Death of a 7-week-old baby girl in April 2012 from a serious head injury. Post mortem revealed additional substantial injuries thought to be at least 10 days old. Father was sentenced to 8 years imprisonment for causing or allowing the death of a child; mother was acquitted of the same charge. Emma was subject to a Child in Need plan following a pre-birth assessment. Father was diagnosed with significant learning difficulties as a child and his family were well known to children's services. He had a significant history of domestic abuse involving: being reported as the perpetrator in more than 10 incidents; being convicted of assault against an ex-partner; and being charged but not prosecuted for Section 47 assault of the 2-year-old daughter of an ex-partner. Mother was understood to possibly have learning difficulties and was in contact with services regarding violent behaviour and anger management. Issues identified include: implications of learning difficulties on how parents receive information and their parenting capacity; and lack of professional curiosity in regards to father's history. Frames key findings using the systems model developed by the Social Care Institute for Excellence (SCIE). Makes recommendations covering: health services, Barnardo's Young Families service, children's services and the commissioning of adult services.
      
 Title:  Serious case review: ‘Emma’: the overview report LSCB: Wakefield and District Safeguarding Children Board Author: Peter Maddocks Date of publication: 2013  This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC.  This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above.                           1        Serious Case Review  ‘Emma’  The Overview Report    December 2013   2   Index  1 Introduction and context of the Serious Case Review 4  1.1 Rationale for conducting a Serious Case Review 5 1.2 Reasons for the Serious Case Review and Terms of Reference  5 1.3 The methodology of the Serious Case Review 6 1.4 The scope of the Serious Case Review 7 1.5 The Terms of Reference as described in statutory guidance in 2010 9 1.6 Particular issues identified for further investigation by the Individual Management Reviews: the key lines of analytical enquiry 9 1.7 The Terms of Reference for the Health Overview Report 12 1.8 The Terms of Reference for the Overview Report 13 1.9 Membership of the Serious Case Review Panel and access to expert advice 13 1.10 Independent author of the Overview Report and Independent Chair of the Serious Case Review Panel 14 1.11 Parental and family contribution to the Serious Case Review 14 1.12 Timescale for completing the Serious Case Review 16 1.13 Status and ownership of the Overview Report 16 1.14 Previous Serious Case Reviews 17 1.15 Synopsis and conclusions of the Serious Case Review Panel 18 1.16 The family and other significant people 34 1.17 Cultural, ethnic, linguistic and religious identity of the family and their community  34 2 Narrative account of agency involvement 35  3 Synopsis of the learning and analysis from the Individual Management reviews  46 3.1 Summary 46 3.2 Significant themes for learning that emerge from the Individual Management Reviews 47 3.3 Good practice identified by the review 48 3.4 Learning difficulty 49 3.5 Violence and control 55 3.6 The limited information about Emma’s father in agency records 59 3.7 The Child in Need Plan  60 4 Analysis of key themes for learning from the case and recommendations  65 4.1 Innate human biases (cognitive and emotional influences): 68  3  repeated exposure of professionals to intractable and long term problems such as domestic violence contributed to a normalisation and de-sensitisation in the response and understanding the significance of deviant or risky parental behaviour that included evidence of historic and current domestic abuse 4.2 Difficulties in achieving a balance between keeping a mind open to new information and making judgments and decisions in a timely fashion for children such as Emma 69 4.3 Responses to incidents; inadequate checking of history and the collation of emerging information created the conditions where individual incidents were viewed in isolation and inhibited the identification and clarification of patterns from different sources; the influence of mind-set 70 4.4 Tools; the tools and assessment process for multi agency collating, sharing and analysing information were not sufficiently developed and embedded and provided no resolution to issues such as whether either parent had a learning difficulty or disability 73 4.5 Management systems; the commissioning and contracting arrangements placed a limit on how aspects of the work was completed 75 4.6 The implementation of new systems including electronic recording arrangements contributed to communication difficulties 75 4.7 The workload and organisational capacity had an impact on how several professionals processed information and worked with Emma’s family  76 5 Recommendations  79 6 Appendix  82    4  1 Introduction and context of the review  1. Seven week old Emma was admitted to hospital via ambulance in April 20121.  The ambulance had been called by Emma’s father because she was gasping for breath.  On arrival at the home address, paramedics noted that Emma was pale, limp and showed little sign of life.  She was ventilated and transported to hospital accompanied by her parents.    2. On arrival at the hospital, doctors continued to ventilate Emma and noted bruising on the right side of her cheek and an external injury on the right forehead.  These injuries were considered to be non-accidental.  Due to these concerns a skeletal survey was undertaken. This identified fractures to the skull, ribs and a limb, a retinal haemorrhage and wide spread brain injury. Medical opinion strongly suggested non-accidental injury possibly from shaking.  Some of the injuries were estimated to be at least ten days old.  3. Due to the severity of her injuries, medical treatment was withdrawn and Emma died.  A forensic post mortem was conducted at a regional children’s hospital.  The cause of death was given as a head injury pending further investigations.  4. Both parents were first charged with a S18 wounding.  Following Emma’s death, both parents were then charged with her murder.  Emma’s father was remanded to custody.  Emma’s mother was also remanded to custody but was subsequently released on bail.   5. There were protracted legal proceedings that saw both parents eventually charged with causing or allowing the death of Emma when the case went to trial. Emma’s father was convicted and was sentenced to eight years imprisonment. Emma’s mother was acquitted of the charge. The Serious Case Review process could not be concluded until these proceedings had ended.  6. The initial Serious Case Review panel met on 10th May 2012 to consider if this case met the criteria for conducting a Serious Case Review.  The panel subsequently recommended to the independent chair of the Wakefield and District Safeguarding Children Board (WDSCB) that the criteria for conducting a Serious Case Review in national guidance were met and therefore should be undertaken. The chair made the decision to commission a Serious Case Review on 11th May 2012. Work began in May 2012 on compiling a chronology of the involvement of different services for the review.  7. Both parents are white British and speak English as their only language. The Serious Case Review Panel identified that both parents have some degree of learning difficulty. They are believed to have begun their relationship in March 2011. Mother was aged 19 years and father was aged 28 years old when Emma died. Emma was their first child together. Father has previous convictions for violence, theft and criminal damage; of particular significance to the review is a history of domestic abuse incidents that                                          1 Emma is not the real name.  5  included a prosecution several years previously and child protection reports relating to violence committed against two ex-partners and allegations regarding the respective partners’ children. Those incidents occurred outside Wakefield. This information was not known to the health and social care services working with Emma’s family before she died.  8. A child in need plan was in place at Emma’s birth as a result of an assessed need for support in relation to parenting and this was reviewed once at the family home on 8th March 2012. The Child in Need plan included a social worker, a Wakefield-based voluntary sector organisation providing support in relation to domestic abuse and anger management (Vol 1), Barnardos (Vol 2) service and a midwife (followed by health visitor after Emma’s birth). A second meeting had been postponed in the week before Emma died due to severe weather disruption and had been re-arranged for a week later.   9. The GP and the health visitor had both seen Emma within 48 hours of her being admitted to hospital with the head injury. Although the health visitor had referred Emma to the GP because of some weight loss no injuries were observed by either the health visitor or the GP.   10. Failure to detect fractured ribs, sustained days before death should not be a cause for criticism.  Such fractures are rarely detected acutely in babies. They do not seem to cause persisting distress and are not usually detected by carers, members of the extended family or professionals.  They are almost always an incidental finding when a child presents for another reason.  This is why they are specifically sought, with  routine chest x-rays, as part of child protection assessments on infants and why further x-rays are taken two weeks after initial x rays as even quite new fractures may not be detected clinically or on a first x-ray.  1.1 Rationale for conducting a Serious Case Review  11. Regulation 5 of the Local Safeguarding Children Board Regulations 2006 requires a Local Safeguarding Children Board (LSCB) to undertake a review of a serious case in accordance with procedures set out in chapter 8 of Working Together to Safeguard Children (2010).   12. The LSCB should always undertake a Serious Case Review when a child dies and abuse or neglect is either known or is suspected to be a factor in their death.   1.2 Reasons for the review and terms of reference  13. The reason for undertaking this review is that Emma had substantial injuries, some of which were considered to be at least ten days old.  Medical opinion strongly suggested a non-accidental injury possibly from shaking.  The post-mortem identified the cause of death as a head injury.  Given the nature of Emma’s death, the panel  6  considered that this case met the following criteria for a Serious Case Review, as stated in Chapter 8(9) of Working Together to Safeguard Children2.  14. The Serious Case Review panel at their first meeting on the 10th May 2012 agreed the scope and overall terms of reference for the review and established a timeline for the completion of work. The panel discussed the chronology and first drafts of narrative information from the authors of the individual management reviews (IMR) at the meeting of the panel in July 2012. The scope and terms of reference of the review was routinely discussed and updated at panel meetings to take account of new or emerging information and reflection.   15. The overall purpose of the review is to establish how lessons can be learned from the case through a detailed examination of events, decision-making and action. In identifying what those lessons are, to improve inter-agency working and to better safeguard and promote the welfare of children in Wakefield.  1.3 The methodology of the Serious Case Review  16. This Serious Case Review was completed using the methodology and requirements set out in the government national guidance (Working Together to Safeguard Children 2010) that applied at the time of the review being commissioned and completed. That guidance has been extensively revised and was reissued in April 2013. The revised guidance has given responsibility for the development of learning and improvement frameworks to LSCBs and greater discretion about how any future Serious Case Reviews should be conducted and includes the use of systems based learning methodology that had been advocated by Professor Munro. The WDSCB are working on how future Serious Case Reviews in Wakefield can be developed in order to provide a more productive window into the local systems for safeguarding and protecting children3.  17. The analysis in the final chapter of this report uses some of the framework developed by SCIE (Social Care Institute for Excellence) to present key learning within the context of local systems. This approach also takes account of recent work that suggests that an approach of developing over prescriptive and SMART4 recommendations have limited impact and value in complex multi system work such as safeguarding children5. The final chapter of the review for example explores the                                          2 The revised version of Working Together to Safeguard Children published in April 2013 has moved the guidance to chapter four.  3 Analysis of clinical incidents; providing a window on the system not a search for root causes. CA Vincent; Quality and Safety in Health Care, 2004;  The article argues that incident reports by themselves tell comparatively little about causes and prevention, a fact which has long been understood in aviation for example and is the basis of developing a systems learning approach to Serious Case Reviews in England.  4 Specific, Measurable, Achievable, Result-oriented/realistic and Timely/Time-bound 5 A study of recommendations arising from Serious Case Reviews 2009-2010, Brandon, M et al, Department of Education, September 2011 The study calls for a curbing of ‘self perpetuating and proliferation’ of recommendations. Current debate about how the learning from Serious Case Reviews can be most effectively  7  influence of family and professional interactions on how some aspects of information was processed, the responses to incidents and the tools used by professionals.   18. Systems methodology collects information directly from the people involved with the family. This is not a systems review but the panel have worked to place the evidence that has been analysed into a framework that begins to explore how the local systems both promote and in some circumstances inhibit professional practice and decision making. A systems based review would provide greater opportunity for the practitioners to be central to the process of the review in terms of collating information and helping develop the analysis and understanding about why the case developed in the way that it did.  19. A Serious Case Review panel was convened of senior and specialist agency representatives to oversee the conduct of the review. The panel was chaired by an independent and experienced person. An experienced and independent person has provided this overview report. Further information about their respective experience is provided in section 1.10.  20. The panel agreed case specific terms of reference that provided the key lines of enquiry for the review and were additional to the terms of reference described in national guidance. The panel established the identity of services in contact with the family during the time frame agreed for the review. For services that had significant involvement they were required to provide an independent management review (and are listed in paragraph 25). These reports were completed by suitably experienced people who had no direct involvement or responsibility for the services provided to the children and their parents.   21. An overview report of the health agencies was provided by the Head of Safeguarding for the NHS Wakefield District Trust in accordance with guidance.   1.4 The scope of the Serious Case Review  22. The period of the review is from the beginning of mother’s known pregnancy with Emma to the death of Emma in April 2012. All information known to a service providing an IMR was reviewed. Any information regarding involvement prior to the period of the detailed chronology and analysis was summarised in the IMR.  23. All agency chronologies include detailed information about when the children were seen, spoken to or observations made about them.   24. Agencies that identified significant background histories on family members pre-dating the scope of the review have provided a brief summary account of that significant history.                                                                                                                              achieved is encouraging a lighter touch on making recommendations for implementation through over complex action plans  8   25. Reviews of all records and materials that have been examined include;  • Electronic records   • Paper records and files  26. Individual management reviews were completed using the template provided by the Wakefield and District Local Safeguarding Children Board (WDSCB), and were quality assured and approved by the most senior officer of the reviewing agency.  27. The following agencies have provided an individual management review that was completed in accordance with Working Together to Safeguard Children (2010), Chapter 8 and the associated WDSCB guidance and relevant procedures.  a) Barnardos (manage the Vol 2 service that provides a referral based and targeted support for young parents)  b) West Yorkshire Police  c) Health services that include:  � The Mid Yorkshire Hospitals NHS Trust (provided hospital including hospital emergency department treatment, midwifery, health visiting services)  � NHS Wakefield District (commission district health services and commissioned the GP IMR6)  d) Wakefield Safeguarding and Family Support Services  are the statutory specialist social care services provided by the local authority  e) Wakefield Early Years Children’s Services (children’s centre service)  f) Wakefield Adult Services (in regard to the referral and assessment by the Community Team for Learning Disability  28. Information was also received from the South West Yorkshire Partnership Foundation Trust7, Wakefield Family Services - Schools and Lifelong Learning Services, Connexions, a supported housing service (a not for profit company who provide tenancies for vulnerable adults on a temporary basis for up to two years) and a local                                          6 Emma’s parents were for most of the time that is examined registered with separate GP practices and up to 12 different GPs had contact.  7 This is a specialist NHS foundation trust that provides community, mental health and learning disability services to the people of Barnsley, Calderdale, Kirklees and Wakefield. Mother was referred for CAMHS support to help with stress, bad temper and bullying when she was 11 years old.   9  Wakefield based voluntary organisation that help people affected by domestic violence to change their behaviour (Vol 1).   1.5 The terms of reference as described in national guidance in 2010  • Keep under consideration if further information becomes available as work is undertaken that indicates other agencies should carry out individual management reviews.  • To establish a factual chronology of the action taken by each agency;  • Assess whether decisions and action taken in the case comply with the policy and procedures of the Wakefield Safeguarding Children Board;  • To determine whether appropriate services were provided in relation to the decisions and actions in the case;  • To recommend appropriate inter-agency action in light of the findings;  • To assess whether other action is needed in any agency;  • To examine inter-agency working and service provision for the children;  • To establish whether interagency and single agency policies adequately supported the management of this case;  • Consider how and what contribution is sought from the family members;   • To develop a clear multi agency action plan from the overview report.  1.6 Particular issues identified for further investigation by the individual management reviews8: the key lines of analytical enquiry  29. In addition to analysing individual and organisational practice, the individual management reviews should focus on:  A. Learning Difficulty  • The Serious Case Review Panel considers that the difference between learning difficulty and learning disability may not be well understood.  Individual Management Reviews should clarify professional understanding of learning difficulty and the impact it may have on parenting capacity.                                           8 These are the detailed issues that are analysed by the IMRs and in the detailed analysis in chapter five of this report.   10  • The Serious Case Review Panel identified concerns within different agencies that Emma’s mother may have had a degree of learning difficulty.  Individual Management Reviews should identify: the extent to which professionals were concerned about Emma’s mother’s learning capacity; the evidence on which concerns about learning difficulty were based; and how evidence of learning difficulty was acted upon (i.e. taken into account when providing services, referral for additional support)?    • The Serious Case Review Panel found that Emma’s father had a learning difficulty.  Individual Management Reviews should identify: if this information was known to professionals working with the family; if professionals had any concerns about Emma’s father’s learning capacity; the evidence on which concerns about learning difficulty were based; and how evidence of learning difficulty was acted upon (i.e. taken into account when providing services, referral for additional support)?   B.  Violence and Control  • The Serious Case Review Panel identified domestic incidents where Emma’s father was alleged to have assaulted Emma’s mother.  Individual Management Reviews should identify: how allegations of domestic abuse were acted upon and followed up, particularly in the context of the risk to Emma; and any missed opportunities to refer the family on to a different agency or source of support, such as a Multi-agency Risk Assessment Conference or other intervention.  Could more have been done to support Emma’s mother to disclose information about violence within the home?   • The Serious Case Review Panel found evidence that Emma’s father was violent, controlling towards Emma’s mother and had sought assistance with anger management.  To what extent were professionals aware of Emma’s father’s violent and controlling behaviour and/or his propensity to be violent?  If they were, was this information shared with other agencies and what were the expectations associated with sharing this information?    C. The Serious Case Review Panel found limited information about Emma’s father in agency records.    • Were professionals sufficiently curious about Emma’s father and his role within the family?    • Did Emma’s father receive information/advice about appropriate handling of the child?   D. Child in Need Plan  • Emma was subject to a Child in Need Plan following a pre-birth assessment.  Was this Plan sufficiently robust, with clear actions, responsibilities and contingencies if the Plan was not followed?  Were professionals clear about their role and the role  11  of other professionals?  Did the family appear to understand the Child in Need Plan and what was expected of them?  Was the plan adhered to?  How was it monitored?  • The Serious Case Review Panel has identified that Emma’s paternal grandmother had a role within the Child in Need Plan.  What was the nature of this role and why was it considered to be necessary?  Was it appropriate? Were professionals clear about this role?  Was the nature of this role sufficiently communicated to Emma’s family?    • Were the support needs and parenting capacity of Emma’s parents adequately considered by professionals and are there any lessons to be learned?   E. Were practitioners aware of and sensitive to Emma’s needs in their work, and knowledgeable both about potential indicators of abuse or neglect and about what to do if they had concerns about a child’s welfare?  Were there any indications or cues from this child that may have indicated that the child was being mistreated?  F. The Serious Case Review panel has been advised that the police held information that would have been relevant to professionals working across agencies.  All Individual Management Reviews will need to examine whether information held by their agency in relation to Emma’s parents was used effectively in terms of assessing risk to the child.  G. Learning lessons about Professional Practice  • Did professionals work with this family in line with expected professional standards?  • Was there sufficient management oversight or supervision of front-line staff involved with this family? Individual Management Review Authors should take account of what level of supervision was available to practitioners and whether management oversight or supervision met the perceived needs of the practitioner.   • What good practice, for other agencies as well as your own, and lessons can be learned from an analysis and evaluation of professional intervention with Emma and the family?  • Where learning is identified for your agency, has this also been identified in previous Serious Case Reviews? If so, what recommendations were made and what action was taken previously? The Individual Management Review should identify why the issue has arisen again in this Serious Case Review.  • To what extent did any organisational issues impact on the way in which your agency worked with Emma and her family? This could include issues related to staffing, workloads, agency structure and staff training as well as any other issues identified by the Individual Management Review author and the staff who were  12  involved with the case. The Individual Management Review should where possible also express the views of the professionals involved in the case.   1.7 The terms of reference for the health overview report  30. The Health Overview Report should provide an overview of the information and analysis provided by all health services for the Serious Case Review. In particular it should address the following:  • Comment on the quality of information and analysis and identify significant themes and areas for learning  • Comment on any specialist referrals or assessments undertaken and the extent to which these contributed to appropriate decision making  • Provide comment on the extent to which evidence about neglect was identified and acted upon by various health services  • Comment on the extent to which the reports provided by health services have identified appropriate learning and have provided sufficiently informed analysis  • Give particular regard to any implications for the likely reform of health arrangements in Wakefield identified through the review regarding the capacity of primary health professionals to identify and follow up of children not presented for routine health advice or treatment  • The quality of action already taken in response to the Serious Case Review and the recommendations and action proposed by the health IMR reports   • Identify any further themes to be explored within the overview report  • Make any recommendations necessary to ensure appropriate implementation of learning across the health service in Wakefield  1.8  The terms of reference for the overview report  31. Provide a multi-agency overview report in accordance with the national guidance in Working Together to Safeguard Children.  32. In addition to the requirements of Working Together to Safeguard Children (2010) and taking into account the specific issues identified above, the overview report author should:  • Comment on whether the individual management reviews have addressed the terms of reference and all relevant issues;  • Examine the inter agency working and communication between all involved agencies;  13   • Determine whether services which were provided, actions taken and decisions made were in accordance with current policies, procedures and government guidance;   • Consider, using the benefit of hindsight, whether different decisions or actions may have led to a different course of events;  • Provide an executive summary on behalf of the WDSCB.  1.9 Membership of the case review panel and access to expert advice  33. An independent person was appointed to chair the case review panel from the outset. Section 1.9 includes information about her experience and knowledge.   34. The case review panel that oversaw this review comprised the following people and organisations;   Position Organisation Service Manager Safeguarding and Family Support  Assistant Director Barnardo's Yorkshire Assistant Director, Patient Experience The Mid Yorkshire Hospitals NHS Trust Service Manager Wakefield Schools Inclusion Service Named Nurse  South West Yorkshire Partnership Foundation NHS Trust (SWYPFT) Serious Case Review Co-ordinator,  WDSCB Head of Safeguarding  NHS Wakefield District and the health overview author Superintendent West Yorkshire Police Service Lay Member  WDSCB   35. The independent author of the overview report attended every meeting of the panel after he was appointed in July 2012.  36. The panel had access to legal advice from a solicitor in the council’s legal service.  37. Written minutes of the panel meeting discussions and decisions were recorded by a member of the WDSCB staff team.  1.10 Independent author of the overview report and independent chair of the Serious Case Review panel  38. Edwina Harrison was appointed as the independent chair of the Serious Case Review panel. Edwina is a qualified social worker and has an MA in management and leadership.  14  She has many years of experience of children’s social care services in the statutory and voluntary sector.  Her experience of Serious Case Reviews is as an author as well as independent chair. Edwina is a director of the National Association of Independent Chairs (LSCBs).   39. Peter Maddocks was commissioned in July 2012 as the independent author for this overview report. He has over thirty-five years of experience of social care services the majority of which has been concerned with services for children and families. He has experience of working as a practitioner and senior manager in local and national government services and the voluntary sector. He has a professional social work qualification and MA and is registered with the Health and Care Professions Council. He undertakes work throughout the United Kingdom as an independent consultant and trainer and has led or contributed to several service reviews and inspections in relation to safeguarding children. He has undertaken agency reviews and provided overview reports to several LSCBs in England and Wales.  1.11 Parental and family contribution to the Serious Case Review  40. Emma’s mother and father were made aware of this Serious Case Review at the outset. In view of the parallel separate investigation by the police and the coroner, the Serious Case Review panel had to ensure that all contact with the family was the subject of appropriate consultation and advice. The panel used the national guidance agreed between chief police officers, the Crown Prosecution Service and the Directors of Children’s Services in England9.   41. The paternal grandmother and maternal grandfather responded to the invitation to meet with a representative of the review panel. The independent author of this overview report and the panel advisor met with them. They were also invited to meet again with the author and panel advisor prior to finalising the report and after the criminal proceedings had been concluded. The maternal grandfather together with Emma’s mother and another relative took up that opportunity. The following four paragraphs summarise key points raised during those discussions for the Serious Case Review and from their point of view.  42. The paternal grandmother was aware that both of Emma’s parents had a capacity to lose their temper with each other. Although the paternal grandmother had advised Emma’s mother that she would need to calm her anger when Emma was born the paternal grandmother did not have sufficient cause for concern to speak with any of the professionals working with Emma’s parents about this. Emma’s paternal grandmother acknowledged that Emma’s father had a temper and also referred to his difficulties with drugs. Emma’s paternal grandmother described Emma’s father as wanting to become a father to his own child. The paternal grandmother did not refer Emma’s father’s convictions.                                          9 A Guide for the Police and the Crown Prosecution Service and Local Safeguarding Children Boards to assist with liaison and the exchange of information when there are simultaneous chapter 8 Serious Case Reviews and criminal proceedings; April 2011  15   43. The paternal grandmother was aware that Emma’s mother had difficulty adjusting and preparing for the pregnancy but felt that her son’s willingness to be involved in the care of Emma was going to be helpful. The paternal grandmother had found it difficult to get to know Emma’s mother although both parents had visited her home. Emma’s paternal grandmother was not clear about why Safeguarding and Family Support Services were involved with Emma’s parents. Emma’s paternal grandmother said that she had not been aware that there had been a plan for her to live with Emma’s parents after Emma left hospital after her birth and she never had stayed with Emma and her parents.   44. Emma’s maternal grandfather (maternal grandfather) was aware of violence between Emma’s parents. His concerns centred on Emma’s father. He had had been involved on more than one occasion in confronting Emma’s father; on one of those occasions he had been telephoned by Emma’s mother for help just after Christmas 2011. He had gone to the house and had been involved in a physical and verbal confrontation with Emma’s father after which he took Emma’s mother to the police station with the intention of supporting her in making a formal complaint about the domestic abuse. He confirmed that Emma’s mother was spoken to in private by police officers and although the police asked if either of them wanted to make a formal criminal complaint Emma’s mother had declined the opportunity; Emma’s maternal grandfather felt unable to do anything further in the circumstances.   45. After the criminal proceedings had been completed they explained that they had concerns that if a formal complaint had been made to the police this would have led to further violence and repercussions for Emma’s mother. This matter is dealt with in detail later in the report.  46. Emma’s maternal grandfather did not seem aware that domestic abuse was something he could report to anybody else apart from the police although he had mentioned concerns about Emma’s father to at least one other professional. He felt that none of the services would take any significant action.   47. Emma’s maternal grandfather felt that some of the professionals working with Emma’s mother had more experience than others; he said that he felt more confident about the more experienced practitioners but was surprised that they were not always the lead professional for a service; for example he thought that the more experienced social worker appeared to take a less active role in the case. Emma’s maternal grandfather was particularly upset and disappointed in how the case had been managed by Safeguarding and Family Support Services although did not describe any specific incident or occasion when particular opportunities had been missed by any service.   48. The maternal grandfather was concerned that the previous history of Emma’s father had not been known to the family or to the professionals who had been working with Emma and her parents. The family felt strongly that there should be mechanisms for women to be alerted to a history of violence and convictions.   16  49. The extended family were critical of the questioning they had during the criminal proceedings about their knowledge of injuries to Emma. They felt that if professionals were unable to identify injuries without x-rays it was unrealistic to expect relatives to be able to do this.   1.12 Time scale for completing the Serious Case Review  50. The case review panel met on twelve occasions between July 2012 and May 2013. The initial chronology of services involvement was largely completed by July 2012.  The first draft of the narrative agency reviews were also completed in July 2012 although not all final drafts including agency analysis were finalised until February 2013. The delay in being able to secure access to relevant health records was a significant barrier to completing a comprehensive narrative and analysis more quickly. The first draft of the Health Overview Report was completed in October 2012. The final report was presented to an extraordinary meeting of the WDSCB in March 2013.   1.13 Status and ownership of the overview report  51. The overview report is the property of the Wakefield and District Safeguarding Children Board (WDSCB) as the commissioning local safeguarding children board. Since June 2010, all overview reports provided to LSCBs in England are expected to be published unless there are exceptional circumstances. This overview report provides the detailed account of the key events and the analysis of professional involvement and decision making in relation to Emma and her family.   52. The Overview Report is primarily written with the intention of addressing professionals involved with the design, oversight or delivery of multi-agency safeguarding services although it should also provide accountability and information to other interested parties. The Executive Summary provides a shorter account of the key findings from the review.  53. Both of the reports have to balance maintaining the confidentiality of the family and other parties who are involved whilst providing sufficient information to support the best possible depth and range of learning required from a Serious Case Review.   54. The purpose of this review is not to try and second guess the judgements and decisions that various people and organisations made at the time of the events examined by the review. Hindsight can severely distort the clarity of information that was available and underplay the impact of time pressures, and the other influences and dilemmas that confront people dealing with a complex interplay of different factors.   55. In reading this overview report, it is important to remain clear about the purpose of the overall review and of this overview report in particular. The review examines with the benefit of hindsight and with other analysis, if it is possible to identify whether alternative judgments and decisions could or should have been taken, and whether different outcomes might have been achieved for Emma. This is summarised in section  17  1.16. The review does not investigate the circumstances of Emma’s death. That is a matter for the coroner and for the judicial system to investigate.  56. The review aims to be very challenging of all services for the purpose of building on the considerable knowledge and expertise that has developed in relation to the safeguarding of children in the UK.   57. The WDSCB will determine how and what further information is provided to the family at the conclusion of the review and submission to the Department of Education.    1.14 Previous Serious Case Reviews  58. The WDSCB in Wakefield has published executive summaries of four Serious Case Reviews undertaken between 2006 and 201010.   59. Reference is made to these previous Serious Case Reviews by several IMR authors and is also referenced where relevant in this overview report. The purpose of this is to highlight where similar issues or themes have been identified in previous reviews. This ensures that action already recommended is not unnecessarily repeated. Themes include domestic abuse, the resistance of some families to professional help and support and the important role of primary health professionals such as health visitors, midwives and GPs in collating information and recognising safeguarding concerns. All of these professionals are working with a large number of patients and have to navigate different information systems and are also subject to significant changes to commissioning and organisational arrangements. GPs in particular are the recipients of a great deal of different information from other health professionals that are stored in the individual patient record that can be extensive and complex. The events examined by the review coincided with the implementation of a revised electronic information system; this caused additional complexity for example in how information between different primary health professionals was shared and accessed.   60. All children’s services in England are subject to inspections. There are also inspections of other services such as health and the police. The panel has considered evidence from those inspections and other sources to inform the analysis and judgments in this case and to maintain a balance between identifying systemic issues or influences that can assist in the continued development of local safeguarding arrangements rather than becoming too preoccupied with case specific issues or hindsight bias. The inspections that are most relevant to the work of this panel relate to the annual assessment of the local authority that includes consideration of strategic partnerships between services and the focused assessment by Ofsted of the safeguarding arrangements.                                           10 These reviews were completed prior to the changes to the statutory guidance relating to publication of overview reports after the coalition government’s notice issued on the 10th June 2010 under section 16(2) of the Children Act 2004 which amended the previous national guidance in Working Together to Safeguard Children.    18   61. Chapters three and four of this review describe in greater detail the specific lessons to emerge from a detailed analysis of this Serious Case Review and include comments on how learning from previous reviews has been used.  1.15 Synopsis and conclusions of the review panel  62. Although Emma and her parents were known for a relatively short time, there was a high level of contact by several different services before and after Emma’s birth. This reflected the priority given by health and social care professionals in supporting Emma and her mother in particular who was recognised to have some additional needs.   63. Emma had not been identified as a child in need of protection although some professionals were concerned about the parents’ relationship and one health professional had felt that Emma’s case should have been discussed at a child protection conference and had raised this with Safeguarding and Family Support Services. However, this was not escalated through any formal processes in health or social care services. At the time, Safeguarding and Family Support Services was satisfied that the case could be appropriately managed as a Child in Need case.   64. With the benefit of hindsight, it is clear that in spite of the high level of contact with the family and the well intentioned and generally sensitive approach to Emma’s parents, there was important information about both of Emma’s parents that was either unknown or was only partially explored.   65. This related to evidence of historical violence, knowledge about the learning difficulties identified in both parent’s childhood and the sharing of information about domestic abuse and medical treatment. Both parents were reluctant to acknowledge problems and presented themselves as being motivated and capable of caring for Emma with contact from relevant services.  66. Emma died as a result of a physical injury for which her father was convicted. It is now known that there is a significant history of violence and anger in the individual history of both of her parents that was not largely known and therefore understood by the professionals in contact with Emma. The review analyses the multiple factors that contributed to how information and Emma’s case was generally managed and this is set out in the following sections of the report.  67. The only guarantee that Emma would not have been harmed would have been if she had been removed from the care of her parents; no professional in contact with the family had judged this necessary at the time although there was consensus about maintaining the high level of contact with the family which had continued up to her death.   68. If any professional had thought it necessary to remove Emma from her parents care it would have required the authorisation of a court for anything beyond using the emergency powers conferred on the police that are only intended for dealing with  19  immediate threat to the safety and wellbeing of a child; those circumstances did not apply in this case.   69. The police never had any contact with Emma. There was one brief episode in late December 2011 when the maternal grandfather took Emma’s mother to the police station following a confrontation with Emma’s father although none of the family made a direct and explicit complaint about violence.   70. A court would have required evidence in regard to the attitude, behaviour and care of both parents towards Emma. During her short life there was a high level of contact by health and social care staff with Emma and her parents’. Nobody identified any evidence of physical harm or injury to Emma and in general had observed parents who appeared to provide appropriate attention and care although recognised that they lacked experience and therefore needed the regular support of health and social care professionals in developing routines such as feeding and regulating the extremes of temperature for Emma for example from being too swaddled. The parents appeared to accept such advice from primary health professionals and this included taking Emma to be examined by the GP just prior to her death.   71. Services such as Safeguarding and Family Support Services were working with other families who at the time presented with a much more explicit level of risk and concern than Emma’s parents who were primarily seen as needing, and were apparently accepting, the contact and support from several different services.   72. The focus of the support was primarily upon Emma’s mother and although there was considerable contact with Emma’s father, his needs and history remained largely invisible for the purpose of formal assessment and planning. Some of this was because the remit of some services was to only work with a teenage parent and Emma’s father was 28.  73. There were gaps in how information that was held by different services was made available to the pre-birth assessment. There were issues for example in how the GP and other health and social care professionals communicated with each other; there were gaps between the midwifery and health visiting services, between hospital and other services, between adult and children’s services, between the police and Safeguarding and Family Support Services as well as between health and Safeguarding and Family Support Services. Signs and indicators of concern in regard to evidence of domestic abuse or abuse and the risk of harm were not sufficiently recognised or acted upon; this reflected a lack of willingness to report violence from within the family as well as no professional observing violence and disagreement over evidence such as bruising on Emma’s mother.   74. Important historical information that was known to some services such as the GP practice was not shared directly (although was shared via a third party who had alerted the GP to the significance of the information) with the social workers undertaking a pre-birth assessment and the social workers did not seek information from GP before or after the third party referral. The GP practices were not aware that a pre-birth  20  assessment was being undertaken. When information was shared by a third party from a non-statutory service it does not appear to have been recognised as potentially significant.   75. The GP practice along with the other health and social care services had a higher than usual contact with Emma’s mother before and after the birth. This contact was not with one individual GP; in line with other GP practices appointments could be made with different GPs. Until Emma’s father registered with the GP practice where Emma’s mother was already a patient, there was no knowledge in the separate GP practices about the relationship between Emma’s parents.    76. There was a degree of difference between professionals regarding aspects of mother’s cognitive functioning and the evidence of verbal and physical violence between the parents which were not satisfactorily resolved and were never properly discussed in a multi-agency meeting. This increased the potential for misunderstanding when information was relayed by third parties and through electronic and telephone messages.  77. The police, a local hospital as well as Safeguarding and Family Support Services did not pass on all relevant information for example when Emma’s mother had been subject of domestic abuse. There were also gaps in how plans were agreed and communicated both between the professionals and with the family. For example, Emma was discharged from hospital on the understanding provided by Safeguarding and Family Support Services that Emma’s paternal grandmother would be living with Emma and her parents; in the words of the health overview report (Health Overview Report) this was ‘lost in the transfer from hospital to home’ because the paternal grandmother never stayed with the family.   78. Although Emma’s mother was not formally assessed as having a learning disability it was apparent to some of the people working with her in 2011 and 2012 that she had difficulties in processing information and there were queries about aspects of her cognitive functioning. A referral was made to the Community Team for Learning Disability although the purpose of the work was the subject of misunderstanding and partial communication. An assessment of mother’s cognitive functioning had not been completed before Emma died.   79. None of the services were aware that Emma’s mother had been supported by the learning support service when she was at school; she was not asked and did not tell anybody about this aspect of her childhood history. Various childhood assessments had established that she had difficulties with auditory memory and sequential memory tasks which had an impact on her verbal understanding. There was indication of specific learning disability such as dyslexia. The problems with processing information were identified by Vol 2, the Parents with Prospects11 (PwP) course tutors and Vol 1.                                          11 Parents with Prospects is the name of the accredited parenting training programme provided nationally working to support parents and their children from birth to three years old in a range of places qualified to provide it that can include for example local colleges and children’s centres. The programme can lead to a  21   80. The only domestic incident recorded on the police systems between Emma’s mother and father was in late December 2011 when mother, along with Emma’s paternal grandfather, had gone to the police in Wakefield with the intention of reporting a physical assault by Emma’s father. None of the other incidents of violence between Emma’s parents in Wakefield were reported to the police.   81. Emma’s father’s history of convictions for violence, theft and criminal damage was not revealed as part of the pre-birth assessment. He had been reported as the perpetrator in ten domestic abuse incidents involving former partners that occurred outside of the time scale of the Serious Case Review and outside the Wakefield district. The incidents of domestic abuse as well as allegations of child abuse had been the subject of enquiries. In 2002 he had been charged with the Section 47 assault of a two year old female child. The victim was the daughter of the partner that he was in a relationship with at the time.  There was no prosecution.  82. Emma’s father subsequently began a relationship with another partner who also lived outside the Wakefield area and who already had a child. It is well documented in that other local authority area that father had subjected that partner to repeated domestic abuse that had escalated in severity and had continued for a number of years until that relationship ended in 2010. The domestic abuse in that relationship had been referred to the MARAC12 in that other area in early 2007, after Emma’s father had subjected his ex-partner to a serious and sustained violent assault in which the ex-partner had suffered broken ribs. Emma’s father was convicted of a Section 47 Assault at Crown Court in 2007 as a result of that assault.   83. Due to the seriousness of the domestic abuse and the fact that there was a young child in the relationship, child protection referrals had been made to the local children’s services (not in Wakefield) after every incident of domestic abuse. In 2008 Emma’s father had been convicted and sentenced to 12 months imprisonment suspended for two years and a supervision requirement for six months. The final reported crime of battery and domestic abuse incident between father and his ex-partner was in early 2010.   84. This information about historic domestic abuse was not known to Safeguarding and Family Support Services in Wakefield before Emma died. Emma was never assessed as a child in need of protection and there were never any concerns about physical or other abuse of Emma. Formal safeguarding enquiries were therefore never invoked in                                                                                                                             foundation learning qualification in parenting, designed specifically for young dads, mums, partners as well as step parents. The training resources encourage discussion, help build confidence in relationships and encourage parents to develop their communication and family skills. The material is relevant to the diverse lifestyles of families and reflects the challenges parents face and especially for young and new parents such as Emma’s. 12 Multi-Agency Risk Assessment Conferences (MARACs): The MARAC is a victim-focused meeting, where information is shared on the highest risk cases of domestic abuse between criminal justice, health, child protection, housing practitioners, as well as other specialists from the statutory and voluntary sectors. A safety plan for each victim is then usually created.   22  Wakefield. The decision to complete a pre-birth assessment did require Safeguarding and Family Support Services to make enquiries of services, including the police, about what they knew about the family.   85. Safeguarding and Family Support Services believed that all relevant enquiries in relation to the pre-birth assessment had been completed although the Serious Case Review has identified that these were not as complete as had been believed at the time. For example, historical records were not accessed due to names being spelt differently.   86. Although there is a record in Safeguarding and Family Support Services of a check being made with the police there is no corresponding record in the police service. The Safeguarding and Family Support Services record is inadequate in as far as it does not identify who made the check from Safeguarding and Family Support Services or record the identity and location of the police contact. Requesting access to police information requires Safeguarding and Family Support Services to provide reasons for such access and there should be clarity in the record of the enquiry with the police about what data is being searched.   87. The discrepancy has been the subject of detailed inquiry in both services and to careful analysis by the review panel. In spite of this work it has proved impossible to fully reconcile the circumstances of the difference in recording within the two services and the reason for important information not being available and therefore not satisfactorily reflected in the pre-birth assessment.   88. Both of the social workers have been consistent in their firm recollection that a phone call was made to the police although neither can identify who had actually made the call.   89. The police check of relevant databases has not shown any evidence of those systems being accessed as an enquiry and check.   90. The Team Manager in Safeguarding and Family Support Services had been told that all relevant checks were completed by the social workers. The circumstances in which such important checks were not completed and recorded as thoroughly as they should be are examined later in this report. The Police and Safeguarding and Family Support Service have worked together to develop a new system for police checks involving an improved audit trail.   91. A combination of factors including heavy workload, a temporary office re-location to a venue in a more remote part of the district away from the community in which the team worked and a significant distance away from line-managers and colleagues, co-working arrangements that did not always define clearly enough responsibility for specific tasks including recording and having an unduly positive and insufficiently sceptical impression of parenting behaviour and motivation all had an influence on how the case was managed.    23  92. Serious Case Reviews frequently identify how events are influenced by men who were invisible to services. In this case there is significant information about Emma’s father that remained hidden from the assessment in particular.   93. The cognitive influence on professional judgment and decision making such as never seeing Emma’s father as a potential source of threat because of the positive way he interacted with social workers in particular is explored in later sections of the report.  94. Initially the focus had been on Emma’s mother’s anger problems and father was seen to be a counterbalance to some of mother’s difficulties. Although Emma’s father was seen on a regular basis by different professionals, the extent and significance of his history remained invisible and when there was a reference to violence it did not attract attention or inference.   95. In a district and culture where men are more often less visible and involved in the day to day care of children, there was an implied and positive inference that Emma’s father was more engaged and interested in Emma’s care and welfare compared to other men in many other families.   96. There is, particularly with the benefit of hindsight, some indication that he was increasingly coercive in his relationship with Emma’s mother and is consistent with the pattern of his previous relationships. The evidence of coercion was most clearly identified by professionals from a non-statutory service and who in relative terms had less training and by implication less professional standing or status in comparison to others.   97. Emma’s mother was both a victim of violence as well as being capable of losing control of her own emotions and this added to the complexity of providing effective help and support for Emma’s mother and for her baby. The grandparents had been aware of the violence in the relationship although each tended to feel that their own child was more the victim than the perpetrator.   98. The evidence of injuries to Emma’s mother, the reports of concerns and her assertion that any bruising was a result of her colliding with doors were heard and recorded but did not provoke more sceptical or curious responses. There was also disagreement between professionals about whether there were bruises or not. On one of the occasions there had been a visit made by a qualified social worker who did not see any bruising.   99. Disclosures about the evidence of injuries were not always communicated and recorded clearly enough; an example occurred between the health visitor and social worker in April 2012. Another was the treatment at hospital for a hand injury that was not referred on.  100. There was an opportunity in late December 2011 for a safeguarding referral to have been made by the police to Safeguarding and Family Support Services when Emma’s maternal grandfather had taken Emma’s mother to the local police station to  24  complain about the assault by Emma’s father that grandfather had stopped. It did not happen because although there was a clear record on the DASH risk assessment about the pregnancy and about prior history of violence the officer responsible for signing off the incident did not check the full documentation thoroughly enough and relied on a shorter summary of the incident that did not identify that Emma’s mother was pregnant.   101. It was recorded on the shorter summary log of the incident that Emma’s mother ‘did not have children yet’; this was rather than making a more explicit statement that she was in fact pregnant and also making clear that the pregnancy was at an advanced stage and therefore any assault represented risk to the mother as well as to the baby she was carrying. The signing off did not challenge how the incident had been handled and recorded in terms of whether there was evidence of violence that deserved investigation as a crime.   102. The reliance on Emma’s mother or her maternal grandfather telling the police that a violent argument had occurred did not have to exclude the police from deciding whether the incident required further enquiry by that service or consulting other agencies such as Safeguarding and Family Support Services. The police were hampered by the lack of information apparently provided.   103. People in other services could also have made safeguarding referrals at other times to Safeguarding and Family Support Services but did not. Concerns were raised especially in February 2012 in regard to how the Emma was being categorised as a child in need in contrast to seeing her as a child who potentially required protection although the concerns were not formalised either as a referral or through other formal escalation procedures. Some of this may have reflected a lack of professional confidence as much as relying on Safeguarding and Family Support Services having all the relevant information required to make an informed and balanced judgment.   104. Several services had information at different times that could have prompted further and better informed enquiries being made that included the GP practice, the specialist midwifery service, Vol 2, the police as well as Safeguarding and Family Support Services. It is now known that the GP records held information about father’s history of violence. The GP made a referral to the Vol 1 with the apparent purpose of helping father with his anger management.   105. Although Vol 1 recognised that this had potential implications in relation to Emma and discussed this with the GP and with Safeguarding and Family Support Services, the GP practice did not share information with Safeguarding and Family Support Services or make a referral. The GP records also contained information about Emma’s mother having been the victim of harassment in regard to a previous partner which was not known by other services.   106. It is highly probable that if all the information known about Emma’s father had been more fully considered, using the local safeguarding processes, he would not have been allowed to have cared for Emma without a very high level of formal supervision and under limited circumstances; the paternal grandmother had expressed surprise that  25  there had not been more apparent supervision and this no doubt reflected the fact that she knew the history although had not realised that Safeguarding and Family Support Services were not in possession of the same level of information.   107. Regrettably, rather than being seen as a potential source of risk because of his historical behaviour, Emma’s father was regarded as a source of day to day care for his daughter and it was felt at the time that he compensated for some of the more apparent difficulties that Emma’s mother has. This was the view of the paternal grandmother who also saw how much her son wanted to be a father. He took responsibility for many of the household tasks and was observed handling and caring for Emma appropriately.   108. Emma’s father had talked with the GP about his anger problems and had initially agreed to participate in local services designed to help change violent behaviour. He seemed responsive to advice from people such as the midwife and health visitor, although there were other occasions when he was seen to be controlling and more reluctant to have contact particularly from health and early year’s workers.   109. The GP practice was not aware that Emma’s father had not engaged with the anger management service until the SCR collated information across the different services. Emma’s father had left the practice and his records were transferred out.   110. There would have been better opportunity to have protected Emma if the risks from both parents had been more clearly identified and had triggered local safeguarding procedures and had been addressed through a child protection plan from the time of her birth. The benefit of hindsight indicates that this is what should have happened.   111. It is an acknowledgement that the lack of knowledge in particular about the history of both parents and their difficulties with violence was a significant influence in how they were both assessed. The pre-birth assessment did not secure this information. There were other factors in addition to the history of anger and violence that that can now be seen as deserving of consideration.   112. From the first contact in regard to Emma in July 2011 when her mother was booked in for ante-natal care for her pregnancy there was recognition that additional support would be required. The sources of vulnerability identified at the initial booking had included the short length of time that the parents had known each other; the fact that mother was 18 years old and father was 28 years old; there were already arguments between the couple.   113. There was far more limited information sought or recorded about father although it was known that he had problems with his anger and he acknowledged that he had attended anger management sessions although no specific information was sought in regard to this.   114. Emma’s father had been diagnosed with significant learning difficulties as a child. There had also been considerable historical involvement by Safeguarding and Family Support Services with his family. This was in addition to the involvement of  26  criminal justice services and of a neighbouring Safeguarding and Family Support Services in regard to father’s alleged physical abuse of previous partners and their children. Reasons for the limited focus on Emma’s father at the outset included the structure of the forms that were used for recording details of a new pregnancy; these have already been changed and midwives are now required to collect more detailed information about fathers at the point of booking a pregnancy that includes relevant history. Inevitably, this information relies substantially on the information that is disclosed by the parent (s).   115. Other factors that contributed to insufficient attention on father and his background at the outset were that the contract for the Vol 2 service was focussed on young people aged 18 or younger. Mother was regarded as the ‘client’ of the service and father remained peripheral and did not qualify for help or advice from the service because of his age. This has already been addressed in a review of the contract and working arrangements in 2010 following a previous SCR in regard to Child D.    116. Although a decision was made by Vol 2 to use the Common Assessment Framework as a means for coordinating information and support when they became involved, this was never adequately completed or used to inform the work of the other services at a later stage. This reflected a range of factors that included confusion arising from the piloting of new arrangements, the heavy workload across the different services, some lack of clarity in regard to specific specialist roles and insufficient co-ordination of information and action between the different people who became involved. All of this was occurring during a time of considerable organisational change for several services.   117. There was also a high reliance on telephone conversations and messages to relay important information that was not routinely followed up in writing or using a written referral to record a concern with Safeguarding and Family Support Services. Some services such as the GP never apparently initiated any contact with the other community health services or Safeguarding and Family Support Services in regard to either parent although made a referral to the Vol 1 in regard to Emma’s father and his anger issues.   118. The case was allocated to one of the specialist midwives who was collocated with and worked closely with Vol 2, a specialist commissioned service, which provides targeted support to young teenage parents designed to help them to become involved in education, employment and training as well as caring for their baby.  119. The involvement of these services meant that a specialist midwife, a Connexions personal assistant (CPA1) and two family support workers (FSW1 and FSW2) were providing intensive and regular contact during the early stages of the pregnancy and the case was allocated to a worker in the Vol 2 service from August 2011.  120. It had been noticed early on that mother appeared reluctant to accept help. This behaviour is not particularly unusual. A critical part of the role and skill of health and social care professionals is to try and develop a relationship with young adults who may feel frightened of professional involvement and may have had a poor experience such as  27  difficulties in education. There was some discussion at an early stage as to whether mother might have a learning difficulty although others also felt that it might be a reflection of just being shy and lacking confidence.   121. In early October 2011 there was an initial meeting involving Vol 2 and Emma’s parents. At that first meeting FSW2 had explained the purpose of the Common Assessment Framework. Mother had needed some persuading to agree to a meeting. This initial discussion focussed upon Emma’s mother and her difficulties with anger and her feelings of depression. Although Emma’s father mentioned that he had a criminal record for violence and that he ‘thought’ he had two children this information was only recorded but not followed up (because he was not seen as the focus of the work). This would otherwise have been the first opportunity to have secured clearer information although there were other subsequent occasions involving other professionals when this information was also missed.    122. The Common Assessment Framework that was subsequently developed had focussed on Emma’s mother. The plan described a list of actions that included securing the appropriate benefit income; this proved to be complicated by the fact that mother moved frequently between Emma’s father’s flat and the maternal grandfather’s home. This occurred largely as a result of the arguments the couple regularly had although this was not understood at the time.   123. The Common Assessment Framework plan also included seeking treatment and support for mother’s depression and encouraging her participation on anger management work with a voluntary organisation in Wakefield. Arrangements were also made for mother to participate in a ten week course at the local college called Parents with Prospects (PWP).   124. The Common Assessment Framework was not shared either with the parents or with any of the other services or professionals at any stage. A similar lack of sharing a plan occurred in regard to the Child in Need plan that was subsequently developed in early 2012. Separate to the Common Assessment Framework process, the GP had made a referral to Vol 1 in regard to Emma’s father’s anger management.   125. It seems the referral was at the request of Emma’s father who knew that his partner (Emma’s mother) was pregnant. Emma’s father had already declined to participate in the anger management work; he cited not having financial support to attend the sessions but during other discussions with professionals he also made clear that he saw no point in participating in such sessions and on at least two occasions made it clear that he had already undertaken work in relation to his anger management. This was never followed up either in ascertaining why he had been referred or what outcomes had been achieved.   126. The concerns about mother’s ability to process information were a reoccurring issue for the Vol 2 practitioners. Examples included a discussion with CPA1 about how mother planned to leave Emma with the maternal grandparents when she and Emma’s father were having arguments. She also talked about sending mobile phone texts to  28  Emma to check she was alright because she had been learning about the importance of bonding with her baby. On another occasion in college she had talked about the difficulties she had in understanding what people were saying to her and she needed to have it ‘broken down’. She was also observed to defer frequently to Emma’s father and to members of the extended family during discussions.   127. As these concerns about mother’s level of understanding were being noted particularly by CPA1, the first evidence about domestic abuse emerged. Mother had disclosed that the arguments she had with Emma’s father were frequent and that it could involve father hitting cupboards. Emma’s mother was also observed on more than one occasion to have bruising; this was noticed in college as well as by the FSW and CPA1. On every occasion mother denied that the injuries were a result of a physical assault and claimed consistently those had been caused by a collision with an object such as a cupboard door. It is notable that there was disagreement on some of these occasions between Vol 2 and Safeguarding and Family Support Services in particular as to whether there was any evidence of a bruise.  128. In November 2011 CPA1 sought advice from the community team for learning disabilities in regard to how she could develop a better understanding about whether mother had a learning difficulty. She was told that she had to make a formal referral through Safeguarding and Family Support Services. She completed this referral and sent it to Social Care Direct where it was mistakenly filed by an administrator as an opened case note on the Care Director electronic records system and was therefore not sent to the Community Team for Learning Disability as a referral until it was followed up in mid-January 2012 by CPA1 asking what had happened. The reason for the misfiling was that Emma’s mother was correctly identified as being an ‘open case’ for Safeguarding and Family Support Services and therefore did not recognise that the referral was specifically for adult’s services. It was filed with Safeguarding and Family Support Services records. Nobody spotted this error.   129. The referral to the Community Team for Learning Disability asked for an assessment of learning difficulty, an assessment of what services could be provided and a consideration of an independent advocate. The purpose of the referral was to have further help from the specialist adult’s service in developing a better understanding about how Emma’s mother was processing information and advice.   130. This was not clearly understood by the Community Team for Learning Disability service who managed the referral as a request for community care services against the framework and criteria set out in relevant national and local guidance and standards in regard to fair access to services against benchmarks or thresholds of learning difficulty.   131. There was continuing divided opinion between Safeguarding and Family Support Services and other professionals as to whether there was evidence of any cognitive difficulty and therefore justifying the need for an assessment by Community Team for Learning Disability. Safeguarding and Family Support Services was more persuaded that Emma’s mother lacked confidence and had been the main point of contact for the Community Team for Learning Disability social worker. Community Team for Learning  29  Disability were therefore influenced by the ambivalence of the social worker in Safeguarding and Family Support Services in regard to learning difficulty in contrast to CPA1 who had originally made the referral.   132. The first referral made to Safeguarding and Family Support Services in early November 2011 was from the supported living service that was working with Emma’s father. The referral stated that neighbours had heard regular arguments between Emma’s parents and the latest argument had included overhearing father saying he would not go back to prison; this had been understood as suggesting he had already been convicted for a previous violent assault.   133. This incident was not reported to the police by either the supported living service or by Safeguarding and Family Support Services after they received the referral. It should have been. Although the case was allocated within timescales the first record of enquiries by Safeguarding and Family Support Services in regard to the information provided by the supported living service was a telephone call to Vol 2 almost two weeks later to find out what information that service could provide. At that stage, a delay may have been attributable to the fact that Emma was not due to be born imminently and there were other cases taking more urgent priority due to the workload in the service.   134. A decision was made that a pre-birth assessment would begin within ‘the next couple of weeks’. This was interpreted by the Vol 2 as meaning that a statutory assessment was being started by Safeguarding and Family Support Services and therefore the Common Assessment Framework was closed. This was in line with the understood practice arrangements that had been developed. It signified that Vol 2 would no longer be the lead agency given the involvement of Safeguarding and Family Support Services.   135. From late November 2011 Vol 2 had remained involved but believed that the lead professionals for co-ordinating work with Emma’s parents were Safeguarding and Family Support Services. In Safeguarding and Family Support Services, although a decision was taken to complete a pre-birth assessment this was not governed by any explicit national standards although there is a local framework that requires multi-agency contribution and for the assessment to be written. Two social workers were appointed to undertake the assessment although it did not begin until February 2012 and had not been written up by the time Emma was born; seven visits had been made and the IMR author confirms that there were detailed handwritten notes.   136. The significance of the assessment not being written is that although a considerable amount of information had been collected, it had not been subjected to a sufficient level of analysis and reflection by the two social workers in consultation with other professionals or in their regular supervision with the Team Manager.   137. It is possible that if a written assessment had been completed by the social workers and had been shared with the other services working with Emma it might have highlighted the gaps and inconsistencies for them to address and would have also been subject to a check by their Team Manager who is very experienced.   30   138. Instead there was a high reliance on discussion in formal supervision as well as other more ad hoc conversation just within Safeguarding and Family Support Services. A number of issues are identified in regard to how the assessment was handled and are analysed in further detail later.   139. The pre-birth assessment had been an opportunity for routine checks with the police (as well as with other services) to discover what information they had about either parent. The pre-birth assessment should have sought contributions from other services. This was not done. There is evidence that Vol 2 and the specialist midwife queried the assessment process on more than one occasion. These were generally met with assertions that the assessment would be completed over the ‘next couple of weeks’ and that it was looking positive. This prompted the CPA1 in particular to try to escalate her concerns.  140.  The process has now been thoroughly reviewed and in respect of pre-birth assessments the Safeguarding and Family Support Service and Mid-Yorkshire Hospitals NHS Trust now work together more closely. Pre-birth assessments are complete jointly between the social worker and the midwife using an agreed written protocol and joint audit activity takes place to enable quality to be assessed.   141. Vol 2 and the specialist midwife wanted to have Emma escalated to a level of formal child protection rather than as a Child in Need in February 2012. Safeguarding and Family Support Services were not persuaded that Emma was a child at risk of significant harm on the basis of the information they had accumulated at that time. The safeguarding procedures would have been invoked by that service if the information about Emma’s father’s history of violence to previous children had been sought.  142. When Emma’s mother was still in labour the hospital were aware of Safeguarding and Family Support Services involvement and sought clarification about the birth plan and the hospital discharge arrangements. No formal written plan was in place although they were informed that arrangements had been made for the paternal grandmother to move into Emma’s household to provide support; reference has already been made to paternal grandmother stating that she had no knowledge about this arrangement although there is evidence of discussions having taken place that involved Emma’s paternal grandmother.   143. After Emma was discharged from hospital there was a high level of visiting by the different services. On the majority of these contacts it was Emma’s father who was providing the care to Emma. For some practitioners such as the children’s centre there was a concern that father was very overbearing.   144. Two days before Emma died the health visitor had made a routine home visit and found that Emma had lost weight. The health visitor wanted Emma to be medically examined and her first choice was for Emma to be seen by the hospital paediatric service. This was a referral she could make direct to the hospital. Emma’s parents were given the option of taking their daughter to the GP as an alternative and reflected  31  sensitive practice given there were no pressing concerns about the immediate safety of Emma. The parents found this arrangement more convenient given their lack of personal transport.   145. The health visitor was unable to speak to the GP but made an entry on SystmOne13. Emma was examined by the GP later that day who regarded the examination as routine and found nothing of concern in the absence of any prior discussion with the health visitor; the health visitor’s recording which was the last entry on the patient record and should have been visible but was not read by the GP, and who therefore remained unaware of the health visitor’s interest in making the appointment for Emma to be seen by a doctor.   146. It is not clear from the reports provided to the SCR panel why the GP did not see and therefore read the record made by the health visitor. However, discussion between the Health Overview Report overview author and the named GP14 has provided a better insight in regard to the use of filters that can be set by users of the electronic records system. For example, the GP can set a filter that limits the notes being shown on their computer screen to just showing clinical records and excluding other information for example from third party entries such as a health visitor.   147. Although it is understandable that a busy professional such as a GP who has limited consultation time with a patient will want to streamline the information they are having to access during a consultation it clearly has implications for how the information is used by all health professionals.   148. This is an example of where in spite of investment in new systems designed to enhance communication within complex and dispersed clinical and organisational settings, human interaction with those systems can be inconsistent for busy health professionals. Significant work has been taken forward to understand the underpinning systems and processes of information sharing between hospital and primary care. The Mid Yorkshire Hospitals NHS Trust has held a number of workshops with hospital and community staff to develop solutions to these problems. This work is still in progress and now forms part of the IT Strategy for the Trust.  149. For the purpose of clarity, even if the GP had read the health visitor’s note, the panel do not believe that the outcome of the examination by the GP would have been different given the injuries that Emma had suffered were largely detected by x-ray. The                                          13 SystmOne, is an electronic patient records system being implemented in some areas within the NHS. The introduction of the system is intended to improve information sharing and provide greater clarity about which services are being provided to a family and helps improve the interface between adult and children’s services protecting children or vulnerable adults.  14 Named Doctors and Named GP's are paediatricians and GP's who have additional roles and responsibility for child protection. They provide advice and expertise to fellow professionals either within their organisation or within their region. They have a key role in promoting good professional practice within their organisation or within their region  32  focus of the consultation was Emma’s slight weight loss and she was brought to the surgery by both of her parents.   150. When the health visitor subsequently spoke with the GP after he had seen Emma, the GP had a clearer understanding about why the health visitor had asked for the examination. Although the GP would have been made aware that Emma was subject of a Child in Need plan, it does not suggest there would have been a different outcome from a physical examination of Emma.  151. During that last visit by the health visitor the maternal grandfather had also told the health visitor that he had to intervene in an argument between Emma’s parents when her father was dragging Emma’s mother by her hair. Although the health visitor telephoned Safeguarding and Family Support Services after her visit the phone call was not included in the Safeguarding and Family Support Services records. It remains unclear whether the information about the physical assault on Emma’s mother was passed on to Safeguarding and Family Support Services.   152. The various contributory factors identified by the review influenced how Emma’s case was managed. The communication of information was not handled with enough clarity of purpose or attention to detail. The practice of allocating co-workers by Vol 2 and by Safeguarding and Family Support Services contributed an additional layer of complexity for both the family in the number of professionals in contact with them as well as managing information between the different workers. It is a possibility that the heavy workloads and co-working was a contributor to the social workers assuming that a check with the police had been completed.  153. Not enough attention and significance was given to what members of the maternal extended family were saying especially about their concerns regarding Emma’s father. The initial referral was not followed up for several days and there were delays in responding to some messages. When the raising of concerns failed to deliver an expected outcome there was reluctance to escalate matters further. Some of this reflected the different professional status for example between the CPA1 and SW1 and SW2. There were also problems arising from the piloting of the Common Assessment Framework system as an initial assessment in the Vol 2 service. The co-location of the specialist midwife meant that she did not have access to her professional intranet communication network and records.   154. Assumptions were also made that key people such as Safeguarding and Family Support Services were in full possession of all the relevant information and were therefore able to make appropriately informed judgments.   155. The health overview report (Health Overview Report) highlights that although individual health practitioners from the GP to specialist staff such as the midwife displayed positive care and attention to the support needs of her mother in particular there were gaps in critical communication within the health community as well as with other services such as Safeguarding and Family Support Services.    33  156. The early recognition that Emma was a pregnancy requiring higher levels of support were notified as usual after booking to the health visiting service who did triage the case as a priority. However Emma’s mother did not receive an antenatal visit. The practice at that time was that on receipt of the booking form with the Perinatal Mental Health Pathway the case should be triaged and placed into a file. Subsequently another person would place it in the allocations file two months prior to delivery to prompt an antenatal visit for “priority” cases only. Immediate action has been taken and the process of receipt and allocation of the information from the midwifery service has been reviewed and a better, uniform approach developed across all health visiting teams within the Wakefield district. Once Emma had been allocated after birth the health visitor very quickly gave priority to Emma and her mother from the first visit.   157. Similarly, GP information about Emma’s father having anger problems was not sufficiently recognised as a potential source of concern when the pregnancy began. However, Emma’s father was registered with a different GP several miles away and therefore there was even less opportunity to link his history with the information about a pregnant girlfriend unless he either volunteered information or had been asked. The GP was not aware of the pre-birth assessment and was never asked for information.   158. Although the midwifery service did know that Safeguarding and Family Support Services were conducting a pre-birth assessment and managing Emma as a child in need no request was made to participate in the assessment or to seek a copy of the Child in Need plan. There was in the words of one of the IMR author’s a general absence of curiosity. It is significant that all of the health services together with the other agencies working with Emma were operating with high levels of workload. Further information and analysis is provided in this report.   159. Other factors identified by the review that had an influence included the overall work capacity of individuals and services; a degree of normalisation in regard to how relationship problems were viewed; professionals being asked to undertake work without understanding the purpose.   160. The assessment that did not reflect multi agency contribution is an important example but there were also problems for example in the request that was made for Emma to be examined when the health visitor assessed that she had lost weight. Another factor was the dilemma and difficulty that confronted professionals wanting to get a foothold with two adults who were not easy to engage or open to contact but who also appeared to be accepting of help.  161. There was limited understanding displayed about the nature of violent and coercive relationships. Reliance by any service on the victim to make open and consistent disclosures is fundamentally flawed and displays a lack of understanding about the psychological and other pressures that operate in such relationships especially during pregnancy and following birth. This has implications for how crime is recorded and investigated as well as for the type of enquiry and assessment by health and social care professionals.    34  162. Many of the services reported very heavy workloads at the time of their involvement with Emma and her family. Examples are the Safeguarding and Family Support Services Team Manager having responsibility for supervising ten social workers who between them had over 280 cases that by definition represent high thresholds of need or risk and complexity or they would not have been allocated. The specialist midwife had a personal case load in excess of what had been anticipated when the post was created and was personally working with 26 very vulnerable young women of whom 18 were safeguarding concerns; significantly, Emma’s mother was not one of those 18.   163. The health visiting service was operating at above average caseload levels and at the time Emma died had one vacancy and a team member on leave out of a complement of 5.9 professional staff working with over 1800 children.   164. This information about resource allocation is not intended to indicate that it is an excuse for what occurred in this case. It is however important to understand the realities and circumstances within which professionals worked with Emma.   165. For example, Safeguarding and Family Support Services and the health visitor were undertaking a higher number of visits to Emma but the quality of their follow up, recording of information and their opportunity for proper reflection are aspects of this case that require a better understanding than simply regarding it as a problem about the performance of any individual.   166. The police also comment about the very high workload in the police safeguarding unit that was a contributory factor in the way in which the report of the domestic abuse in December was recorded and checked.   1.16 The family and other significant people  167. At the time of Emma’s death she was living with both of her parents at their home. The grandparents live locally and were in regular contact. They participated in some meetings with professionals. Considerable reliance was given to their involvement in being able to mitigate some of the vulnerability.   168. Emma’s father was diagnosed as a child with a significant level of learning difficulty which if it had been known about deserved examination within a parenting assessment.  1.17 Cultural, ethnic, linguistic and religious identity of the family and their community  169. Emma’s parents are white British. They speak English as their only language. They were both unemployed. There is no known affiliation with a particular religion.    170. The large majority of the population in Wakefield is white British (96.7 per cent), which is significantly higher than the national figure of 87 per cent. There is, however, a significant Pakistani community in Wakefield East.  35   171. Wakefield ranks as the 66th most deprived local authority in England out of 354 based on the average Index of Multiple Deprivation scores, with particular issues around household income and employment. According to the October 2010 school census, just over 17 per cent of statutory school aged pupils are enrolled for free school meals. The area in which Emma’s family lived is amongst the most disadvantaged areas in the district. There are higher levels of unemployment and ill health. Diet and life styles are poorer.    2 Narrative account of agency involvement   172. This chapter provides a narrative of professional contact with Emma and her family which has been summarised in chapter one. Although the focus of the Serious Case Review is upon the involvement of different services from when it was known that mother was pregnant with Emma up to her death there is relevant prior history that is summarised in the IMRs.    173. This chapter provides an account of the most significant events and decisions from the different services involved with Emma and her family.  The analysis of that involvement is provided in chapter four of this report against the key lines of enquiry.  174. The parents made an application for housing on 28th June 2011 after becoming homeless due to the maternal grandparents asking them to leave their home. They secured a tenancy on the 4th July 2011. As part of that tenancy agreement they were required to come to the supported living service once a week to discuss with their case worker how the service could assist them with moving onto a secure and longer term tenancy as well as providing help with training and work.  175. On the 1st July 2011 mother attended for an antenatal booking with the community midwife at approximately seven weeks of her pregnancy. A routine booking and a pre Common Assessment Framework assessment was undertaken and the community midwife identified low BMI (body mass index; low BMI is associated with adverse outcomes such as low birth weight); the midwife provided information about diet and noted ‘the possibility of learning difficulties’.   176. The community midwife made a referral to the specialist midwife who met with Emma’s mother on the 18th July 2011; she was provided with leaflets and the suggestion was made about agreeing to the midwife making a referral to the Vol 2 service.  This referral was made the following day.   177. Unknown to the midwife, Emma’s mother had received treatment at The Mid-Yorkshire Hospitals NHS Trust emergency department on 14th July at 18.34hrs with abdominal pain. She was sent home and follow up was arranged for the early pregnancy assessment unit. Later on the same evening Emma’s mother had gone to a different hospital outside the Wakefield district at 22.57hrs when she was admitted to a ward with symptoms associated with the pregnancy. She was discharged on the 15th July at 03.00hrs.   36   178. A letter was received at the GP practice on the 20th July regarding the hospital emergency department attendance out of district. Although there is no record that Emma’s mother stated that the visit to either emergency department had followed any physical violence or that she was specifically asked whether she had been assaulted, it remains a possibility that the visits to the hospitals had followed a violent argument. Further information is analysed in later sections.    179. The referral to Vol 2 on the 19th July 2011 stated that Emma’s mother was 18 years old and about nine weeks pregnant.  Emma’s father was named on the referral as Emma’s mother’s partner but was not referred in his own right; this would become significant for the ways services were provided and allowed father to remain of secondary interest.  The reasons for the referral were that Emma’s mother and father’s relationship was relatively new and they were arguing daily. The analysis provided in later sections of this report reflects on the extent to which mother remained the focus of contact.     180. The referral noted that Emma’s father had said that Emma’s mother could get very aggressive and ‘lash out’ or ‘throw things’ and that Emma’s mother had acknowledged she had issues with anger that she would like support with before the baby arrived.  Emma’s father had also acknowledged that he had issues with anger in the past for which he had attended anger management sessions.  Emma’s mother’s expectations of the referral were recorded as support with her relationship and parenting.  The specialist midwife noted on the referral that she had spoken to Emma’s parents about completing a Common Assessment Framework when she returned from annual leave.   181. The specialist midwife subsequently discussed during supervision with the safeguarding midwife, the disclosure of anger management issues and of arguments between Emma’s parents but did not open a Common Assessment Framework which would have been the expected practice and would have provided the initial opportunity for coordinating an early assessment involving other services.  182. Vol 2 undertook an assessment using the Common Assessment Framework which was completed on the 31st August 2011.  The assessment was in the name of the unborn baby but focussed mainly on mother’s needs and abilities.  At the point of that assessment Vol 2 thought that there appeared to be a lot of strengths for mother including her strong family support; she was beginning a college course in September 2011; she appeared to have good self-care skills; she appeared to have an understanding of the responsibilities and demands of parenting and she was apparently keen to access support.    183. The main risks identified were that Emma’s mother had nowhere settled to live; she was living between her parents’ home and the flat that Emma’s father had; she would be a first time parent; she had difficulties with her anger control (on one occasion she had thrown a cup of hot coffee at Emma’s father) and she was not in receiving any money of her own.  During the assessment process Emma’s mother had said that ‘family  37  services’ had been involved with Emma’s paternal uncle but she did not know the reason for that involvement.    184. The recommendations of the assessment were to put a multi-agency Common Assessment Framework plan in place; to involve Emma’s father in the support; to work with them to be better prepared for parenting; to access support around anger management and be in a better financial position (by accessing all benefits that they were entitled to receive as parents as well as access to training for employment)  185. Following the assessment, arrangements were made to give Emma’s mother a lift to her first appointment at the Vol 1 for support with her anger management.  She was not at home when a worker went to pick her up.  She subsequently said she would attend the next appointment in September 2011. It is significant that when Emma’s mother did attend at Vol 1 in October 2011 she declined to give her consent to information being shared with other services such as social workers and primary health care workers. This issue is explored further in later chapters; although it is required practice to seek the agreement of parents in regard to sharing sensitive and confidential information with third parties, the legislation and codes of professional practice are explicit about a higher duty to discuss information when there are concerns about the safety or wellbeing of children (or vulnerable adults).  186. A family support worker was allocated to work with Emma’s mother on the 13th September 2011 and she updated the Common Assessment Framework with Emma’s mother on the 22nd September.   Emma’s mother disclosed that members of her close family had received support because of their anger issues which consisted of shouting when angry but neither she nor her brother had witnessed or experienced any physical violence as children.  She appeared to have an understanding of her own anger issues identifying that it mostly happened when she was with Emma’s father and acknowledged that she could ‘hit or throw drinks’.  She said that Emma’s father would hit doors when he got angry but that he had not hit her and that he would also like to be helped to address his anger.    187. Emma’s mother appeared to understand the risks that this behaviour could pose to her baby when it was born and stated that this was why she wanted to accept support.  She had not yet attended an appointment at Vol 1 but had attended one session of the teenage ante-natal group at the children’s centre.  At this stage mother said that she did not find Emma’s father’s family supportive and would not want them to attend a Common Assessment Framework meeting.  188. On the 4th October 2011 Emma’s mother went to the emergency department at The Mid-Yorkshire Hospitals NHS Trust to receive treatment for swollen fingers on her right hand that she had sustained when she had punched a wall three days previously. She told a nurse that she had problems with her partner who becomes violent when he is drunk. She told the nurse that she had moved to her mother’s home to be safe. An X-ray was taken that showed no fractures. The doctor who examined mother was a locum (and therefore was not available for a discussion with the IMR author). There is no recorded evidence that the disclosure of domestic abuse was discussed. The GP practice  38  was notified about this visit to the emergency department. Coincidentally Emma’s mother was also in contact with the midwife to cancel the planned Common Assessment Framework meeting.  189. There were attempts to engage both of Emma’s parents in the Common Assessment Framework process in early October 2011; however Emma’s mother declined further involvement on the day and whilst a further Common Assessment Framework meeting was arranged by specialist midwife and Vol 2 for 16th November 2011 Emma’s mother continued to resist involvement in the Common Assessment Framework.  190. The first Common Assessment Framework meeting was on the 6th October 2011 that was attended by Emma’s parents and the maternal grandparent.  Emma’s mother had tried to cancel the meeting and when asked why, she initially said she didn’t know, and then had said that her family didn’t think she needed support but that she was persuaded to go ahead with it.  At the meeting Emma’s father stated again said that he didn’t think they needed support but when the concerns around mother’s anger issues posing a risk to a baby were explained they all agreed to the process.     191. At this meeting Emma’s father disclosed that he had a criminal record for violence and also thought he might already have two children that he did not have contact with.  He talked about being anxious about having this baby taken away from them.  Emma’s mother discussed having been bullied in the past and feeling depressed and crying a lot of the time.  A plan was agreed to provide support to mother. This involved mother talking to her GP about sources of help with her depression; she would also attend appointments at the Vol 1; she would attend ante-natal classes with Emma’s father and maternal grandfather to prepare them for parenthood; sort out her benefit entitlement. Analysis is provided in later sections about the lack of follow up to the information about father’s criminal record or previous children.  192. In October 2011 Emma’s mother was accepted onto the Parents with Prospects (PwP) course (a Level 1 accredited course with a focus on developing parenting and life skills) run by Vol 2; she started attending on the 11th October 2011.  Her college tutor had identified that because of her learning needs she was struggling with a Level 1 health and social care course and felt that the content of PwP would be more appropriate for her.  193. During this time Emma’s mother was supposed to be attending appointments at Vol 1 (although was not engaging with that service), attending PwP, and accessing counselling for her depression at the GP surgery.  The PwP tutors were becoming aware that Emma’s mother was struggling to understand the course content.  194. On the 20th October 2011 Emma’s mother shared with one of the PwP tutors that she often found it difficult to understand the meaning of what people were saying and was struggling to apply the learning from PwP into her life.  She said that Emma’s father often had to explain to her what the midwife had said and that generally she needed things ‘broken down’ in order to understand them.  This was a source of  39  frustration that made her angry and could lead her to argue with Emma’s father or her family.  She went on to say that what she was learning at Vol 1 was also motivating her to keep attending.  195. On the 21st October 2011 Emma’s mother told a member of staff that her plan to keep her baby safe when she and Emma’s father argued was to leave the baby with her mum or dad.  When she was reminded about the work she had done at PwP about the importance of bonding and about the need to be close to her baby mother stated she would text to see if the baby was ‘ok’ but upon further discussion she appeared to understand the need to have a safe place for her baby and said she would approach her dad to see if she could stay there.  196. At the beginning of November 2011 the GP had referred Emma’s father to the Vol 1 to provide support on anger management. The letter of referral describes Emma’s father as having a long history of anger and violence resulting in several prison sentences possible exacerbated by his use of cannabis. He is described as having a poor relationship with Emma’s mother and that father ‘recognises he needs to do something about his anger if he is to be a good enough parent’.  197. On 7th November 2011 the supported living service received a written complaint from other tenants alleging that Emma’s father may be physically abusing mother. On 8th November 2011 the manager telephoned Social Care Direct to pass on this information and spoke to a social worker. Emma’s mother was five/six months pregnant at the time and the supported living service was concerned about the domestic abuse displayed by Emma’s father. Safeguarding and Family Support Services was told that father had a history of violent behaviour and that their neighbours had reported concerns to the supported living service. At the time, parents seemed to have separated although this was not clear.  On 9th November 2011 the manager followed up the telephone contact in writing by email the details of what had been discussed on the telephone.   198. On the 9th November 2011 Emma’s mother had a ‘very confusing conversation’ with a worker at PwP where she stated that she had bruises on her neck and back and that Emma’s father had done it.  However, she then subsequently went on to say she hadn’t seen any bruises, couldn’t feel the bruises and that Emma’s father had not been responsible.    199. The worker asked to look and couldn’t see any bruising.  Emma’s mother stated she didn’t know why she thought she had bruises but maybe she had bumped her head.  She appeared relaxed and in good spirits during the conversation and when asked did not seem to recognise the inconsistencies in what she was saying.  She said that she sometimes felt scared of Emma’s father and linked this to her experience of adult relationships when she was younger.  She also said that her own father had said, ‘if (Emma’s) father is capable of doing this when he’s sober, imagine what he could do if he was drunk’.  When the worker had tried to clarify this, Emma’s mother reiterated that Emma’s father had not done anything.  The worker felt unable to establish what had actually happened and that there was no evidence of physical harm.   40   200. The referral that had been made to Safeguarding and Family Support Services was transferred to ACPT1 on 11th November 2011 and the case was allocated for a pre-birth assessment. On 17th November 2011 the housing manager received a telephone call from a social worker who had been allocated to the referral and they discussed the complaint. On 18th November the housing manager emailed the written complaint and confirmation of what was discussed on the telephone to the social worker. Because of the delay in the follow up the opportunity to check for signs of injury on Emma’s mother had been lost.  201. On the 14th November 2011 the Vol 1 made their first phone call to Safeguarding and Family Support Services following an initial telephone call to the GP about the potential child protection issues and seeking permission from the GP practice to make a third party disclosure to Safeguarding and Family Support Services. According to Vol 1 they informed the social worker about the information they had received from the GP regarding Emma’s father and passed on the details of the GP practice with the expectation that Safeguarding and Family Support Services would make further inquiries. There is no record of the phone conversation in Safeguarding and Family Support Services recording and no evidence that a follow up was made with the GP either. Further analysis is provided in later sections including the role of the GP practice in sharing information and making referrals to Safeguarding and Family Support Services.   202. At the Common Assessment Framework meeting on the 16th November 2011 it was agreed to continue to support mother around housing and benefits; to access support around her anger and depression; to attend ante-natal classes and PwP and arrange for her to participate in a healthy eating course; to make a referral to the Community Team for Learning Disability for an assessment of Emma’s mother’s understanding.   203. On the 22nd November 2011 Vol 2 were informed that Safeguarding and Family Support Services would be undertaking a pre-birth assessment following a referral by the supported living service in respect of domestic abuse perpetrated by father.  Details of Vol 2’s involvement with Emma’s parents and the concerns around their relationship, their issues with anger and Emma’s mother’s ability to understand were shared with the social worker.    204. On the 23rd November 2011 Emma’s mother attended Vol 1 and disclosed a significant level of coercive behaviour from Emma’s father; this included threatening to make her homeless, lack of income and an impact on Emma’s mother’s emotional wellbeing from threats that Emma’s father intended to reconcile with his previous partner and return to live with her. This information was shared by Vol 1 during a telephone discussion with SW2 on the same day. The conversation also included reference to concerns about mother’s possible learning difficulties.   205. On the 24th November 2011 mother confided with other students whilst at PwP that Emma’s father was likely to be violent to her later that day but stopped talking  41  when she realised the tutors could hear what she was saying.  She went on to say that Emma’s father was upset because his granddad had died but when she was asked what she thought might happen she said she didn’t know.  This information was shared with the social worker on 28th November 2011.   206. In November 2011 Emma’s father was referred to the Vol 1 by his GP for help with his anger management. The Vol 1 made contact with him however he was only prepared to attend if Vol 1 paid his bus fares. As Vol 1 did not have access to funds this was not possible and he did not engage with the service.   207. On the 8th December 2011 the specialist midwife was made aware by a phone call from the FSW at Vol 2 of the domestic abuse incident (8th November 2011) and the subsequent referral made by housing to Safeguarding and Family Support Services and was told about the pre-birth assessment by Safeguarding and Family Support Services; she commenced an Integrated Care Pathway (ICP) document for the unborn baby15. The specialist midwife recorded in the Safeguarding Integrated Care Pathway her attempts to speak to the allocated social worker.   208. The Common Assessment Framework was closed on the 8th December 2011 as the case had now been accepted as a referral for Safeguarding and Family Support Services involvement although Vol 2 continued their contact with Emma’s mother.  209. On the 9th December 2011 the Vol 2 service made a referral to the adult Community Team for Learning Disability service requesting a learning disability/capacity assessment of mother and asking for the provision of an independent advocate.  This was re-referred on 18th January 2012 after there had been no response (further information is provided later about the misfiling of the referral). Emma’s mother was assessed in February 2012 by the Community Team for Learning Disability but was not considered to meet criteria for Community Team for Learning Disability service as she has most skills to enable her to live independently. A referral was made to a specialist centre16 by the social worker in ACPT1.  210. On the 13th December 2011, a Vol 2 worker visited Emma’s mother and observed bruising around her right eye.  Emma’s mother stated that she had walked into a door but appeared anxious so the worker did not ask any further questions in front of Emma’s father.  The information was shared with the social worker on the 14th                                          15 This is a health based clinical pathway rather than describing a multiagency or LSCB protocol. Clinical pathways, also known as care pathways, critical pathways, integrated care pathways, or care maps, are one of the main tools used to manage the quality in healthcare concerning the standardization of care processes. It has been proven that their implementation reduces the variability in clinical practice and improves outcomes. Clinical pathways promote organized and efficient patient care based on the evidence based practice and in this case are evidence that mother’s circumstances required clear coordination between specialist, hospital and community based services. 16 A new centre located at a local hospital providing specialist services for people with learning difficulties. The accommodation includes both day care and short stay units that offer a wide range of facilities for assessment, treatment and special therapies.   42  December 2011. Emma’s mother was also asked about the bruising again at PwP; she reiterated that she had walked into a door.   211. On the 27th December 2011 Emma’s parents had a verbal argument at their home address regarding Emma’s father wanting to visit mother’s father (PGF) who had arrived at their property and removed Emma’s mother after hearing them shouting. Emma’s mother and PGF had gone to the police station as the PGF believed that Emma’s mother had been assaulted. Whilst at the police station, Emma’s father had arrived and remonstrated with the maternal grandfather. No complaints were made by any of the parties. Mother denied that she had been assaulted; it was noted by the police that she was 26 weeks pregnant at the time.  A DASH risk assessment was completed17; the result was ‘standard risk’. A letter and Information pack were sent to Emma’s mother.   212. Emma’s father was taken to his mother’s address. Analysis is provided in later sections about why the police did not complete a domestic abuse notification or a child protection referral to Safeguarding and Family Support Services.  213. The children’s centre contacted the family in January 2012 because the Vol 2 had registered them as new parents on the EStart electronic system. When a new family are registered on the system the children’s centre undertakes an initial welcome visit. This is routine and does not reflect a cause for concern for the contact to be made with the family.  214. On the 12th January 2012 a family play and learning worker and a student called at the family home to introduce the children’s centre and its services and to invite mother to a Vol 2 event.  On returning to the children’s centre the worker spoke to the children’s centre manager and expressed her concerns about the apparent dominance of Emma’s father.  The manager recommended that the worker should contact Vol 2 and share her concerns with them.  The worker telephoned Vol 2 and although she could not speak with the worker who was in contact with mother, she was assured that her concerns would be passed onto the mother’s worker in Vol 2. No written information was provided.   215. On the 1st February 2012 two workers from Vol 2 visited the parents and agreed a support plan around support with benefits, housing repairs and for mother to attend a cookery course.  Following this visit one of the workers shared their concerns with the social worker that Emma’s father did most of the talking during their visit and was behaving in a controlling way towards mother.                                            17 The introduction of the Domestic Abuse, Stalking and Honour Based Violence (DASH 2009) Risk Identification, Assessment and Management Model from March 2009 meant that for the first time all police services and a large number of partner agencies across the UK are using a common checklist for identifying and assessing risk with the aim of saving lives. ACPO (association of chief police officers) Council accredited the DASH (2009) model to be implemented across all police services in the UK from March 2009.   43  216. On the 2nd February 2012 Vol 1 emailed information to Safeguarding and Family Support Services about the original referral from the GP in November 2011 describing the history of violence and reference to several prison terms in relation to Emma’s father that had been included by the GP. The email also confirmed that Emma’s father had never attended Vol 1 because they were unable to fund his bus fare. It was the following day that Safeguarding and Family Support Services recorded making a telephone inquiry with the police Public Protection Unit (PPU) regarding Emma’s father; there is no corresponding record by the police of a telephone call or other enquiry being made.   217. On the 8th February 2012 the specialist midwife spoke with the social worker who reported that the pre-birth assessment was progressing positively. Both the specialist midwife and the Vol 2 worker discussed their concerns in a telephone conversation; however they were both told that the social worker had no concerns; they were informed that there was one further session with the parents to complete the assessment when a decision would then be made. The specialist midwife requested it be managed at child protection plan level and the social worker indicated it would be at least a child in need decision18. The specialist midwife recorded that there were currently no concerns by the social worker regarding the parents taking their baby home following the birth although that could change. Later analysis explores that this was one of the opportunities for an escalation of concern.  218. Further phone calls by Vol 2 following up the initial call to Safeguarding and Family Support Services on the 1st February 2012 were made on the 8th February 2012 and again on the 15th February 2012. This last phone call was to reiterate their request for a multi-agency meeting and plan and to also express the service’s opinion that the severity of their concerns around mother’s ability to understand and the risks in Emma’s father and mother’s relationship were not apparently being acknowledged by the social workers.    219. Several further phone calls were made by the specialist midwife and FSW at Vol 2 until the 22nd February 2012 when the social worker spoke by telephone to Vol 2 and after discussion agreed to talk to her manager about arranging a multi-agency meeting.   After a further phone call from Vol 2 on the 29th February 2012 the social worker said there would be a Child in Need meeting the following week.  220. On the 25th February 2012 mother was admitted to hospital having begun her labour. The labour ward midwife caring for mother attempted to contact Safeguarding                                          18 This distinction refers to the different sections described in the Children Act 1989 and summarised in the appendix to this report. Children in need are defined in law (S17) as children who are aged under 18 and need local authority services to achieve or maintain a reasonable standard of health or development, need local authority services to prevent significant or further harm to health or development or are disabled. S47 describes specific enquiries and duties in regard to children at risk from or suffering significant harm.    44  and Family Support Services at 12.45 hours to inform them that mother was in labour and to seek clarification on the situation with regard to safeguarding the baby after delivery as there was no evidence of a birth plan or instructions from Safeguarding and Family Support Services in the records. The phone was not answered although a further call was apparently made later. The labour ward midwife recorded that she had spoken to Safeguarding and Family Support Services and the social worker had confirmed that mother and father were ‘OK’ to take the baby home as long as the grandmother stayed with them as agreed. Reference has already been made to the paternal grandmother stating that she had not been aware of this arrangement despite evidence of discussions with Safeguarding and Family Support Services and further analysis is provided in later sections of the report.  221. Eleven sessions had been undertaken by the two allocated children’s social workers prior to birth to develop the pre-birth assessment and a child in need plan. According to case recording made by the social workers as part of assessment, a request was made to the police about information on both parents. The case recording states that the police advised Safeguarding and Family Support Services on the 3rd February 2012 that there were no relevant offences regarding either parent. The police have no record of any contact from Safeguarding and Family Support Services or providing any information.   222. The records in Safeguarding and Family Support Services do not record who made the contact from Safeguarding and Family Support Services or who they spoke to. It is now known that in addition to the incident in December 2011 father had several incidents of domestic abuse with previous partners; one previous allegation in 2002 concerned him allegedly punching the two year old daughter of a previous girlfriend and there were allegations of sexual abuse. Emma’s father had been charged but the case had then withdrawn before it went before a court. Further analysis is provided in later sections of this report.  223. The first home visit after Emma’s birth by Safeguarding and Family Support Services was with the specialist midwife on the 27th February 2012. The specialist midwife on examining Emma found her clothing to feel damp and that there were five blankets on Emma. Father told the midwife that grandmother had encouraged them to keep Emma warm. The specialist midwife discussed sudden infant death syndrome (SIDs) and demonstrated how to position Emma in her cot as well as discussing the making up of formula feeds19.  Mother indicated she felt confident with Emma’s care.   224. At the child in need meeting on the 8th March 2012 mother was observed to have a bruise on her head; this was the second occasion a bruise had been recorded.                                           19 SIDs is also referred to as cot death; approximately 300 babies die suddenly and unexpectedly in the UK each year. Most of these deaths occur during the first three months after birth; babies who are premature and are a smaller birth weight and male are most at risk. The cause of such deaths is unknown although others can reduce the risk of SIDS by not smoking while pregnant or after the baby is born, and always placing the baby on their back when they sleep. Other measures included not letting the baby get too hot and for parents not to sleep with their baby on beds or sofas; hence the advice and demonstration provided.  45  She said that she had bumped into a cupboard. The meeting was attended by SW 1 and SW 2, both Emma’s parents and the Vol 2 worker.  Apologies had been received from the specialist midwife and health visitor. Emma’s paternal grandmother and Emma’s maternal grandfather were also unable to attend the meeting.  225. On the 14th March 2012 the specialist midwife asked Vol 2 staff to speak in private to mother when they got a chance about a bruise she had seen on her head during a visit that day; this was the third bruise that had been observed.  Mother had told the midwife that she had bumped into a cupboard.  226. On the 28th March 2012 a worker from Vol 1 rang FSW2 to say that when Emma’s mother had attended a session that day she had a black eye that she was unable or unwilling to explain; this was the fourth incident of bruising.  FSW2 had not noticed this on a visit the day before but the room was dark because the curtains had been closed.  The FSW was told that Emma’s father had been referred to Vol 1 for support (although had not attended) and that he had a history of perpetrating domestic abuse in his previous relationships.  Emma’s mother agreed to encourage him to attend; this was not realistic. The Vol 1 worker told FSW2 that she would contact Safeguarding and Family Support Services about the bruise; this was done.  227. The social worker made a home visit on the 30th March 2012 to discuss the report of mother having evidence of being bruised; this was met with denials that she had been subject of domestic abuse; further analysis and comment is provided in later sections about how the evidence of domestic abuse was managed.  228. A Child in Need review meeting was to have taken place on 4th April 2012 but this was postponed due to heavy snow.   229. On the morning of the 10th April 2012 Emma was seen at home by the health visitor with her mother and the maternal grandfather; Emma’s father was reported to have been upstairs but was not seen. Emma’s mother stated they had tried to feed Emma every three hours but that Emma had vomited after her feed. The feeding and management of reflux was discussed by the health visitor. Feeding was observed with good swallowing reflex and tone. The health visitor noted that Emma had a ‘weak cry’ and advised that a paediatrician or GP should see Emma. The health visitor arranged an appointment with the GP to review Emma’s weight loss and reflux and to provide an opinion or diagnosis. During this visit the maternal grandfather had mentioned that he had stopped father dragging Emma’s mother up the stairs in the home.   230. The GP saw mother and Emma on the 10th April 2012. The health visitor had tried to contact the GP practice by phone but was not able to speak to the GP before they saw Emma. The health visitor made an entry on the electronic patient record although this was not seen by the GP who therefore regarded the consultation as routine and at the request of the parents. The GP had no concerns about Emma from the examination although advised Emma’s mother to seek an earlier review if the symptoms (of falling weight) or any new concerns emerged. Further analysis and  46  comment is provided in later sections about the clarity of communication with the health visitor and the reliance of the GP on mother seeking appropriate advice.   3 Synopsis of the learning and analysis from the individual management reviews.  3.1 Summary  231. This part of the report is an opportunity to try and to understand what people knew and how they were making their judgments at the time. The key lines of enquiry provided a framework for structuring particularly important areas for learning and development to come from the review.   232. Writing an IMR is a significant piece of work. The majority of authors provided their IMRs within timescales and have undertaken redrafting following discussion at the panel. The panel undertook a detailed critical reading of each IMR.  233. For some of the authors, they were simultaneously working on IMRs for other Serious Case Reviews. All of the authors were also undertaking their usual range of professional roles and responsibilities.   234. All of the services contributing to the Serious Case Review have ensured that the quality of information provided to the panel has supported appropriate learning. When senior managers became aware of problems regarding the quality of some agency reports, action was taken to address this and to ensure that the panel had sufficient quality of information and analysis.   235. The review has revealed particular issues in regard to the ethical and professional concerns that face professionals in possession of sensitive and confidential information. This has had an influence for example in how information sharing was managed by one of the GP practices during their routine contact with Emma and her parents and during the Serious Case Review itself. That GP declined to provide detailed information for the Serious Case Review until very late into the review despite rigorous efforts to obtain the information by health representatives to the Serious Case review Panel.   236. The conduct of a Serious Case Review is an opportunity to examine in detail the systems and professional practice and is also a litmus test for the capacity of the individual organisations to understand both the quality and the quantity of the services for which they are responsible.   237. The skills required to undertake an effective IMR are the skills that a good manager should want to develop and have the capacity to deploy in their day to day role; the work involves collating relevant information, understanding what the experience of children and families are when they come into contact with their service, be confident that staff have appropriate skills and experience and are making balanced and informed judgements and be able to analyse how to improve practice and service further. In the most simple of terms the objective should be on encouraging and  47  ensuring that people are making the right judgments that lead to the right action and making it more difficult to make poor judgments and to take the wrong action.   238. Serious case reviews are essentially about trying to understand how events looked to key people at the time and understanding what frameworks and information were being used to help them make their judgments. Hindsight always identifies the other options that may have been available; the effective learning comes through understanding why things happen.   3.2 Significant themes for learning that emerge from examining the IMRs  239. The agency reviews identify themes that apply to all services working with children and that have implications for policy development and staff training. In the summary of the review’s finding provided in chapter one there is acknowledgement that some of the issues to come out of this review are reflected in the findings of national evaluation and research. Important messages for learning from this review include:  • Effective safeguarding is only achieved if all professionals understand the importance of recognising signs and symptoms of abuse that can harm children before and after birth and understand their responsibilities to share such information with the relevant services;  • Historical information is essential to understanding the significance of current events and identifying long term patterns of concern; evidence about childhood abuse, history of violence and use of drugs, and learning difficulty was not established and led to minimisation;  • Coercive relationships combined with poor self-esteem and emotional vulnerability combined with unemployment and fear of homelessness will all present significant barriers for women to disclose information about domestic abuse; threats of physical violence were also a factor in this case;   • Cognitive functioning may not reflect frameworks of diagnosis or thresholds of priority for service; father’s significant learning difficulties were not recognised by any of the agencies and the queries in regard to mother were not analysed or resolved within any meaningful structure of assessment;  • The different professional status in multi-agency working can be a threat to effective communication; CPA1 had a consistent level of concern about domestic abuse and mother’s cognitive functioning; her concerns were not regarded with sufficient attention;  • Busy services and high caseloads that comprise significant levels of social problems can lead to professionals becoming more tolerant of issues such as violent arguments; using cultural relativism to tolerate inappropriate behaviour;   48  • Other cases that are displaying more explicit and unambiguous concerns can distract and demand more urgent attention; in this case the writing up and analysis of the pre-birth assessment was apparently deferred although visits and contact with Emma’s parents were taking place;  • Supervisors and line managers need the capacity to provide the quality of critical challenge, oversight and reflection; none of the services were able to provide an effective response to the domestic violence and seeing the underlying themes and patterns;  • Telephone and face to face conversations are not a substitute for making formalised referrals of concerns to relevant services;  • Effective multi agency working requires clear professional leadership and the full participation of relevant people;  • Critical professional activity such as assessment requires appropriate frameworks to guide multi agency contributions and analysis and planning;  • The education records of young parents can be an important source of information relevant to assessing adult needs and capacity.  240. The remainder of this chapter summarises key evidence relating to the terms of reference established for the IMRs.  3.3 Good practice identified through the review  241. To support the learning from the review the panel looked for examples of good practice. To constitute good practice, the panel looked for action or decision making that went beyond compliance with local and national policy, procedures and guidance.   242. Examples of good practice identified by the review include;  • There was a much more frequent level of contact with Emma’s mother by health and social care services than was required by local and national standards and expectations;  • The early identification that Emma’s mother would require additional support when the first ante natal booking was taken and a referral was made to the specialist midwife and Vol 2 service;  • There was a good level of communication between the college tutors and the Vol 2 service in regard to mother’s cognitive problems and evidence of domestic violence;  • The referral by the CPA1 to Community Team for Learning Disability showed a commitment to exploring Emma’s mother’s level of understanding and she showed persistence in following up the lost referral;  49   • The health visitor ensured that Emma was seen on a very frequent basis and the focus on her physical development ensured a prompt referral on two occasions in regard to Emma’s weight;  • When the health visitor was unable to speak to the GP about her concerns on the 10th April she ensured that information was entered on to the SystmOne that would have allowed an opportunity for the GP to access it before or during the consultation;  • The GP practice sent SMS (short message service) text reminders to Emma’s mother about medical appointments.  243. The remaining sections of this chapter summarise the most significant learning from the IMRs against each of the case specific terms of key lines of enquiry.  3.4 Learning Difficulty  The Serious Case Review Panel considers that the difference between learning difficulty and learning disability may not be well understood.  Individual Management Reviews should clarify professional understanding of learning difficulty and the impact it may have on parenting capacity.  244. Learning disability is the term used by the government and is utilised throughout all government produced documents. Learning difficulty is the term preferred by the self-advocacy movement such as People First and is the term used by many local services to people with learning difficulties.   245. The two terms are often used interchangeably but it can be confusing as ‘learning difficulty’ is also a more general term used within education as well as by other services. However people who have a specific educational difficulty do not generally fit into the definitions given below.  246. Learning difficulty is a term used to describe any one of a number of barriers to learning that a child may experience. It is a broad term that covers a wide range of needs and problems, including dyslexia and behavioural problems, and the full range of ability. Most people with a learning disability have only a mild disability that simply means they need more help than most to learn new skills.  247. A learning difficulty is a permanent condition. People with learning difficulties grow and develop as individuals, but at a slower pace. Some people with learning difficulties may also have physical disabilities or other medical conditions, but many do not. Valuing People20 states that a learning disability includes the presence of:                                           20 This was the first White Paper on learning disability for thirty years published in 2001 and set out an ambitious and challenging programme of action for improving services  50   • A significantly reduced ability to understand new or complex information, to learn new skills (impaired intelligence), with;   • A reduced ability to cope independently (impaired social functioning);   • And which started before adulthood, with a lasting effect on development.  248. This definition encompasses people with a broad range of disabilities. The presence of a low intelligence quotient, for example an IQ below 70, is not of itself a sufficient reason for deciding whether an individual should be provided with additional health and social care support. An assessment of social functioning and communication skills should also be taken into account when determining need. (DOH.2001 pp14-15)  249. A learning difficulty/disability is said to exist then if:   • The person has an intellectual disability developed before the age of 18;   • The person has reduced ability to understand new or complex information;   • The person has reduced ability to cope independently;   • The person has difficulty or is unable to learn new skills;   • The person has been assessed to have an I.Q. of less than 70.  250. Clarity about the nature of learning disability or a learning difficulty has implications for both informing a professional’s understanding about how parents are receiving information and advice as well as having implications for how different services use such definitions to apply threshold judgments in terms of access to services. This was an issue in this case for example in regard to the referral to the Adults Community Team for Learning Disability service.   251. It is significant that most of the references to learning difficulty are in respect of the mother and does not include father. This reflects the degree to which father was not as central to the assessment that did take place; this is a factor commonly identified in reviews such as this one. In this case, Emma’s father was seen to be dominating of Emma’s mother and he was apparently influential in both parents being less engaged with the people offering help and support.  252. Emma’s father was the subject of a statement of educational need (SEN) when he was at school; this identified borderline severe learning difficulties and he received additional support for much of the time he was in education including at a specialist school.  253. Emma’s mother was never the subject of SEN assessment whilst at school although she did have support in regard to her anger management. It was noted that whilst she  51  was still at primary school that she took a long time to respond to most words and sentences; this led to assessment for any hearing impairment. No impairment was diagnosed.  254. A referral was made to the Community Team for Learning Disability when it was becoming apparent that Emma’s mother was having some particular difficulty in applying the learning from her parenting sessions. The initial referral was filed as a case episode that meant it was not processed as a referral for action and it was in February 2012 that an assessment was undertaken by the service.   255. The assessment did not involve any discussion between the assessing social worker with CPA1 who had made the referral. The response by the service appeared to focus on whether mother had a learning disability that qualified her for support from the service rather than assessing any needs or difficulties she might have in processing information.   256. The assessment was conducted against the criteria and framework of the Community Care Act which was different to the type of assessment that was sought. The Community Team for Learning Disability social worker was assessing under NHS and Community Care Act 1990 which is the normal practice for the service. She advised Safeguarding and Family Support Services that an assessment of cognitive abilities was not within her area of responsibilities and ensured that a referral went to the local specialist service. As a result of this Serious Case Review the Safeguarding and Family Support Service and Adults Services are now working together in relation to assessments of parents who are felt to have learning difficulty or learning disability.   257. It is not known what information the GP had in regard to either parent’s learning difficulties. No consultation was made by the other services with the GP.   The Serious Case Review Panel identified concerns within different agencies that Emma’s mother may have had a degree of learning difficulty.  Individual Management Reviews should identify: the extent to which professionals were concerned about Emma’s mother’s learning capacity; the evidence on which concerns about learning difficulty were based; and how evidence of learning difficulty was acted upon (i.e. taken into account when providing services, referral for additional support)?    258. Emma’s mother completed her statutory schooling in 2009. Although a significant amount of information was lost in a school fire there were records held by the education service in regard to the difficulties that Emma’s mother had. She received support from specialist services who identified that mother had some problems in processing information. This information was not known to any of the people who were working with Emma’s mother in 2011 and 2012.  259. When Emma’s mother booked, the midwife (RM1) presumed she had learning difficulties on the basis of her own informal assessment, noting that she often looked to others to answer questions for her.  This was one of the three factors she highlighted in her pre Common Assessment Framework assessment and was included in her referral to the  52  specialist midwife. She did not initiate a formal assessment of Emma’s mother’s learning ability through the local pathway protocol or file a Common Assessment Framework herself believing that this would be the responsibility of the specialist midwife.  260. The specialist midwife did not initially feel that Emma’s mother had a learning difficulty that would affect her ability to care for Emma.  However she did record possible maternal learning difficulty in the Integrated Safeguarding Pathway (ICP) and highlighted concerns about mother’s understanding and about mother and fathers parenting ability when speaking on the phone to SW1 shortly before Emma was born. She also discussed the possibility of mother having learning difficulties with the health visitor after Emma was born.  She never thought father had a learning difficulty nor had access to any information about this.  261. The concerns about parenting ability and possible maternal learning difficulty were among the reasons the specialist midwife referred to Vol 2 for additional support. She also planned with Vol 2 that a Common Assessment Framework would be completed and towards the end of pregnancy listed this among her concerns when asking SW1 to manage the case at an escalated child protection level.   262. The health visitor felt she was unable to assess any learning difficulty in mother and had queried if she was just shy. This view was apparently shared by the social worker in the Safeguarding and Family Support Service and subsequently by the social worker in adult’s services. The health visitor allocated Emma and her family to the Complex Programme as a result of multiple concerns and had planned to assess the parenting although this work was not complete when Emma was injured and died.  263. During the course of Vol 2 involvement with Emma’s mother, CPA1 developed significant concerns relating to her capacity to learn and submitted the referral to Community Team for Learning Disability at the beginning of November 2011. This followed a discussion with the Community Team for Learning Disability duty worker who recommended this course of action.  CPA1 had also informed the social worker in the Safeguarding and Family Support Service that Emma’s mother did not seem to understand the pre-birth assessment.   264. It was the CPA1 who raised the referral to the Community Team for Learning Disability by sending it through to Safeguarding and Family Support Services on the 9th December 2011. The referral stated clearly the purpose of the referral. It requested an assessment to be undertaken of Emma’s mother’s needs so that support could be provided that would give her the best chance of parenting her child.   265. The referral added two distinct requests, for the team to provide an advocate for Emma’s mother to support her through the pre-birth assessment and for an assessment to be made to ensure she can understand legal proceedings which may follow. The referral included details summarising the involvement that the service had to date along with detailed examples that might illustrate the concern, including details about the “confusing” conversation she had held with Emma’s mother.    53  266. According to the IMR regarding the Community Team for Learning Disability service the original referral was placed on Emma’s file as an open activity case note for Safeguarding and Family Support Services. It was only sent through as a referral on the 18th January 2012 by the CPA1. It is probably significant that the adults IMR states that the primary purpose of the referral was for an assessment of eligibility for support; this certainly was the principal focus of the assessment by the social worker allocated to undertake the Community Team for Learning Disability assessment.   267. The adult’s IMR acknowledges that the assessment was too preoccupied with whether Emma’s mother had a learning difficulty that would qualify her for access to support and services. It did not give attention to specific issues such as the pregnancy and impending parenthood and inquire as to the capacity and implications for Emma’s mother. This probably reflected a misplaced assumption that this was entirely the responsibility of Safeguarding and Family Support Services rather than being seen as a ‘corporate’ responsibility.   268. CPA1 was aware from her conversations with the college that Emma’s mother had been receiving additional support through the Flex Team (a team for students with learning difficulties). CPA 1 had undertaken conversations with Emma’s mother where in her assessment she appeared to have been unable to absorb any understanding from the learning being undertaken at the PWP group.  During a particular conversation with Emma’s mother she appeared to indicate she may have been suggesting that she would text to see if the baby was ok and appeared to have no understanding about the importance of bonding which she had just learned about on the PWP course.   269. CPA1 was concerned by conversations she had with Emma’s mother where she seemed unable to recognise or understand the contradictions in what she was saying for example in relation to the suitability of living with her parents when the baby arrives, whilst providing obvious information to the contrary.  270. CPA1 was aware that Safeguarding and Family Support Services was undertaking a pre-birth assessment but when CPA1 discussed this with her, Emma’s mother did not appear to have any level of understanding of what this entailed. Following this referral there remained concerns, an example being that Emma’s mother did not appear to have an understanding about where she could for example buy baby formula milk.   271. Following the re-submission of the referral in February the Community Team for Learning Disability social worker reported back that they would not be able to undertake an assessment because mother was due to give birth in two weeks’ time; the original referral had been sent almost three months previously.    272. According to the adult services IMR, once the referral had been sent through correctly in January the case was allocated on the 23rd February 2012. The IMR does not state whether this is a usual timescale for allocating a referral.  The one home visit made by Community Team for Learning Disability was made on the 15th March 2012. This was a joint visit with SW1 from Safeguarding and Family Support Services.    54  273. The respective IMR states that the Community Team for Learning Disability does not undertake assessments of cognitive functioning and that Emma’s mother did not meet criteria for the service.  According to the IMR she presented initially as being quite shy. However her confidence grew in the interview and told SW2 that she thought most of the questions asked were things that everyone should know. SW2 in interview was very clear in interview that mother gave appropriate answers to her questions and showed no evidence at all about not being able to understand information or manage her day to day life. The Community Team for Learning Disability social worker had previously spoken with the housing support worker who stated that she did not believe that mother had a learning disability.   274. The IMR does not provide any further insight into how the judgment about not qualifying for service in the absence of an assessment of cognitive functioning was reached. The social worker informed CPA1 that she had made a referral to the local specialist service for an assessment of her cognitive functioning; the CAP1 recorded this as a psychological assessment. Although the adults services IMR states that the Community Team for Learning Disability social worker followed the referral up with the local specialist service there is no specific information about what this involved or outcome. The Community Team for Learning Disability social worker had put referral in to a specialist centre and arranged for it to be discussed at the allocation meeting within two days. The social worker also spoke to the psychologist who was allocated the case. These conversations are recorded on the case file although do not appear to have been communicated to the CPA1 who had initiated the original referral.  The Serious Case Review Panel found that Emma’s father had a learning difficulty.  Individual Management Reviews should identify: if this information was known to professionals working with the family; if professionals had any concerns about Emma’s father’s learning capacity; the evidence on which concerns about learning difficulty were based; and how evidence of learning difficulty was acted upon (i.e. taken into account when providing services, referral for additional support)?   275. The police had father in police custody on ‘numerous times’ over a period of several years; this contact was not known to other services working with the parents until 2012 and after Emma had died. According to the IMR the police knew that father had learning difficulties although the severity is not recorded and was generally limited to knowing that father had ‘trouble with reading and writing’.   276. The other service that had information about Emma’s father (and her mother’s) learning difficulty was the education service. This information is not routinely sought although this case has demonstrated the potential value in helping establish whether parents have an identifiable learning or communication difficulty.  The records collated by health services during childhood are subject of record keeping policies that require their destruction after 25 years.    277. Although several professionals began to consider whether mother had a learning difficulty that is described in greater detail in the next section, none of the professionals ever considered whether father had a learning difficulty or disability. This is in spite of father  55  having a support worker and living in a supported housing scheme. An important contributory factor in Emma’s father not being regarded as having a learning difficulty was that he had good verbal skills and was much more confident in conversations. This was observed when father was at school and assessed as having significant learning difficulties.  278. The concerns in regard to father related to anger control, the evidence of him controlling mother and a concern about whether he was physically abusing her.   279. Emma’s father told the health visitor that he had “difficulty reading long words” at her first visit but this was the only reference to him having learning difficulty in The Mid-Yorkshire Hospitals NHS Trust records during the period under review. The details of his special educational needs statement in the child health files would be subject to a policy of destroying historical records.    280. There is no evidence on file that the staff at Vol 2 were aware that Emma’s father had a learning difficulty and this was confirmed by all the staff that had direct involvement with Emma’s mother at interview as well as their Supervisor and the Service Manager.  281. The Community Team for Learning Disability IMR confirms that they did not know about Emma’s father’s learning disability and acknowledge that they did not seek any information either about him from the Safeguarding and Family Support Services social worker or from father direct. Community Team for Learning Disability were aware that he was living in supported accommodation and imply that they understand that he had the tenancy and was therefore the focus of that support.  The Community Team for Learning Disability did not know about the cognitive functioning difficulties identified when Emma’s mother was attending school; they were instrumental in making a referral to the specialist centre although this assessment had not been completed when Emma died.   3.5 Violence and Control  The Serious Case Review Panel identified domestic incidents where Emma’s father was alleged to have assaulted Emma’s mother.  Individual Management Reviews should identify: how allegations of domestic abuse were acted upon and followed up, particularly in the context of the risk to Emma; and any missed opportunities to refer the family on to a different agency or source of support, such as a Multi-agency Risk Assessment Conference or other intervention.  Could more have been done to support Emma’s mother to disclose information about violence within the home?   282. There were four visits to hospital emergency departments while Emma’s mother was pregnant. On one of those occasions she acknowledged that she had injured her hand during an argument with Emma’s father. This information was not shared outside the emergency department. The GP was informed of the other visits to the emergency department in Wakefield and out of district; although Emma’s mother did not disclose any information about domestic abuse the GP practice was made aware of the history of violence and harassment.    56  283. Although there were several reports of Emma’s mother having physical injuries such as bruises there were just two formal allegations of domestic abuse that were recorded and were made by third parties (neighbours) rather than from mother or another family member. The maternal grandfather made three statements or reports about domestic abuse although these were not formally recorded as domestic abuse  284. The first referral to the Safeguarding and Family Support Service was made by the Supported Living Service on 8th November 2011. The information given to Safeguarding and Family Support Services included information about Emma’s father’s previous history of domestic abuse and that he had served a prison sentence as result. This information was not discussed with the police or with probation. A decision was taken to not undertake an initial assessment but rather complete a pre-birth assessment because of the risk to the unborn Emma. The basis of the decision was that a detailed assessment was required over and above an initial assessment which was therefore not completed. The case was allocated to the social worker on 17th November 2011.   285. The social worker discussed the referral with supported living services on the 18th November 2011; the conversation appeared to focus on Emma’s father’s history of being homeless, his mental health and that he had self-harmed. The focus does not appear to have been upon the allegation of domestic abuse.   286. The implications of the decision were that none of the preliminary enquiries were undertaken at the outset; this for example meant that the specialist midwife was not consulted by the social worker (although did learn of the referral and made contact). Most critically, no discussion took place with the police. This would have provided an opportunity to investigate the allegation and that could have led to a disclosure to Safeguarding and Family Support Services of the previous history of violence in a neighbouring area.  287. The pre-birth assessment included a session that explored domestic abuse by asking questions from the parents and family. Significant misdirection appears to have occurred when Emma’s father said that his prison sentence was for breach of an order and only referring to being drunk and disorderly and public order. Checks were not made with probation to verify the information or to check the anger management work that Emma’s father claimed he had done and who felt did not need to do any further work in site of the evidence of continuing issues.  288. On the 1st February the maternal grandfather told the social worker about an incident of domestic abuse in December 2011; it is not clear if this was the same incident that the police had been informed about. The maternal grandfather described Emma’s mother phoning him screaming that Emma’s father was grabbing her and he said that believed there were other incidents when she had been grabbed and bruised.   289. It was two days after this conversation that the social worker has recorded that they had contacted the police asking for any information about relevant offences. The police have no record of this contact and the Safeguarding and Family Support Services records do not provide details about who their police contact had been. The social worker’s recording  57  stated that no offences were disclosed and this was reported to the Team Manager who therefore believed that all the relevant checks had been completed.   290. These types of enquiry by Safeguarding and Family Support Services to the police are routine and the expected practice would be for the police to provide any relevant information over the telephone after having confirmation that it was in relation to s47 enquiries (in which case there would be a strategy discussion) and information would be provided or if the case was being managed as a child in need there would been a formal request for information under the relevant protocols. Emma was being managed as a child in need although the detail of the assessment and plan was not shared with other services.  291. On the one occasion in December 2011 when the police were told about an allegation of domestic abuse, the DASH assessment was completed. This recorded the fact that Emma’s father had a prior ‘domestic history with other partners’ but did not include information about any of the alleged child abuse. The DASH did record the fact that mother was 26 weeks pregnant.  No statements were taken after Emma’s mother declined to make a formal complaint. A routine letter was sent out to mother with an information pack about advice that was available. Further comment is provided in later analysis in this report.  292. The police service policy requires a formal child protection referral to be made if the victim is pregnant. The referral was not made; although the officer completing the assessment knew mother was pregnant and correctly recorded this information on the DASH risk assessment the shorter summary of the incident upon which the authorising officer relied upon for signing off the incident stated that there were ‘no children as yet’.   293. Although the statement is true and accurate, it meant that the officer reviewing the documentation and assessment was not aware of the pregnancy. The IMR describes how the volume of work within the safeguarding unit at the time was high and therefore there was an increased reliance on written information providing sufficient detail to make decisions on summaries such as the information in the occurrence entry log (OEL).  294. The two incidents in November and December 2011 provided the clearest opportunity for information about domestic abuse to have been properly accessed and shared and would almost certainly have resulted in a multi-agency discussion and enquiry under the WDSCB framework.   295. The booking midwife RM1 did not suspect or know of any domestic abuse but the IMR author comments that she should have considered it when seeing the mother behaving differently at her second contact when Emma’s father and his mother were not present.  This was an opportunity to raise the question of domestic abuse.  296. The specialist midwife became aware of mother having anger management issues at the end of her first contact when paternal grandmother urged her to disclose this and this was a factor in her deciding to add Emma’s mother to her case load, involve Vol 2 and to propose a Common Assessment Framework. The specialist midwife learnt from FSW2 on the 8th December 2011 that a referral had been made to Safeguarding and Family Support Services following a “domestic violence incident”.  She included this information in the  58  integrated safeguarding record that she opened on the 6th January 2012.  This could have been an opportunity to escalate by making a referral on the basis of her safeguarding concerns.  297. The health visitor was not aware of domestic abuse issues until informed of this by the specialist midwife after she had made initial contact with family.    298. There are at least four references to bruising being observed on mother by professionals other than the social workers. Neither of the social workers observed the bruising; on one occasion there was a difference of view about whether Emma’s mother’s complexion rather than a bruise was visible. The result was that several professionals had more concern about possible domestic abuse than was shared by the social workers.   The Serious Case Review Panel found evidence that Emma’s father was violent, controlling towards Emma’s mother and had sought assistance with anger management.  To what extent were professionals aware of Emma’s father’s violent and controlling behaviour and/or his propensity to be violent?  If they were, was this information shared with other agencies and what were the expectations associated with sharing this information?    299. At the initial postnatal visit the health visitor commented that Emma’s father attended to all of Emma’s needs and that her mother was not observed to handle her baby.  Her instinct had suggested this might be controlling behaviour but she felt that establishing a relationship and ensuring access was more important than pursuing this at that stage.  These types of dilemma are not unusual for all professionals although what should have happened in this case is for advice to have been sought after the visit. If there had been a clearer structure to the pre-birth assessment and plan this might have also encouraged a more appropriate discussion and reflection with Safeguarding and Family Support Services.   300. On the 16th March 2012 she was informed in a phone call with SW2 that both parents were attending anger management sessions. She had once seen a “flash of anger in his eyes” when she was discussing care of the baby, but otherwise she personally saw no evidence of domestic abuse.  The IMR comments that she could perhaps have liaised with the Multi Agency Risk Assessment Conference (MARAC) to see if more information was available especially when she learnt more about background.   301. During her visit on 10th April 2012 the health visitor saw mother and maternal grandfather and was told that Emma’s father was upstairs and that Emma’s maternal grandfather had no time for him and that he had seen him “dragging” mother upstairs the previous week.  The IMR comments that this could have been an opportunity to escalate with a safeguarding referral to social care or to liaise with MARAC. A telephone message was left with Safeguarding and Family Support Services although there is no reference to the information provided by the maternal grandfather.   302. The Vol 2 IMR describes how their staff became suspicious about the possibility of ‘further violence’ and in their referral to the Community Team for Learning Disability described Emma’s mother as being in a violent relationship. Bruising had been observed on three occasions to mother although on each occasion attributed the injuries to accidents  59  rather than any assault. There are references in the records to Emma’s father’s behaviour appearing to make Emma’s mother nervous and watchful. For example, during a visit to the home on the 13th December 2011 Emma’s father ‘walked through the room for no apparent reason’; the conversation at the time was about the injury to Emma’s mother’s face.  303. On another occasion Emma’s father is described as doing all the talking for Emma’s mother and the staff at the children’s centre found him to be ‘overpowering’.   304. On one occasion a worker asked why Emma’s mother was so quiet when Emma’s father was present; she replied that she found talking in front of people to be embarrassing. It is not clear that this was ever explored further by professionals working with her or in any future conversation with her.  305. In spite of the injuries and concerns about Emma’s father’s influence on Emma’s mother, these do not escalate beyond a sense of what one IMR describes as ‘niggles’.   3.6 The limited information about Emma’s father in agency records  Were professionals sufficiently curious about Emma’s father and his role within the family?    306. Although the social workers believed that they had made sufficient enquiries of other services to acquire appropriate information about father there were significant limitations to what was actually achieved. If a request for information had been made, it was not done in accordance with the well-established protocols. When a domestic abuse incident occurred in Wakefield requiring a police response, information was not forwarded either through the domestic abuse or child safeguarding protocols in regard to the unborn Emma.   307. Limited information about Emma’s father was gathered by RM1 as this was not required as part of the pregnancy booking process. She was not aware of father’s learning difficulty.  Since then the booking form has been redesigned to require more information about fathers. The Health Overview Report explains the information pathways that had been put in place following an earlier SCR to ensure that fathers were considered although the electronic recording system was not in place; the Health Overview Report provides historical context in regard to the liquidation of a key supplier of information recording systems.   308. The Vol 2 ’were not sufficiently curious’ about Emma’s father according to the IMR authors. This could be applied to other services that were in contact with the family after mother’s pregnancy was confirmed and the Common Assessment Framework and subsequent support was arranged.   309. The adult IMR confirms that no information was known about Emma’s father’s history. The social worker had been given limited background information about a previous domestic abuse issue by the referrer but was not given any detail and made no contact with CPA1. SW2 was aware that Emma’s father was in accommodation with support so should  60  have known that he had some support needs. SW2 did not ask the nature of these support needs, although he was present during the home visit on the 15th March 2012. SW2 took the view that she had been asked by other professionals to do a specific piece of work and accepted this on face value. SW2 said that she did not consult the relationships screen on Care Director (the electronic records system) which would have allowed her to access case notes on unborn Emma or her father. The IMR comments that this displays a lack of curiosity. The gaps in information about Emma’s father means that if such a check had been completed it is unlikely that this social worker would have been able to be much better informed.   Did Emma’s father receive information/advice about appropriate handling of the child?   310. Emma’s father was present at booking and was subsequently seen by both the specialist midwife and health visitor, both of who felt that he was given as much information as mother with regard to child care issues.  Specifically he was given information about handling a baby, temperature control, cot death prevention, feeding advice, advice about not shaking babies. The health visitor continued to make a high level of visits.   3.7 Child in Need Plan  Emma was subject to a Child in Need Plan following a pre-birth assessment.  Was this Plan sufficiently robust, with clear actions, responsibilities and contingencies if the Plan was not followed?  Were professionals clear about their role and the role of other professionals?  Did the family appear to understand the Child in Need Plan and what was expected of them?  Was the plan adhered to?  How was it monitored?  311. Although the referrals that were made to services such as Community Team for Learning Disability and Safeguarding and Family Support Services are generally described as containing a good level of information, the overall approach between the services relied heavily on conversations by telephone, in occasional meetings and individual supervision sessions.   312. The child in need plan was not circulated outside of Safeguarding and Family Support Services. Whilst there are references to possible child in need meetings within the Mid-Yorkshire Hospitals NHS Trust records there is no evidence in their records of them being informed that a child in need meeting ever took place or that a Child in Need plan was ever produced.  No member of staff ever attended or contributed to a meeting or saw a written plan.     313. Consequently no Mid-Yorkshire Hospitals NHS Trust employee was aware of its contents. The Health Overview Report comments that the health visiting and midwifery professionals would have known that a Child in Need plan was being developed and that they could have been more assertive and proactive in following up the absence of information. The final chapter of this report provides further reflection about the context and circumstances for the different professionals and how it could influence aspects of behaviour and decision making.  61   314. The Vol 2 service had an ‘implicit understanding’ that their role was to ‘continue to support mother’. There were no explicit conversations about how information was to be coordinated or the various indicators of concern were to be monitored.  315. The child in need meeting on the 24th February 2012 involved only the two social workers, the Community Team for Learning Disability and family. The purpose of the meeting was to discuss the outcome of the pre-birth assessment. Although the plan set out expectations that the parents would ‘engage’ with support that would include father participating in the safe @ home21 men’s group and that concerns were to be reported by the family, the content of the on-going assessment and work with services such as Vol 2 ‘could have been more clearly outlined’.   316. The second meeting that was planned for the beginning of April was cancelled due to severe weather although the health visitor did a home visit on that day. The adult’s IMR makes clear that they were unaware of the Child in Need plan.  317. The Health Overview Report comments on how high workloads have a clear link with the inflation of thresholds for follow up and more intensive intervention and the implications for specialist practitioners. This is explored further in the final chapter of this report.  The Serious Case Review Panel has identified that Emma’s paternal grandmother had a role within the Child in Need Plan.  What was the nature of this role and why was it considered to be necessary?  Was it appropriate? Were professionals clear about this role?  Was the nature of this role sufficiently communicated to Emma’s family?    318. The role of the grandparents was not clear over and above the expectation that Safeguarding and Family Support Services had that the paternal grandparent would provide support when Emma and her mother were discharged from hospital following the birth. Discussion in the meetings did not clarify the role of the maternal and paternal grandparents.   319. The Community Team for Learning Disability social worker was made aware by Safeguarding and Family Support Services that the paternal grandmother planned to move into Emma’s home after her birth to provide support. The respective IMR acknowledges that no inquiries were made in regard to the reasons for the support and in the absence of any information about father or his background it was none the less seen to be a positive source of support for Emma. This reflects a common assumption that extended families will be a source of positive support and influence.                                              21 A specialist ‘one stop service’ offering advice, support and information to those affected by domestic abuse in the Wakefield district.  62  Were the support needs and parenting capacity of Emma’s parents adequately considered by professionals and are there any lessons to be learned?   320. It was recognised that Emma’s parents had additional support needs and steps were initiated to address these.  At the initial booking RM1 expressed concern and involved the specialist midwife.  The specialist midwife at first contact learnt about anger issues and referred to Vol 2 and agreed a Common Assessment Framework should be filed.  Also as delivery approached the specialist midwife liaised with Safeguarding and Family Support Services to highlight her concerns in consultation with Vol 2.  321. However, the IMR authors acknowledge that there was a lull in activity in the middle of pregnancy particularly in relation to making progress with the Common Assessment Framework.  This should have been managed on a tighter timescale and when the parents withdrew a referral to social services would have been appropriate.  The parents were apparently both involved in anger management support but their engagement was never adequately achieved.   322. Although Emma’s father said that he would have participated if bus fares had been paid the reluctance of both parents to participate meaningfully in the Common Assessment Framework reflected an unwillingness to be involved; it is generally thought that Emma’s father was very influential in controlling Emma’s mother’s responses.    323. Much of the direct family work was placed with the Vol 2 service although The Mid-Yorkshire Hospitals NHS Trust had a responsibility to ensure this was proceeding satisfactorily.  The IMR from Vol 2 comments that the ownership of the Common Assessment Framework process needs to be made explicit. For example, in this case RM 1 should have completed the pre-assessment form to show who was going to be responsible for it and the specialist midwife should have either taken responsibility for filing it or at least ensured that it was progressed in a satisfactory manner.  324. The adult service IMR comments on several aspects of learning to have emerged from examination of their involvement. In particular the IMR refers to the importance of understanding the requirements of the relevant legislation that includes the Mental Capacity Act 2005 and ensuring that assessment practice takes account of the particular circumstances of an adult. In this case there was insufficient understanding about the implications of the pregnancy and parenthood to be incorporated into the enquiries by Community Team for Learning Disability.   325. The focus of the adult assessment was on a narrow aspect of whether mother individually qualified for access to any services; the IMR author makes reference to the fact that access to services will require a high level of urgent need. The IMR acknowledges that no assessment of mother’s (or father’s) cognitive functioning had been undertaken. There had been discussions with a housing support worker and the one home visit that involved it appears the use of an everyday tasks questionnaire did not reveal any concerns for either social worker about mother’s level of understanding.    63  326. In the absence of any detail or comment about the tool that was used by the Community Team for Learning Disability social worker and the extent to which it could have probed how mother was processing information is not clarified. There was no discussion with CPA1 who had raised the original referral.   327. The referral by the GP to Vol 1 in regard to Emma’s father’s anger problems was a response to providing support to Emma’s parents. However it was in isolation from talking with any other professionals either within the health service or with other services such as Safeguarding and Family Support Services. As highlighted previously the GP was not consulted by other services other than Vol 1 who discussed the safeguarding implication of the referral to their anger management service.   328. The locum doctor and triage nurse who dealt with Emma’s mother and her injured fingers in the hospital emergency department in October 2011 did not apparently recognise that she was the victim of domestic abuse. The triage nurse was unaware of local services and arrangements such as the Safe @ Home integrated domestic abuse service or other relevant local groups offering advice, support and information to those affected by domestic abuse in the Wakefield district. The Mid-Yorkshire Hospitals NHS Trust has now taken action to improve the awareness of staff in relation to domestic abuse. An independent person was asked to review the content of the existing domestic abuse training in the trust and as a result of this work the delivery of this training has been strengthened considerably for example all Emergency Department staff now receive training on domestic abuse along with nursing and medical staff and this has been supported by a new campaign involving posters, screensavers etc. that are visible to all staff.  Were practitioners aware of and sensitive to Emma’s needs in their work, and knowledgeable both about potential indicators of abuse or neglect and about what to do if they had concerns about a child’s welfare?  Were there any indications or cues from this child that may have indicated that the child was being mistreated?  329. Although the involvement of the specialist midwife and the organisation of the Common Assessment Framework and referral to the Vol 2 service were all indicative of the early recognition that Emma’s parents had additional needs, when it came to the birth of Emma and the involvement of the health visitor there was not an adequate plan in place. The completion of the Integrated Care Pathway (ICP) had not provided an opportunity to provide prior notice to the health visitor of a birth to a vulnerable family. The health visitor allocated to Emma had no prior information.  330. The health visitor who made the referral to the GP on the 10th April 2012 mentioned that Emma had a cry that was “not usual” at her initial visit but this was too nonspecific to require any action.  However, when the health visitor noted the weight loss, on the background of the other concerns she correctly recognised the need for a further assessment which is when she made her referral via the GP.  She would have preferred a paediatric referral but as parents had problems getting to the hospital she referred to the  64  GP instead.  Unable to speak to GP she had put her concerns on SystmOne22.  The GP did not know about the health visitor’s concerns placed on the electronic patient record until he spoke to her the next day after seeing Emma.    331. The IMR says that she had appropriately identified the possibility of safeguarding issues and should have either insisted on a paediatric referral or been explicit in her referral to GP indicating that she wanted the child admitted.  After speaking to the GP there was also another opportunity to refer to social care with her safeguarding concerns.  332. The GP practice had important information about the harassment that Emma’s mother had experienced and was also aware of father’s extensive history of violence that had resulted in more than one term of imprisonment. Although the referral to the Vol 1 had resulted in that service contacting the GP practice to highlight the implications for child protection, no referral or other contact was made by the GP practice with Safeguarding and Family Support Services or any other health practitioners who were in contact with Emma’s mother in relation to the pregnancy.   333. The visit by Emma’s mother to the Mid-Yorkshire Hospitals NHS Trust in October 2011 for the injury to her fingers was reported to the GP but did not include information that it had occurred during an argument with Emma’s father; the information was not shared with any other service. This was a significant gap in sharing information.   334. The Health Overview Report comments that the absence of involvement by health practitioners in the Child in Need plan and the apparent lack of appreciation that Emma’s mother had stress and anger issues presented to the GP during pregnancy had implications for her emotional and practical capacity as a parent demonstrates a degree of insensitivity to needs.   335. The adult service IMR acknowledges the lack of curiosity on the part of the Community Team for Learning Disability social worker who undertook the home visit. There is no substantial comment about the extent of knowledge and responsibility that the service expects of its staff in collating information about potential neglect. The IMR confirms that Emma’s parents and grandparent presented a very positive picture during the home visit.   The Serious Case Review panel has been advised that the police held information that would have been relevant to professionals working across agencies.  All Individual Management Reviews will need to examine whether information held by their agency in relation to Emma’s parents was used effectively in terms of assessing risk to the child.  336. The police had significant information about Emma’s father in regard to the domestic abuse in previous relationships and physical injury of a child. In 2002 a two year                                          22 SystmOne, is an electronic patient records system being implemented within the NHS. The introduction of the system is intended to improve information sharing and provide greater clarity about which services are being provided to a family and helps improve the interface between adult and children’s services protecting children or vulnerable adults.   65  old child was injured and this was the subject of police investigation and enquiries through the child protection procedures of a neighbouring authority.  337. Emma’s father subsequently began a relationship with another partner who also had a child. That relationship lasted for several years during which time it is known that he subjected the partner to domestic abuse that escalated over time. The ex-partner suffered a particularly violent assault during which her ribs were broken. Emma’s father was convicted and received a prison sentence that was suspended. Child protection procedures were again invoked in regard to the child.  338. The police were told about an incident of domestic abuse between father and mother at the end of December 2011. Although there was a DASH assessment that recorded the history of domestic abuse with previous partners it did not include reference to the allegations of child abuse. The incident was not reported to Safeguarding and Family Support Services by the police safeguarding unit. No statements were taken when Emma’s mother declined to make a complaint.   339. The earlier incident at the beginning of November 2011 that was reported to Safeguarding and Family Support Services by the housing provider was not reported to the police; this was in spite of information that indicated that Emma’s father had physically assaulted Emma’s mother.  340. The Health Overview Report comments on the lack of detailed analysis about risk assessment available from health reports and information. Although the specialist midwife made a number of attempts to raise issues about Emma’s mother in the latter months before the birth she did not formally escalate any concerns about any risks to Emma to others. The GP had information about Emma’s mother suffering harassment from a previous partner and also had information about Emma’s father and his history of violence including imprisonment. Although referrals were made to a specialist service to help both parents with anger there was no referral to Safeguarding and Family Support Services.   341. The specialist voluntary organisation was concerned about the implications of Emma’s father’s history and contacted the GP about this; the GP did not make any referrals or share information with any other service. The specialist service did make two contacts with Safeguarding and Family Support Services; once by phone in 2011 and again in a follow up email in February 2012. Although the information referred to the GP having information about a history of violence, they did not make a formal referral or follow up concerns in writing.   4 Analysis of key themes for learning from the case and recommendations  342. This report began with an acknowledgment of the imminent changes that are to take place over the forthcoming months in the conduct of Serious Case Reviews locally and across England. These changes are driven by the recognition that any meaningful analysis of the complex human and professional interactions and processes for decision making that characterise multi-agency work with vulnerable families has to understand why things  66  happen and the extent to which local systems help or hinder effective work within ‘the tunnel’23.   343. There is a risk when undertaking a Serious Case Review that has examined the involvement of several different services, for it to then result in a range of recommendations that overwhelm rather than promote the further positive development of services and practice. A review can also become misdirected in trying to fix a set of issues that relate to a specific case or particular historical circumstances that are out of the ordinary or have already been resolved. The overview author also has to take account of the number of recommendations and action plans that are the outcomes of the IMRs and the health overview report.   344. From the start of this review the panel have been determined to be very challenging in order to bring out as much learning as possible. It is for this reason that a great deal of detail has been reflected upon within many of the individual agency reviews, the health overview report and within the content of the previous chapters to this overview report. The IMRs and the Health Overview Report have generated over 19 recommendations as a result of this specific review and are also working on action plans following previous Serious Case Reviews.   345. The review panel acknowledge the contribution made to the learning from this review by the many people who participated in the interviews and discussions with the agency IMR authors. The panel also acknowledge the considerable work undertaken by the authors of the agency IMRs and of the Health Overview Report. These are complex and significant processes taken on by people already with a wide and extensive range of responsibilities in their usual professional role.  346. There is a temptation in thinking that reports such as this will resolve the areas for learning and development identified through the review. It is not the reports that achieve this but rather the dedicated and purposeful work of the managers, specialist advisors and practitioners in the different services and of the WDSCB who will oversee the learning from the review. It is their work with some of the most vulnerable children and young people that can make a difference in continuing to achieve ever better outcomes for children.   347. This report and all the others that are provided through a Serious Case Review should acknowledge the complexity facing people working in these services. The benefit of the hindsight offered through a review should not over simplify or devalue the skills and knowledge that the combined workforce of criminal justice, education, health and social care professionals has developed and that they deploy on a daily basis.                                            23 View in the Tunnel is explained by Dekker (2002) as reconstructing how different professionals saw the case as it unfolded; understanding other people’s assessments and actions, the review team try to attain the perspective of the people who were there at the time, their decisions were based on what they saw on the inside of the tunnel; not on what happens to be known today through the benefit of hindsight and a far more detailed compilation of information.  67  348. In this final chapter of the report, the focus is upon the key points of learning to come out of this particular review. Members of the maternal family have expressed their hope that there is effective learning and that it is implemented from the review. The process of undertaking the review has already generated learning across several services and therefore it is of doubtful quality to take an unduly forensic approach of dealing with every detailed aspect; such an approach leads to over complicated and ultimately less effective action plans and strategies. The fact that this overview report is a public document also means that the full content is available for relevant training and development to promote continued learning.   349. A few well-chosen critical reflections are more likely to be effective than trying to address every micro detail, especially at a time when all organisations are also managing significant change in response to the national and local challenges. This final chapter’s purpose is to be proportionate in identifying those most important areas for learning that result from this particular Serious Case Review.  350. There is nothing to prevent any organisations or individuals from identifying additional action as a result of their own management review or the overarching themes highlighted by either the health overview report or in this overview report.  351. The key findings in this chapter are framed using a systems based typology developed by Social Care Institute for Excellence. Although this Serious Case Review has not used systems learning to collate evidence there is value in using the following framework to identify some of the underlying patterns that appear to be significant for local practice whilst accepting there are some limitations and mismatch between how the evidence has been collated and this form of presenting the key findings.   a) Innate human biases (cognitive24 and emotional) b) Family and professional interactions c) Responses to incidents d) Longer term work with vulnerable children and families e) Tools f) Management systems  352. The remainder of this report aims to use this particular case, to reflect on what it appears to reveal about gaps and areas for further development in the local safeguarding system and use it as far as possible as a window into those local systems.   353. In providing the reflections and challenges to the WDSCB there is an expectation that the Board will want to provide a response to each of the key findings as well as to the recommendations and action plans that are described in the IMRs. As far as the key finding described in the remainder of this chapter it is anticipated that the Board will take the following action.                                           24 This describes the functions of knowing, perception and intuition   68  a) Does the Board accept the finding? b) How is the Board to take this forward? If not, please explain why. c) Who is best placed to do this? d) What are the timescales for response? e) How and when will it be reported?  354. The WDSCB will determine how this information is managed and communicated to relevant stakeholders. The reason for structuring this final and important part of the report in this way is that it gives responsibility and empowerment to the people who know their community and services to develop appropriate responses rather than have action imposed.   355. The remainder of the report summarises key influences in relation to the key practice or episodes.   4.1    Innate human biases (cognitive and emotional influences): repeated exposure of professionals to intractable and long term problems such as domestic violence contributed to a normalisation and de-sensitisation in the response and understanding the significance of deviant or risky parental behaviour that included evidence of historic and current domestic abuse  356. Emma’s family were not regarded as the most vulnerable family known to the various services that were all under significant workload pressures. The fact that the pre-birth assessment had not been written up and analysed probably reflects that other cases were taking a higher priority in Safeguarding and Family Support Services.   357. Services that are regularly dealing with domestic abuse did not recognise information as significant. Examples included the disclosure by Emma’s father about a record of imprisonment and reference to violence during the first Common Assessment Framework meeting. Safeguarding and Family Support Services was provided with information about concerns regarding Emma’s father’s history and behaviour.   358. The response by the police when the maternal grandfather took Emma’s mother to the police station and the reliance on mother making a complaint rather than taking a more proactive stance to the evidence of domestic abuse indicates a degree of normalised behaviour reflected by all of the services in this particular case; none were able to overcome the reluctance of Emma’s parents to take opportunities to address the violence in their relationship.  359. The only professional referral of domestic abuse (in contrast to the telephone discussions and messages between professionals) was in early November 2011 from the supported living service to Safeguarding and Family Support Services. It is not clear why the police had not been called when the argument was occurring although it may reflect a reticence to have contact with police from a community that feels it to be living on the margins by virtue of their lifestyle and circumstances.   360. A Multi-Agency Safeguarding Hub (MASH) will be operational at the new Wakefield District Police Headquarters by the end of January 2014. The Wakefield MASH will involve  69  statutory and other services in co-ordinating reports and information and making joint analysis in relation to children where concerns about safety and vulnerability are being identified. In the meantime social workers undertaking S47 Enquiries and police officers are already co-located at a local police station and this has led to closer working and improved information sharing. The MASH will include representatives from the Safeguarding and Family Support Service, West Yorkshire police and health agencies.  361. At no stage during the time period under review was there a sufficiently structured meeting that involved the different services to collate the information that was held by different people and services; the pre-birth assessment was a framework for doing this but did not involve other services and the two Child in Need meetings did not involve all relevant people involved with Emma and her family.   362. Evidence of domestic abuse did not attract sufficient sceptism.  Although Emma’s father had considerable contact with several different professionals, some of whom had significant information about his history, this remained effectively invisible for the purpose of any formal assessment and analysis of information.   363. Vol 1 made two contacts with Safeguarding and Family Support Services as well as one telephone call to the GP to raise their concern about the information regarding Emma’s father. The telephone call to Safeguarding and Family Support Services in November 2011 and the email in early February 2012 clearly expected that further discussion would take place between Safeguarding and Family Support Services and the GP. It did not happen.  364. Vol 2 had become concerned; this reflected a greater level of contact even when they believed the case had effectively been taken over by Safeguarding and Family Support Services to undertake the pre-birth assessment.   365. The maternal grandfather commented about his lack of confidence in services taking sufficient notice and action in response to domestic abuse.   366. The Health Overview Report acknowledges the learning that has been identified in previous Serious Case Reviews in regard to exploring the possibility of domestic abuse with pregnant women and refers to ‘Asking the question’. Recommendations in regard to Abigail (WDLSCB 2012) are addressing this.   4.2    Difficulties in achieving a balance between keeping a mind open to new information and making judgments and decisions in a timely fashion for children such as Emma  367. The Safeguarding and Family Support Services author refers to the dangers and influence of cognitive fixation that prevents people from giving proper inference to new or contradictory information that does not fit with a prevailing mind-set. In this case there was a mind-set from very early on that inferred that Emma’s mother had the greater level of difficulties and that Emma’s father was going to be a committed father who could compensate for some of the areas of difficulty.    70  368. Although this view of father was being challenged by the Vol 2 by the beginning of 2012 it was apparent that Safeguarding and Family Support Services did not see Emma as a child requiring protection but rather a family needing and accepting help and support. This may have been an unconscious influence on how important tasks such as making the enquiries of other services such as the police were dealt with.   369. They were not expecting to receive information that would challenge a pre-existing view based on their own observations of Emma’s parents who wanted to present a positive front to statutory services that would have been able to remove Emma if they had concerns.   370. Emma’s father expressed his motivation to be a good parent to Emma. He talked with the GP about his anger difficulties and he attended sessions with different professionals. He had the support of his family. The degree to which either of Emma’s parents had the capacity to overcome their difficulties was the subject of much optimistic hope and intention and not enough attention to the barriers and contra indicators.   4.3    Responses to incidents; inadequate checking of history and the collation of emerging information created the conditions where individual incidents were viewed in isolation and inhibited the identification and clarification of patterns from different sources; the influence of mind-set.   371. There will be surprise as well as concern about how the very significant history in regard to Emma’s father did not become known more clearly prior to Emma’s tragic death. Safeguarding and Family Support Services were told on two separate occasions by Vol 1 that they had been given information by the GP that Emma’s father had a history of violence and had served several terms of imprisonment. The referral in early November 2011 from supported housing had also included reference to the overheard comments by Emma’s father that he would not go back to prison.  372. It is quite possible that the nature of the discussion between the two social workers was such that neither checked that it was the other who had actually made the phone call and because they had only seen him providing attentive care to Emma they did not have a prior anticipation that he was a source of risk to Emma.   373. It remains somewhat problematic trying to understand why having been told in unequivocal terms by Vol 1 that Emma’s father had a record of violence and had been in prison that a further verification was not made. The fact that both social workers and their manager felt overwhelmed by their workload is a contributory factor that impeded their opportunity for meaningful reflection and challenge.   374. This impaired capacity was probably a contributory factor to explain why a further check was not made with the GP or with the probation service. There would have been a further opportunity for a check if the GP practice had made a referral to Safeguarding and Family Support Services with first-hand information.    71  375. The rule of optimism25 has been recognised as a significant cognitive influence in how professionals receive and process information. The significance is that it leads to minimising information that represents a source of risk by concentrating on information that supports a positive framing of parental capacity for example.   376. In this case the mind-set that had developed was that it was mother who had difficulties with her anger and household management but that Emma’s father was presenting himself as being motivated and more than prepared and capable to take responsibility for Emma and her mother; he was regarded as an important source of resilience to counteract the deficits that had been identified.   377. Too many of these judgements had relied on observing the parents behaviour for relatively short periods of time without closer attention to collating historical information and involving all relevant people in helping with collation and analysis of information. Background information is always important to consider alongside direct observation.   378. Some professionals faced particular problems in how stored information was available to inform their judgement. For example, the complexity of data systems in health services often means that several different sources of information have to be accessed to ensure sufficient information is revealed. The storage of patient information in GP practices does not routinely identify for example relationship links between men with a violent history such as Emma’s father with a pregnant woman.   379. This is exacerbated when different GPs see a patient and therefore are not in a position to have a personal overview of information although with the number of patient consultations undertaken by a GP there will always be a high reliance on what is stored in the patient record. In Emma’s case, although there was information about his violent history and imprisonment this was not known or looked at in detail until after Emma had died.  380. There are also complex and difficult ethical and legal dilemmas that confront professionals such as doctors in determining when they should share patient information. The GP practice often has information that can be a crucial part of a multi-agency jigsaw of data and intelligence about a child and their family. In this case there were specific opportunities when the GP practice could have made a referral about Emma’s father and the GP practice also had important information about the vulnerability and needs in regard                                          25 In 1983, Dingwall, Eekelaar Dingwall and Murray, (The Protection of Children: State Intervention and Family Life, Blackwell, Oxford) investigated professional decision making in an English child protection system. They developed the 'rule of optimism' to explain how health and social workers were screening or filtering out many of the cases with which they were involved. These researchers asserted that under the 'rule of optimism' workers applied a heuristic or routine method of practice which was used to reduce, minimise, or remove the concerns for the child's welfare or safety. This was done via the workers applying overly positive interpretations to the cases that they were assessing. The same research suggested that the 'rule of optimism' was only discounted when parents refused to cooperate with workers and rejected help (a 'failure to cooperate'), or when there was a 'failure of containment' where a number of workers became involved with the case and the pressure for protective action became too great. Child death inquiries and Serious Case Reviews have continued to comment on the phenomenon and Lord Laming has also referred to the same rule of optimism.  72  to Emma’s mother. Not all of this information was known to any single GP and the fact that more than one GP practice had contact with Emma’s parents was a further hindrance to seeing a complete picture about Emma’s circumstances.   381. Another cognitive influence was the work circumstances that several of the professionals were experiencing; the ability to stand back and reflect on the contradictions and inconsistencies in regard to information and observation are more limited when people feel under pressure to process information quickly and make judgements based on that fast processing. Daniel Kahneman describes how human brain function is dominated by fast and intuitive functioning that primarily relies on personal experiences and immediate information where as more analytical processing is far more difficult to achieve without conscious discipline26.   382. The significance of understanding the impact of such cognitive influences on the behaviour and processing of information by professionals has to be recognised in developing the conditions that make right judgments more probable. In this case the simple description of how key aspects of information were processed leads to a linear conclusion that people made misguided decisions. But trying to understand why the decisions do not stand up to hindsight examination requires a more challenging and rigorous response.   383. The referral to adult’s services did not result in any checks of historical information; both Safeguarding and Family Support Services and the Community Team for Learning Disability remained unaware of the history of learning difficulty for both of Emma’s parents.    384. There were disclosures of his violence during early discussions but because mother was the focus of professional involvement and he was not seen as a person meeting the criteria for support from the service (he was not a young parent whereas Emma’s mother was) and there was no follow up.   385. The review has highlighted that conditions such as workload and information management contributed to an over reliance on how Emma’s parents behaved with professionals.  There were also further missed opportunities in later meetings when for                                          26 Thinking, fast and Slow; Daniel Kahneman, (New York: Farrar, Straus and Giroux, 2011. The title of the book refers to what Kahneman, adapting a device that other researchers originally proposed, calls the “two systems” of the human mind. System 1, or fast thinking, operates automatically and quickly with little or no effort and no sense of voluntary control. Most System 1 skills such as detecting the relative distances of objects, orienting to a sudden sound, or detecting hostility in a voice are innate and are found in other animals. Some fast and automatic System 1 skills can be acquired through prolonged practice, such as reading and understanding nuances of social situations. Experts in a field can even use System 1 to quickly, effortlessly, and accurately retrieve stored experience to make complex judgments such as undertaking what might be regarded as a routine assessment. A chess master quickly finding strong moves when he recognises a defensive weakness are examples of acquired System 1 thinking. System 2, or slow thinking, allocates attention to the mental activities that demand effort, such as complex computations and conscious, reasoned choices about what to think and what to do. System 2 requires most of us to “pay attention” to do things such as drive on an unfamiliar road during a snowstorm, calculate the product of 17x24 or understand a complex logical argument.  73  example Emma’s father was ambivalent to participate in anger management sessions because he had already done this in the past.   386. The lack of reporting to the police about incidents in November 2011, February and April 2012 left the police outside of the circle of information sharing for the for pre-birth assessment and Child in Need plan. Safeguarding and Family Support Services were not aware of the contact that Emma’s mother and maternal grandfather had with the police in December 2011 because a safeguarding referral had not been made to Safeguarding and Family Support Services; the circumstances and the reasons have been described previously.  387. The IMR from Safeguarding and Family Support Services has acknowledged there was information that was not sought in relation to this case. There were other checks in addition to the police that were not completed adequately. The consequence was that the information being passed through particularly from Vol 2 was never given the inference it deserved if the historical information had been secured.   388. This resulted in over reliance on what the social workers observed during their seven visits of meeting with Emma’s parents and during which father in particular made sure that Emma was seen to be well cared for.  4.4 Tools; the tools and assessment process for multi-agency collating, sharing and analysing information were not sufficiently developed and embedded and provided no resolution to issues such as whether either parent had a learning difficulty or disability  389. The effective sharing and analysis of information within a framework of theoretically robust and child focused assessment is a perennial challenge for multi professional teams and practitioners and has been described and discussed in national research, inspections of children’s services as well as being a regular feature in Serious Case Reviews.   390. The assessment of neglect and the quality of emotional care of very young children is especially problematic if the information and professional systems do not have the capacity to reflect upon the accumulated evidence of direct observation and professional reporting. It is being able to identify and understand the underlying patterns to behaviour and interaction rather than relying on single defining events (such as a physical injury for example) that are important to safeguarding children.  391. National efforts to achieve improved consistency have largely resulted in processes becoming ever more bureaucratised and process driven through computer based electronic recording frameworks. This has left professionals completing processes that have little apparent benefit for improving the clarity and insights regarding complex behaviours and family circumstances and their interplay. The tools focus on describing events or behaviour and offer limited opportunity to record professional reflection, hypothesis or analysis.   392. In this case there were issues identified by some professionals regarding the cognitive functioning of Emma’s mother. These were never adequately explored or resolved. Historical checks with education services is not a local or national requirement and is not a usual or required practice; in regard to Emma’s father and mother there was  74  important and relevant information within the education service in regard to childhood learning difficulties that could have helped inform the pre-birth assessment.  393. The current systems work with the greatest effectiveness when a tangible event or incident is being reported or recorded and this has encouraged a degree of reliance on the single record or event needing to provide a compelling and clear reason for a reaction especially from specialist higher tier services that are working with the most vulnerable of children. Most of the IMRs reported that the attention of professionals was being diverted to other more pressing cases at the time.   394. There was very little information sought about the parents’ personal and family histories27. The current assessment framework almost invites such an approach. The national frameworks for assessment are likely to be changed as a result of the national consultation referred to at the start of this report and will place a greater emphasis on local areas developing their own arrangements28.   395. Too much practice reflected through this case for Safeguarding and Family Support Services is a one dimensional and static approach to viewing the needs and circumstances of children and a preoccupation on physical conditions rather than the emotional needs and circumstances of children for example. The completion of the assessment appeared to be regarded as an administrative task rather than being an important exercise of professional skill and judgment that involved other people in the completion and subsequent planning of action. The fact that the assessment had not been written up by the time of Emma’s birth is also perhaps indicative that other assessments were regarded as more urgent at the time because Emma was not viewed as being a baby at risk compared to other children requiring professional attention at the time.  396. Another dimension revealed in this review and which is reflected in national studies29 concerns the extent to which questions about what a child means to a parent and what the parent means to that child in respect of their emotional care and security are not routinely explored. The same report offers reflection on the important relationship between having a good understanding about all aspects of maltreatment and its relationship with the development of children.                                               27 Reder and Duncan found similar issues in their review of Serious Case Reviews in 1999; Lost Innocents: A Follow-up of Fatal Child Abuse. It has become apparent in this review. 28 The national consultation guidance proposes the abolition of national frameworks and standards and instead will emphasise that local areas are clear about legal requirements, secure effective and co-ordinated cross agency working and increased responsibility for monitoring and challenge through local accountability arrangements. 29 Brandon, Sidebotham, Ellis, Bailey and Belderson. Child and family practitioners’ understanding of child development: Lessons learnt from a small sample of Serious Case Reviews Department for Education May 2011  75  4.5 Management systems; the commissioning and contracting arrangements placed a limit on how aspects of the work was completed  397. This Serious Case Review has revealed that the commissioning arrangements for services can create unintended consequences. The creation of the specialist midwife role has been recognised as good practice in recent inspections of local services. The co-location of the midwife with the Vol 2 service is an example of good collaboration.   398. It is known that the police and Safeguarding and Family Support Services have created a Joint Investigation Team (JIT) and plans are well advanced for establishing a Multi-Agency Safeguarding Hub (MASH) to create the conditions for more effective management of domestic abuse referrals; this was planned before the completion of this review although is seen to be an important measure of implementing the learning from Emma’s case.  399. The terms of the contract agreed for the provision of the Vol 2 service meant that Emma’s father could not receive a service from that team of workers. It is acknowledged that this had some influence on how the case was initially handled and the disclosures of information.   400. The case has also raised issues in regard to the clarity of understanding between specialist adults services and professionals seeking their advice and help in regard to the functioning of adults caring for children. Health professionals have used the learning difficulty protocol on several occasions but it is obviously not fully implemented as health did not use it in the case and the initial adult services IMR author was not aware of its existence despite it being a joint protocol. The issue will continue to be problematic unless resolved across agencies   4.6 The implementation of new systems including electronic recording arrangements contributed to communication difficulties  401. More than one of the IMRs provided for the review have described how the implementation of new working arrangements had an influence on how information was shared and managed between different people and service locations. For example, the co-location of the specialist midwife removed her from the professional intranet and other communication tools. This created barriers for effective communication and left her professionally isolated from her peers.   402. The challenge of creating conditions in which busy professionals are enabled to share information efficiently and have the ability to identify emerging patterns is a regular feature in reviews and inspections of services.   403. In this case, the introduction of co-located professionals had unintended consequences in compromising their access to information systems; there misunderstandings and differing assumptions about aspects of working arrangements when Safeguarding and Family Support Services became involved and managing the transition from a Common Assessment Framework to higher level of support.    76  404. Organisations that have staff sharing information systems across different service locations will have considerable challenges in managing the logistics associated with implementing new systems and achieving consistent use of the systems. For example, in this case, information contained in some of the SystmOne health system was not used in the same way by different health professionals.   405. For example, when the health visitor agreed with Emma’s parents that Emma would be seen by the GP just prior to her death, the health visitor placed a note on the electronic patient system that was intended to alert the GP to the fact that Emma was the subject of a Child in Need plan. The GP did not read that entry.   406. The review has identified that the use of filters to help busy professionals access and use extensive patient information records might be a factor in why the health visitor note was unread in this case. It has to be remembered that in this case, the health visitor did not have enough information to be concerned about Emma’s immediate safety and wellbeing; if she had been it is very likely that the health visitor would have ensured a conversation with the GP was had before the examination.   407. This is not to suggest that if the GP had seen the note the outcomes would have been different for Emma but it does highlight that when the health visitor was unable to speak by phone she had assumed that there would be her background information for the GP to consider alongside the fact that it was the health visitor who had advised the consultation with the GP rather than Emma’s parents having taken the initiative themselves.   408. It became apparent through the review that there are variations in how different work locations such as GP practices place patient related information such as copies of referrals to other services into the recording system.   409. The workload and organisational capacity had an impact on how several professionals processed information and worked with Emma’s family 410. The majority of IMRs reported that individual practitioners or services were working with higher levels of need than other comparable services or had been anticipated in the original service specifications for commissioning services.   411. Some of the practitioners and managers reported how they felt overwhelmed by events occurring at the time; for example some services were experiencing reorganisation; several individual practitioners were clearly working with a personally very demanding workload that involved working far in excess of their core hours.    412. Senior managers and strategic bodies are involved in the delivery of complex services against a background of significant constraint or reduction in the resources that are available. The type of activity that is carried out by these services and the professionals involved in this case do not lend themselves to the application of a set of practical heuristics and objective formulae.   413. For example, a workload that feels manageable can change quickly as a result of an unexpected crisis involving a child at risk. The nature of the work requires an ability to  77  process a significant range of complex information. People are less likely to show the level of curiosity, analysis and reflection required when they are also required to deploy considerable pragmatism to how they prioritise a range of competing tasks and demands. Emma was one child among several who required the attention of different individual professionals already under considerable stress and pressure.  414. By definition, the range of work and the responsibility that individuals carry is very difficult to quantify either in respect of the level of demand or the range and complexity of the task. Those people at the public front of the service in direct contact with families had to apply a degree of pragmatic thinking and action.   415. When individuals began to feel higher levels of concern about Emma it proved difficult to achieve an escalation on the part of other professionals and organisations. This applied in regard to the communication between Vol 2 and Safeguarding and Family Support Services as well as the information sharing between the health visitor and the GP. The review has described and analysed the various factors that influenced communication.   416. This phenomenon of people being unable to recognise new and significant information and analyse the significance has been identified in research and Serious Case Reviews. Although this implies that it is more an issue for cognitive and other functioning, the capacity of individual professionals to think critically and to reflect upon information will be affected by the conditions within which they work. The organisational context for effective safeguarding work was highlighted by the Munro Review.   417. It is notable that all the IMRs have reported that supervision arrangements complied with the organisational standards and requirements. In effect this meant that people had supervision at the required intervals and had access to advice and guidance.   418. Examination of Emma’s story has revealed that some fundamental aspects of practice were not dealt with adequately and with sufficient attention to detail.  Some of this might reflect pragmatic cutting of corners in a case that at the time was not seen as the most problematic or dangerous for a child’s safety and wellbeing.   419. For example the quality of recording activity such as checks with other agencies and ensuring that assessments are written up and plans involved other services more fully. The approach taken to sharing information by all of the professionals who were all very busy relied on relatively informal methods rather than for example opening a Common Assessment Framework or making a written referral of concern.   420. With the benefit of hindsight, if there had been a better capacity to provide challenge and reflection as well as checking that work such as the pre-birth assessment was being completed appropriately and on time, it is quite possible that the gaps and inconsistencies that were missed particularly in Safeguarding and Family Support Services would have been recognised.   421. In Safeguarding and Family Support Services the Team Manager was supervising ten social workers who between them had 280 cases. The statutory role of a children’s service  78  inevitably means that all the cases will reflect a high level of need and risk. Regarding one case as being more risky than another creates the conditions within which the hidden or latent risk continues to go unrecognised.   422. There were additional barriers for practitioners being able to access relevant archived records that were held in paper files. For some services such as health, there are cost implications that arise for example if health practitioners seek historical information.   4.7 Issues for national policy  423. The only statutory requirement of all GPs under the remit of the Primary Care Trust is that they must “give regard to the local safeguarding policy”. The arrangements in Wakefield exceed this statutory requirement in that local contracts with GP practices insert an explicit requirement to comply with the local safeguarding policies and procedures. This includes specifying the arrangements for a Serious Case Review such as this.   424. The difficulties encountered during this review to secure the full disclosure of information by the GP practice has been a significant impediment for the panel and added to the overall workload for the panel and are in contrast to the experience in other reviews and with other GP practices. An appendix to this overview report sets out the advice and guidance in place at the time of the Serious Case Review taking place.   425. The national guidance in regard to the conduct of Serious Case Reviews was the subject of a government consultation that was closing as this review was being completed. The panel have noted that the proposals made by government in regard to learning and improvement will remove any national guidance to assist local safeguarding children boards on such matters.  426. Guidance was sought from the General Medical Council (GMC) and the Medical Protection Society (MPS) in regard to the professional responsibilities of doctors providing treatment for women known to be pregnant. The GMC reinforces that in the first instance doctors should provide what support they can including the provision of advice and information that encourages the woman to seek help.   427. The GMC also acknowledges the public interest justification in dealing with cases where there are concerns about the safety of the baby. The GMC and the MPS both recognise the absence of legal identity and right to protection for an unborn baby. The GMC reflects on the need to balance the potential harm that could arise from not sharing information about a pregnant woman and the potential for harm to her baby against the duty of confidentiality to the patient.   428. The MPS also encourages doctors to take action and share any concerns about a pregnant woman in regard to the safety of her baby. The MPS and the GMC both emphasise the importance of seeking advice from lead or specialist practitioners and to comply with any local guidance and protocols.    79   5. Recommendations  The Mid Yorkshire NHS Trust  1. Following review of training in relation to Domestic Abuse the Assistant Director of Patient Experience and Improvement will ensure the content and quality of the training meets the specific needs of the Health Visiting, Midwifery and Emergency Department professionals  2. Health visitors are informed of all antenatal bookings but there needs to be a more reliable and effective system of allocation of cases to individual health visitors than is currently in place.  An effective pathway will be developed by the Division of Integrated Care with:  • clear time scales (related to stage of pregnancy), • defined individual responsibilities (i.e. who receives referral, who allocates, who visits) • compliance checks to ensure all women are allocated and visited as planned  • escalation plans (i.e. what to do if women remain unallocated or unvisited within defined  timescales)   The proposed standard is “All first time mothers should receive at least one face to face antenatal contact with a health visitor in the third trimester.”  Current performance will be audited against this standard by April 2013 and a further audit to assess progress will be undertaken in October 2013. (Target 75% compliance by October 2013)  3. Review the provision of midwifery support to the pregnant teenager.  Currently there is only one part time Specialist midwife providing tailored support to a proportion of these clients in one half of the Trusts catchment area.  Alongside this and on both sides of the district there is an increasing development of the Family Nurse Partnership (FNP).  There is significant overlap of the responsibilities of each role and the services they offer.  This introduces a risk of both duplication of, and gaps in, provision.    Consequently there needs to be a review of the model of provision of these services leading to a strategic decision about the best way forward  4. All staff to whom a pregnant woman might disclose domestic abuse need to be aware that LSCB safeguarding procedures require them to follow Local Safeguarding policies.   5. The Mid-Yorkshire Hospitals NHS Trust will ensure that all level 3 practitioners who become aware that a child is subject to a Common Assessment Framework, Child in Need plan, Child Protection Plan or is Looked After, will communicate this to other The Mid-Yorkshire Hospitals NHS Trust professionals involved in the care of the child (e.g. HV, Midwife, AHP). This recommendation should also consider how this could include information sharing with GPs.  80   6. When considering the communication between health visitors and GPs (Abigail SCR 2012) The Mid-Yorkshire Hospitals NHS Trust will consider the communication structures to enable the SPM to communicate with GPs.  Barnardo’s Young Families  7. Barnardo’s Young Families staffing structure should be reviewed to ensure:  • that when more than one line manager is involved in a case there is an appropriate communication strategy and clear lines of responsibility for escalating concerns  • the staffing structure reflects the level of knowledge, skills and experience required at management and supervisory levels of Safeguarding  8. Barnardo’s Young Families should review the use of Common Assessment Framework and clarify the assessment process to ensure that all staff understand their roles, specifically if identified as lead professional, and are able to engage significant adults and other agencies in the process.  9. Barnardo’s Young Families reviews the Safeguarding Policy to ensure all staff understand their responsibilities in escalating concerns and that line managers intervene at the appropriate level with written communication  10. Barnardo’s Young Families to consider how domestic abuse knowledge is shared in the Service in order to embed good practice and ensure the staff team are all able to respond appropriately to indicators of domestic violence  Safeguarding and Family Support Services  11. There should be a review of information sharing systems between the Safeguarding and Family Support Service and the Police in relation to Police checks on S.17 cases, under the Children Act 1989, to ensure a streamlined and timely route for such information sharing  12. The Service Director will consider the configuration of the Social Work Teams and the need for any redesign of the local operational child and family social work system to ensure configuration is the most effective to meet the needs of children and families.  13. As part of the development of practice standards for Social Work, relevant sections should outline:  • The timeliness and accuracy of recording, including the recording of multi-agency views in pre-birth assessments and the distribution of assessments and Child in Need plans  • A formal recording mechanism in relation to Social Workers recording the name and designation of the Police Officer who completed a police Check, including the  81  reasons and whether any parental or young person’s consent has been given or overridden, with reasons as to why  • The quality of management assessment, oversight and supervision  14. The Service Director should ensure that a sample of pre-birth assessments is undertaken in relation to the quality of referral taking, evidence of multi-agency assessment, analysis, planning and review  15. The Service Director should implement training or developmental learning in relation to reflective practice, professional curiosity and methods to engage families  Wakefield MDC – Adults Operations and Strategy and Commissioning   16. Staff working with young people over the age of 16, including people with a learning disability or learning difficulty should be trained to understand the principles of the Mental Capacity Act, 2005.  17. A clear protocol for practitioners in Community Teams for Learning Disabilities to deal with cases where there are parenting issues, specifically if there is an unborn child.  18. Ensuring holistic assessments take place when a parenting issue is identified of both the unborn child and parents, establishing role clarity and effective communication.  19. Effective recording required when practitioners make a decision on eligibility, using appropriate assessment and documentation, if the referral is allocated to the team    6. APPENDIX  Procedures and guidance relevant to this Serious Case Review  Legislation  The Children Act 1989  Section 11 of the Children Act 2004 places a duty on the key people and bodies described in the Act30 to make arrangements to ensure that their functions are discharged with regard to the need to safeguard and promote the welfare of children. The application of this duty varies according to the nature of each agency and its particular functions. The Section 11 duty means that these key people and bodies must make arrangements to ensure that their functions are discharged having regard to the need to safeguard and promote the welfare of children and this includes any services that they contract out to others.  Section 17 imposes a duty upon local authorities to safeguard and promote the welfare of children in need.  Section 47 requires a local authority to make enquiries they consider necessary to decide whether they need to take action to safeguard a child or promote their welfare when they have reasonable cause to suspect that a child is suffering, or is likely to suffer significant harm.  These enquiries should start within 48 hours. The local authority is required to consider whether legal action is required and this includes exercising any powers including those in section 11 of the Crime and Disorder Act 1998 (Child Safety Orders) or when a Baby Has contravened a ban imposed by a Curfew Notice within the meaning of chapter I of Part I of the Crime and Disorder Act 1998.  Section 46 provides the Police with Powers of Protection to take children into police protection where a constable has reasonable cause to believe that a child would otherwise be likely to suffer significant harm.  The Children Act 2004  Section 10 requires each local authority to make arrangements to promote co-operation between it, each of its relevant partners and such other persons or bodies, working with children in the authority’s area, as the authority consider appropriate.  The arrangements are to be made with a view to improving the wellbeing of children in the authority’s area – which includes protection from harm or neglect alongside other outcomes.  This section is the legislative basis for children’s trusts arrangements.                                           30 Local Authorities, including District Councils, the Police,  National Offender Management Service, NHS bodies, Youth Offending Teams, Governors/Directors of Prisons and Young Offenders Institution, Directors of Secure Training    Section 11 of the Children Act 2004 places a duty on the key people and bodies described in the Act31 to make arrangements to ensure that their functions are discharged with regard to the need to safeguard and promote the welfare of children. The application of this duty varies according to the nature of each agency and its particular functions. The Section 11 duty means that these key people and bodies must make arrangements to ensure that their functions are discharged having regard to the need to safeguard and promote the welfare of children and this includes any services that they contract out to others.  Safeguarding Procedures  The Wakefield Safeguarding Children Procedures  The procedures provide advice and guidance on the recognition and referral arrangements for children suffering abuse. This includes emotional abuse that involves causing children to feel frightened or in danger. The procedures also cover physical abuse of children. The procedures also describe abuse involving the neglect of children that includes failing to protect children from physical harm or danger or the failure to ensure access to appropriate medical care or treatment. This includes describing distinct action to be taken when professionals have concerns about a child, arrangements for making a referral, and the action to be taken. The procedures cover arrangements for the ACPC (now superseded by LSCB) to ensure there are effective arrangements that promote good interagency working and sharing of information and training. The procedures describe specific responsibilities for all agencies contributing to this Serious Case Review.   National guidance32  Working Together to Safeguard Children (2010)  The national guidance to interagency working to protect children is set out in Working Together to Safeguard Children: A guide to inter-agency working to safeguard and promote the welfare of children. The guidance includes safeguarding and promoting the welfare of children who may be particularly vulnerable.   Framework for the Assessment of Children in Need and their Families 2001  The guidance in respect of the Framework for the Assessment of Children in Need and their Families is issued under section 7 of the Local Authority Social Services Act 1970 and is therefore mandatory.                                            31 Local Authorities, including District Councils, the Police, National Offender Management Service, NHS bodies, Youth Offending Teams, Governors/Directors of Prisons and Young Offenders Institution, Directors of Secure Training Centres. 32 The election of a coalition government in May 2010 may result in changes to guidance and policy developed by the previous government.    The framework sets out the framework for ensuring a timely response and effective provision of services to children in need. It makes clear the importance of achieving improved outcomes for children through effective collaboration between practitioners and agencies. The framework sets out clear timescales for key activities. This includes making decisions on referrals within one working day, completing initial assessments within seven working days and core assessments within 35 working days. As part of an initial assessment children should be seen and spoken with to ensure their feelings and wishes contribute to understanding how they are affected. If concerns regarding significant harm are identified they must be subject of a strategy discussion to co-ordinate information and plan enquiries. Child protection procedures must be followed.  Assessments should be centred on the child, be rooted in child development that requires children being assessed within the context of their environment and surroundings. It should be a continuing process and not a single or administrative event or task. They should involve other relevant professionals. The outcome of the assessment should be a clear analysis of the needs of the child and their parents or carers capacity to meet their needs and keep them safe. The assessment should identify whether intervention is required to secure the well – being of the child. Such intervention should be described in clear plans that include the services being provided, the people responsible for specific action and describe a process for review.   Common Assessment Framework (Common Assessment Framework)  The Common Assessment Framework is a key part of delivering direct services to children that are integrated and focused around the needs of children and young people. The Common Assessment Framework is a standardised approach to conducting assessments of children’s additional needs and deciding how these should be met. It can be used by practitioners across children's services in England. The Common Assessment Framework promotes more effective, earlier identification of additional needs, particularly in universal services. It aims to provide a simple process for a holistic assessment of children's needs and strengths; taking account of the roles of parents, carers and environmental factors on their development. Practitioners are then better placed to agree with children and families about appropriate modes of support. The Common Assessment Framework also aims to improve integrated working by promoting coordinated service provisions.  All areas were expected to implement the Common Assessment Framework, along with the lead professional role and information sharing, between April 2006 and March 2008.    