made and attended that same morning. The GP thought the baby might have a minor infection and prescribed saline drops. The GP noted no evidence of injury to the baby and had no concerns about the interaction between mother and baby. Antonio was peaceful and appeared relatively well throughout the consultation.   4.7 The following day the student midwife, who had been in touch with Mrs B during the pregnancy, called on the family to get an evaluation form signed and to terminate her involvement. This was not a pre-arranged visit. The student midwife held the baby and has subsequently reported that he appeared well and she had no concerns for him.  4.8 Two days later in the early morning Antonio was taken to DVH by his parents. He had multiple serious injuries. The parents had not called an ambulance. Mr B said that resuscitation had been attempted at home. The nature of the injuries immediately suggested to staff that they had been non-accidentally caused. Child protection procedures were implemented without delay.   4.9 A Consultant Paediatrician, CP1, called police to advise of his concerns that Antonio had been non-accidentally injured. Hospital staff telephoned KCC Children’s Services (KCS), leading to a discussion between KCS and police. It was decided that there would be a Strategy Meeting3 later that morning, when all key agencies could be represented. In view of the nature and extent of the injuries it was also decided that the child’s immediate safety be ensured by formally taking him into police protection4 . This was done at 10:55. Checks were made with the family GP and it was confirmed that the child had been seen three days previously.  4.10 The Strategy Meeting was held at 11:20 and was attended by senior officers from KCS, police and health services. KCS and police had no previous knowledge of the family. CP1 advised of the account he had been given by Mr B, who had said that he had found Antonio cold and blue when going to feed him at 04:20 that morning. Mr B had said that he had made attempts to resuscitate the baby although Mrs B said that she was unaware of any such attempts. Mr B said that he had immediately noticed bruising and Antonio’s swollen head but had not thought it necessary to call an ambulance. He then discussed the situation with Mrs B and they decided to bring the child to hospital. Both parents said that they had not seen any injuries the previous evening and both made suggestions as to how the injuries might have been accidentally caused.                                             3 An inter-agency meeting held under child protection procedures to share information and determine whether and how a formal investigation should be carried out. 4 Whenever a police officer has reasonable cause to believe that a child would be at risk of significant harm unless action is taken immediately s/he may: remove the child from the situation and take them to a place of safety  take action to prevent the child's removal from a place of safety. When a police officer has taken such action the child is deemed to be in police protection. No legal order is necessary. The child may be in police protection for no longer than 72 hours.  This report is the property of the Kent Safeguarding Children Board. It is confidential and is not to be disclosed without the permission of that Board Page 7 of 19  4.11 CP1 gave the meeting an evaluation of each of the injuries and the extent to which they might have been accidentally caused. He said that he was highly suspicious of some non-accidental causation. It was agreed that KCS would apply for an order to protect Antonio on the expiry of the police protection arrangements (and this application was duly made and granted). In the late morning Antonio was transferred to KCH for specialist intensive care, accompanied by his mother and a police officer.   4.12 Later that day both parents were arrested on suspicion of having assaulted Antonio. They gave an account of their actions and both denied any criminal acts. They were given bail with various conditions including no contact with the child. It was subsequently agreed, after police enquiries, that both sets of grandparents could visit Antonio, under the supervision of hospital staff.  4.13 Two days later detailed information about these events was published in the local and national press, including information which enabled the family to be identified. This information had apparently reached the press from within one of the agencies involved with the family, either deliberately or through carelessness. All agencies investigated this but neither the agency nor the person(s) responsible have been identified.   4.14 This led to public disturbance at the family home, and at the home of the maternal grandparents. This required police attendance and subsequent arrangements for the parents and grandparents to be moved to undisclosed addresses.   4.15 A few days later a further Strategy Meeting was held, attended by all the agencies now involved in this matter. There were signs of improvement in Antonio’s medical condition. A detailed multi-agency plan was agreed, covering the further investigations and assessments necessary and the exploration of possible care arrangements for Antonio when he was ready for discharge from hospital.   4.16 Antonio subsequently came into the care of the local authority and the usual planning processes were put in place, considering all options for his future care.   4.17 Mr B was subsequently charged with one count of “Causing Grievous Bodily Harm (with intent)”. This is the most serious assault charge short of homicide offences. The matter came to trial and Mr B was found guilty and jailed.  This report is the property of the Kent Safeguarding Children Board. It is confidential and is not to be disclosed without the permission of that Board Page 8 of 19 5. THE AGENCIES  5.1 Darent Valley Hospital  5.1.1 The principal involvement of DVH for the purposes of this Review, was Antonio’s ante-natal care, birth and follow-up by maternity services. He was also brought to DVH after suffering his injuries.  5.1.2 Mrs B booked in for ante-natal care in a timely fashion. There were no indications of concern from her presentation. At this first contact she talked openly about the medical condition from which she had previously suffered. This was largely dealt with appropriately as discussed below.  5.1.3 Mrs B was fully compliant with ante-natal care, having seventeen contacts with maternity services during the course of her pregnancy. Recording of those contacts is generally positive. There are references to her “engaging well”, “feeling excited about the birth” and being “happy, well supported and prepared for the baby”. Towards the end of the pregnancy she was noted to be feeling “anxious and stressed” but this was not felt to be unusual or unexpected at this stage of the pregnancy. At birth Antonio was a good weight and no unusual concerns arose from the birth and immediate follow up.  5.1.4 As noted above Antonio had a minor condition which might affect feeding. This was identified without delay and specialist advice and support were provided by midwives. Mother and baby were able to be discharged home after two days. Care was transferred to community midwives who visited routinely four times in the next nine days, noting nothing unusual. One of the visits was by a midwife with specialist expertise in feeding, who discussed the baby’s medical condition and made a referral to KCH.  5.1.5 The report from DVH also deals with Antonio’s presentation there after being injured. This appears to have been dealt with appropriately and comprehensively. Concerns that his injuries had been inflicted were identified and acted on without delay. Antonio was then well cared for in DVH until his transfer to KCH for paediatric intensive care services.  5.2 Kent Community Health NHS Trust  5.2.1 This agency was responsible for providing a health visiting service to the family. Involvement was very limited.  5.2.2 When Mrs B was first pregnant and saw midwifery services, health visiting services were routinely notified. Health Visitors will sometimes make contact with a family before a child is born, depending upon the family’s level of need as assessed by the midwives. In this case it was judged that there was no need for pre-birth contact by Health Visitors. However, as mentioned below, the Health Visitors should have been advised that this issue had been discussed.  This report is the property of the Kent Safeguarding Children Board. It is confidential and is not to be disclosed without the permission of that Board Page 9 of 19 5.2.3 The Health Visitors became directly involved after Antonio was born. A Health Visitor made a routine visit to the family home by appointment when Antonio was two weeks old. The Health Visitor saw Antonio and his mother. His maternal grandmother was also present. A standard “Family Needs Assessment” and an “Infant Mental Health Assessment” were carried out. The IMR reports that Mrs B told the Health Visitor that “she had good support, had never experienced any form of abuse, and did not have contact with anyone who posed a risk to children”.   5.2.4 Mrs B did talk to the Health Visitor about the medical problems she had previously mentioned to the midwives. She said that these problems had occurred when she was in her late teens, had required treatment for 2-3 years and that she was now well. The Health Visitor, who was appropriately trained and experienced, judged that there was nothing in the presentation of Mrs B or the baby to cause any concern. The IMR notes that “The Family Needs Assessment together with the Mother and Infant Mental Health Assessment did not show any concern that would impact on the parent’s (sic) parenting capacity”.  5.2.5 The Health Visitor weighed and measured Antonio and confirmed that he was gaining weight adequately despite the minor medical issue which might have hampered his feeding. The Health Visitor arranged to see them again routinely in three months.   5.2.6 There were no immediate indications of concern either in Antonio’s presentation or in Mrs B’s conduct. It was encouraging that Mrs B talked openly about previous difficulties. There is no information about the extent to which Mrs B’s mother was involved in the discussions, if at all, but her presence at the home suggested a supportive relationship. It was not documented at the time but, when interviewed for this review, the Health Visitor recalled that Mrs B and Antonio had good interaction and Mrs B’s handling of the baby was good. Mr B was at work and therefore not seen.   5.3 Kent Police   5.3.1 Prior to the hospital admission which led to this review Kent Police had no involvement with Antonio or his parents.  5.3.2 When the injuries to Antonio were reported by DVH, police responded rapidly and appropriately. They attended the hospital, liaised with colleagues there and at KCS and took immediate action under their statutory powers to protect the child and prevent any attempt to remove him from hospital. Their management report notes that “This information sharing and decision making process was clearly designed to ensure Antonio’s safety and development was properly addressed. This mutual co-operation greatly assisted the investigative process”.  5.3.3 The management report goes on to judge that “The main area of learning centres around the way in which agencies respond to cases which have attracted the attention of the national media”. This report is the property of the Kent Safeguarding Children Board. It is confidential and is not to be disclosed without the permission of that Board Page 10 of 19 This comment relates to the unauthorised disclosure of information, some of which was subsequently found to be inaccurate, to local and national press.  Investigations were carried out by all agencies but the source of the disclosure could not be traced. Agencies largely worked together to manage this situation, which was of concern both in terms of public order and because it might have hampered the police investigation. Generally there were good lines of communication between police and KCH, although these became strained when police decided to disclose information about Antonio’s injuries and the arrangements for his discharge from hospital. Police report that this was a considered decision, made to end speculation and some inaccurate press reports. It served to  “ease the growing public concern, and diffused a potential public order problem”.  5.3.4 However police have acknowledged that their dialogue with KCH on this decision could have been better. The information necessarily referred to investigations and treatment at KCH. It would therefore have been appropriate to ensure that KCH were consulted, both about the disclosure in principle and about what was being disclosed. By this time, because of the legal steps taken, KCS had shared parental responsibility for Antonio and should also have been consulted about the actions proposed by police.  5.3.5 The management report identifies one recommendation, arising from the issue of press coverage: “This case should be used to trigger discussions between agency media departments with a view to establishing protocols and good practice when dealing with high profile cases involving potential child abuse or neglect”.  5.3.6 This is appropriate and is reinforced by a recommendation from this Overview Report.   5.4 Kent County Council Children’s Services  5.4.1 KCS had no knowledge of Antonio or his parents prior to the events giving rise to this report. Their involvement with the family began when he was brought to DVH with injuries. They responded promptly that day, ensuring that checks were carried out with other agencies and attending a Strategy Meeting at DVH that morning. KCS continued to be closely and appropriately involved in planning with the other agencies.  5.4.2 While Antonio was in hospital KCS carried out a “Core Assessment5 ”. The IMR notes that this assessment lacked detail and appropriately suggests that it would have been sensible to wait until there had been a fuller engagement between KCS and the family before trying to complete this assessment. KCS have subsequently reported that a revised Core Assessment has been carried out to a satisfactory standard.                                             5 An in-depth assessment of a child’s needs and his family’s capacity for responding to those needs – a key part of the national Framework for the Assessment of Children in Need and their Families (Department of Health 2000) This report is the property of the Kent Safeguarding Children Board. It is confidential and is not to be disclosed without the permission of that Board Page 11 of 19 5.5 Kings College Hospital  5.5.1 KCH was involved only after transfer from DVH (except that they had also received the referral in relation to Antonio’s minor feeding problem). The IMR submitted by KCH is extremely thorough, describing excellent clinical care, sensitive management of family contact issues and well-considered assistance in the police investigations. The report describes how learning from previous serious incidents, relating to use of guidance and thoroughness in documentation, was implemented in this case. The problems caused by the police decision to release information are acknowledged and the report demonstrates that KCH has confidence and expertise in cases where media management is an issue. The report also recognises how difficult it was for staff, including senior and experienced nurses, to deal with a child as young and as seriously harmed injured as Antonio was, and describes the arrangements which were put in place to support them. The IMR recognises some areas where practice might have been improved relating to parental consent for investigations, recording and inter-agency communications but, overall, KCH’s response to the challenges in this case was impressive.  5.6 General Practitioners  5.6.1 Initially the arrangements for this review did not adequately include the family’s general practitioners. Basic information was established from GP records but the GPs were not directly involved until they were provided with a draft copy of this report. They had no further comment to make but should have been involved from the outset.  6. SPECIFIC ISSUES IDENTIFIED IN THE TERMS OF REFERENCE FOR THIS REVIEW  6.1 Introduction  6.1.1 There was a lack of co-ordination in the arrangements for setting up this review. As described above, the GPs were not fully consulted. Some management reports were submitted before the Terms of Reference had been finalised. This probably would not have happened if this had been a statutory SCR.   6.1.2 The government has indicated that Safeguarding Boards should conduct a range of different reviews, including reviews of cases, such as this, which do not meet the statutory SCR criteria. The Board is currently considering various review models and a framework will be developed which includes learning from this case. There is a recommendation from this report to the Safeguarding Board highlighting the need for clearly agreed Terms of Reference to be put in place before any case review is initiated.   6.2 What was your agency’s involvement with Antonio and his family from January 2011 until this review was initiated?  6.2.1 This has been dealt with in the preceding sections of this report.  This report is the property of the Kent Safeguarding Children Board. It is confidential and is not to be disclosed without the permission of that Board Page 12 of 19  6.3 Did your agency hold any significant history of any member of this family prior to this time?  6.3.1 Police, KCH and KCS had no contact with this family prior to the events leading to this review.  6.3.2 Health services held no information relevant to this review about Antonio himself. There had been no unusual problems before or during his birth. The only health issue arising after birth was his minor feeding problem. Feeding difficulties in a small baby, with inexperienced parents, may be a cause for concern but there is no evidence to suggest that this was not managed and dealt with appropriately. Advice and support had been given in hospital and follow-up arrangements had been promptly put in place.  6.3.3 Health services had been involved with Mr B, to perhaps a greater extent than is generally the case, since his childhood. It does not appear however that he had had any recent contact with health services, nor that his previous involvement had any direct significance to the matters leading to this review.  6.3.4 In respect of Mrs B it was reported that there  “seemed to be a distinct deterioration in her …health at the age of 19 following the death of her grandmothers and her uncle”. This led to continuing input from health services although prescribed medication was terminated by Mrs B after two months and she then “seemed to settle well over the next 2 years”.  6.3.5 At the age of 21 there was a recurrence of similar problems. Mrs B was prescribed medication which she again terminated after two months. She also declined any continuing contact with other services in relation to this problem.  Some 9 years later, three years before Antonio was born, Mrs B was again similarly unwell. She again terminated treatment after about two months. She then had no significant known contact with any health service until her pregnancy with Antonio.  6.3.6 The nature of Mrs B’s health condition and its recurrence do indicate a degree of vulnerability. The agencies’ recognition of that and their response are discussed below.  6.4 Evaluate the nature of support provided within the Maternity Unit including preparation and support arrangements in relation to discharge, and transition from midwifery to health visiting services.  6.4.1 The medical problems disclosed by Mrs B at her first ante-natal appointment with midwives were not shared with Health Visitors. She had seen a Consultant Obstetrician with specialist experience and it was judged that no onward referral was necessary at that stage, given the nature of those problems and the time that had elapsed since her last illness. This Review This report is the property of the Kent Safeguarding Children Board. It is confidential and is not to be disclosed without the permission of that Board Page 13 of 19 concluded that this was a reasonable decision but Health Visitors should have been notified of it.  6.4.2 In relation to subsequent ante-natal care the report from NHS Kent & Medway advises that  “Mrs B attended all appointments and fully engaged with the service, not raising any concerns for her emotional health or well being. Contact with Mr B during this time again does not raise any health or social concerns. When visits took place at home there was no reason to find that this would be an unsuitable place for a child, and they appeared well prepared for a baby. ... The family assessment was completed, father’s assessment was completed and mother’s mood assessment was thoroughly checked throughout her whole maternity pathway …Mother’s care provided was text book and unremarkable”.   6.4.3 It is not clear from the reports submitted how the report reaches these conclusions about the home or about Mr B. The report does not mention any home assessment which would confirm that adequate preparations had been made for the baby. That report also refers to a ” midwifery assessment on the father” but there does not appear to be evidence of any direct contact with Mr B recorded by any professional, prior to the parents bringing Antonio to hospital after he had been injured. The author of that report no longer works in Kent and it has not been possible to confirm this, but the Panel concluded that these comments were based on incorrect assumptions.   6.4.4 Antonio’s birth was relatively straightforward. He spent three hours in special care as a precautionary measure but it was rapidly established that he could be returned to standard post-natal care arrangements. While in hospital there is evidence that Mrs B received and responded well to good advice and guidance in relation to feeding. This continued after discharge from hospital. Midwives visited four times in nine days without any concerns arising. They continued to provide advice and support about Antonio’s feeding problems, and a referral for specialist intervention was made without delay. On one visit Mrs B was reported to be tearful but this was not felt to be unusual in the circumstances of a first-time mother experiencing feeding problems with a young baby. There is no evidence of any contact with Mr B.  6.4.5 The agencies involved have not provided a detailed account of handover from midwifery to health visiting provision, probably because this was judged to be straightforward. The implication is that no particular arrangements were necessary and care was transferred routinely. That was confirmed in discussion at the Review Panel.   6.4.6 A Health Visitor made one visit at which she saw Antonio, Mrs B and Mrs B’s mother, The report of that visit describes that: “During the visit a Family Needs Assessment was (routinely) completed, to determine (whether) additional targeted services (should) be planned. Mrs B reported that she had good support, had never experienced any form of abuse, and did not have contact with anyone who posed a risk to children. Mr This report is the property of the Kent Safeguarding Children Board. It is confidential and is not to be disclosed without the permission of that Board Page 14 of 19 B was not reported as having any physical or mental health problems. During the assessment, Mrs. B disclosed a history of (a medical problem) when she was 18 years old and that she had taken (medication) for 2-3 years. She stated she was currently well”.  6.4.7 As detailed above the medical problem which Mrs B mentioned had actually affected her three separate times, requiring treatment on each occasion for a period of months. It may be significant that Mrs B did not disclose the extent of this problem, or she may understandably not have wanted to present as an over-anxious new mother.  6.4.8 Mr B “was not reported as having any … health problems”. This may mean that Mrs B said that he was well at the time of the assessment. In fact we know that he had above average contact with his GP, and a long history of reported medical problems.  6.4.9 The final contact with any professional prior to Antonio’s presentation in A&E was the unscheduled visit by a student midwife. This was less than 36 hours before he was brought to hospital. The student midwife held the baby and noted nothing that caused her any concern.   6.4.10 This was an educational rather than a clinical visit, and consequently was not recorded in medical notes. The Panel judged that this practice was not ideal and that all contacts between patients and professionals ought to be recorded. Revised guidance will be issued accordingly.  6.5 How did your agency take into account parents’ previous history, family and social relationships when assessing their parental capacity prior to the incident?  6.5.1 Again there was no contact with police, KCH or KCS prior to the injuries.  6.5.2 Maternity services appear to have taken appropriate and considered account of Mrs B’s previous medical history.  6.5.3 The Family Needs Assessment, as discussed above, was completed during the one contact from the Health Visiting Service after Antonio was born. It reflects what the Health Visitor was told by Mrs B and, as it stands, would not have triggered any further enquiries or referral to the GP.   6.5.4 Any information-gathering about previous history appears to have related only to Mrs B. It may be that it would be helpful also to make similar enquiries about fathers.  6.6 If predictive risk factors were known, were they acted on appropriately and shared across all agencies?  6.6.1 The only potential “predictive risk factor” was the knowledge about the previous medical histories of Mrs B and, to a lesser extent, Mr B.   This report is the property of the Kent Safeguarding Children Board. It is confidential and is not to be disclosed without the permission of that Board Page 15 of 19 6.6.2 The “predictive risk factors” relating to Mrs B’s medical history led maternity services to refer her for assessment by a Consultant Obstetrician with expertise in that area. This doctor was satisfied that no onward referral was necessary.  6.6.3 NICE guidelines suggest that Ms B should be asked whether she wished to be referred to more specialist services, and a written care plan should be drawn up.  6.6.4 It is not clear that Mrs B was asked about referral to specialist services.  If she had declined such a referral, that should have been recorded and a care plan drawn up which ensured regular review of the situation. In fact, although no targeted care plan was drawn up, it is reported that “ there is evidence that due to the past history the mother’s (condition) was considered at each visit or appointment (and) closely monitored with a system that DVH have in place in accordance to their policy which has been revised according to NICE guidance (submitted separately).  They use a traffic light system to refer to the specialist team if deemed to meet the threshold. No concerns were identified during the whole of maternity interaction”.  6.6.5 However, I think that hindsight may over-inform a view expressed in the report from NHS Kent and Medway that “it may have been appropriate to convene a multi-professional meeting at an early stage”. It does not seem to me that there was any evidence to suggest that a multi-agency meeting was necessary. Mrs B had talked openly about her health and gave no indication of being currently unwell or unsupported. Certainly there was no evidence to indicate that a referral to children’s social care services ought to have been considered at any point.   6. 7 What lessons can be learned from this case in relation to the way local professionals and agencies worked together to safeguard and promote the welfare of the child?  6.7.1 Reviews of this nature, with the benefit of hindsight, can often identify actions and processes, within and between agencies, which could be improved. In this case there was no evidence which should have led any professional or agency to suspect that Antonio might be deliberately injured, let alone that those injuries would be substantial.   6. 8 What was the quality of work undertaken by each agency and how did it contribute to the wider multi agency response?  6.8.1 This is not a situation where serious concerns arise about any of the agencies: • The Dartford and Gravesend NHS Trust was responsible for maternity services. Their general management of Mrs B throughout her pregnancy and beyond, appears to have been of a good standard.  • The Kent Community Health NHS Trust was responsible for health visiting services and had only one contact which was satisfactory. This report is the property of the Kent Safeguarding Children Board. It is confidential and is not to be disclosed without the permission of that Board Page 16 of 19 • Kent Police became involved after Antonio had been injured. Their response was swift, authoritative and appropriate. • Kent Children’s Social Care also became involved after the injuries to Antonio. Their involvement in the immediate response to Antonio’s presentation was again rapid and robust.  • Kings College Hospital again only became involved after the injuries. The care provided to Antonio was excellent, as was the sensitivity to child protection issues.  6.8.2 As discussed below agencies worked well together in their immediate response to Antonio’s injuries.  6.9 Is there evidence of good practice illustrated by this case?  6.9.1 OFSTED6“Good practice… with appropriate consideration of its potential for wider implementation”.  has suggested that the “best” case reviews will identify Good practice should also mean more than complying with agencies’ routine expectations of staff and services.  6.9.2 In this case it is right to recognise the impressive speed and thoroughness displayed in the multi-agency response to the discovery of Antonio’s injuries. Agencies made time urgently to research the situation, meet, share information, plan and work together to manage a distressing and difficult situation.                                              6 OFSTED SCR Descriptors January 2009 This report is the property of the Kent Safeguarding Children Board. It is confidential and is not to be disclosed without the permission of that Board Page 17 of 19  7. CONCLUSIONS: KEY LEARNING POINTS AND MISSED OPPORTUNITIES  7.1 There is no evidence arising from this review to suggest that Antonio’s injuries could have been predicted or prevented. There was never any information which might have suggested a risk of physical harm.  7.2 This review has not identified any significant weaknesses in the services provided by any agency during the period under review.  7.3 It was decided that no referral for specialist medical assessment was necessary when Mrs B first engaged with ante-natal services. Her condition was monitored throughout her pregnancy although this was not fully recorded. She was fully co-operative with Maternity Services and remained well.  7.4 There was a “leak” of confidential information about this case to the press. Despite a thorough investigation the source of this has not been traced. This “leak” led to significant public disorder. In the wake of these events police disclosed information about Antonio’s discharge from hospital without adequate liaison with the hospital or KCS. This has highlighted the need for a co-operative approach to working with the media in such circumstances.  7.5 Terms of Reference for this Review should have been more clearly drawn up and agreed.  This report is the property of the Kent Safeguarding Children Board. It is confidential and is not to be disclosed without the permission of that Board Page 18 of 19  8. RECOMMENDATIONS  8.1 Introduction  8.1.1 As has been described above, the agencies contributing to this review had either or no knowledge of the family, or no significant contact during the period under consideration, or previously. It was appropriate to conduct this review but the only issues leading to recommendations are about inter-agency practice after such a tragic incident.   8.2 Recommendations to Kent Safeguarding Children Board  8.2.1 The Board should establish inter-agency protocols and good practice guidance for dealing with high profile cases.  8.2.2 The Board should ensure that there are clear Terms of Reference for all case reviews, whether or not they reach the threshold for carrying out a statutory Serious Case Review.   This report is the property of the Kent Safeguarding Children Board. It is confidential and is not to be disclosed without the permission of that Board Page 19 of 19 APPENDIX A: Biographical details of report author  Kevin Harrington trained in social work and social administration at the London School of Economics. He worked in local government for 25 years in a range of social care and general management positions. Since 2003 he has worked as an independent consultant to health and social care agencies in the public, private and voluntary sectors. He has a particular interest in Serious Case Reviews, in respect of children and vulnerable adults, and has worked on more than 35 such reviews. Mr Harrington is also involved in professional regulatory work for the General Medical Council and for the Nursing and Midwifery Council. He has undertaken investigations for the Parliamentary & Health Service Ombudsman and has served as a magistrate in the criminal courts in East London for 15 years.                             