Death of a 6-week-old infant in April 2014. Both parents received prison sentences for offences of child cruelty and causing or allowing the death of Child D. No specific learning was identified. Recommendations include: ensure that midwifery, health visiting and early help assessment records include a standard section that prompts practitioners to ask questions about whether either parent/carer has any other children and if so the level of contact held with their children.
      
 Title:  Child practice review report (final): re: Child D. LSCB: Staffordshire Safeguarding Children Board Author: Daphne Rose Date of publication: 2020  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     STAFFORDSHIRE SAFEGUARDING CHILDREN BOARD CHILD PRACTICE REVIEW REPORT (FINAL) RE: CHILD D    CONFIDENTIAL : This report should not be shared without the permission of Staffordshire Safeguarding Children Board  Review Process  Circumstances resulting in the review   On 29th April 2014 in the early hours of the morning an ambulance was called to the family home of a child (Child D). When the ambulance arrived the mother was performing cardio pulmonary resuscitation (CPR). Child D was considered to be lifeless and although further resuscitation attempts continued whilst Child D was taken to hospital, 20 minutes after their arrival at hospital resuscitation attempts were discontinued. The police report indicated their concerns that both parents were under the influence of alcohol at the time of the Child’s death and there was a notable delay between the time that the parents reportedly found their child unresponsive and lifeless, to them calling for an ambulance.   On initial medical examination no obvious marks were identified on Child D’s body, however the subsequent post-mortem investigation identified potential non-accidental injuries. This was an area of concern identified by panel members at the initial scoping panel process as the reported non-accidental injury was clearly evident during the post-mortem investigation.  Due to the nature of the injuries sustained by Child D, the Police investigation included the arrest, detention and interview of the parents. They were both released on Bail from Police Custody whilst the investigation continued, and a File of Evidence prepared for the Crown Prosecution Service (CPS).   Following that independent assessment of the evidence, the CPS made their Charging Decision.   2  In May 2019 following a trial at Stafford Crown Court, a jury returned a guilty verdict for Criminal Offences of Child Cruelty and Causing or Allowing the Death of Child D.  The mother was sentenced to a 5 year Term of Imprisonment.  The father was sentenced to an 8 year Term of Imprisonment.  Legal Context  As a result of the death of this child, Staffordshire Safeguarding Children Board (SSCB) convened a Serious Case Review Scoping Panel Meeting in accordance with the requirements set out in Chapter 4 of the statutory guidance Working Together to Safeguard Children, 2013 (Department for Education). This multi-agency panel meeting was convened in line with local SSCB inter-agency procedures in order to share partner agency information about the baby and their family and to make a shared judgment about whether the criteria for a formal serious case review had been met.   In this child’s case, panel members were not unanimous in respect of whether the statutory criterion for a formal review had been met. This was on the basis that although the child had died and abuse or neglect was suspected, the scoping panel information sharing process had not highlighted any clear areas of concerns about how agencies worked together to safeguard the child. The SSCB Manager sought further advice from the Department for Education and based on the response received; a recommendation for a formal serious case review was agreed by panel members and proposed to the SSCB’s Independent Chair. The Chair supported this decision and requested for the Welsh Child Practice Review systems methodology to be used for this learning review process.   The Terms of Reference and Timeline for this learning review can be found attached at the back of this document as Appendix 1 (Terms of Reference) and Appendix 2 (Review Timeline). Appendix 3 sets out the Timeframe of this review.    Methodology  This review was undertaken in line with the requirements set out in Chapter 4 of the statutory guidance ‘Working Together to Safeguard Children’ (DfE, March 2013) and reflects the principles required within this learning and improvement chapter. In accordance with the wishes of the SSCB Chair the methodology used was the Welsh Child Practice Review process (‘Protecting Children in Wales, Guidance for Arrangements for Multi-Agency Child Practice Reviews’, Welsh Government, 2012).  The Child Practice Review process was introduced in Wales in January 2013 to replace the existing serious case review approach. This is an innovative formal process that allows practitioners to reflect on cases in an informed and supportive way and it is consistent with the systems approach advocated in ‘Working Together’ 2013.  The CPR process is an effective learning tool for Local Safeguarding Children Boards (LSCBs) to use when reviewing cases which have met the threshold for undertaking a formal serious case review. The detail of the information that informs this review and leads to the analysis and recommendations of the review, have been made succinct in this report as the main focus is on understanding what happened and on identifying areas of good practice and areas for improvement. It also needs to be recognised that even though a review has been held, it does not necessarily mean that working together arrangements and practice is found to require improvement.    3  The role of the partner agencies involved is to engage and contribute to the analysis of case issues; to provide appropriate challenge; and to help ensure that the learning from the review can be used to inform local systems and practice development. In this case the criterion was met for a Concise Review in accordance with CPR process guidelines as opposed to an Extended Review which requires two reviewers. This is because the child had died and abuse or neglect was suspected, but the child was not the subject of a child protection plan at the time of death or in the 6 month period prior to their death.   A CPR Review Panel was established in accordance with the CPR guidance. The Panel has an important role to play in challenging the issues raised from the learning event, including identifying and agreeing any learning points and whether there is a need for changes to practice or policy. This panel was Chaired by the Head of Safeguarding at Staffordshire and Stoke on Trent Partnership NHS Trust (SSOTP) who is also the Chair of the SSCB Serious Case Review Subgroup. The panel also included representation from relevant health, police, children’s social care services (CSC), an independent panel member of the SSCB Serious Case Review Subgroup and the SSCB Manager (for a full list of panel members please see page 6). Daphne Rose (RGN RHV BA (Hons) MA) was commissioned as the independent reviewer to work with the panel and to undertake the review.   The terms of reference period for this review is from the ante-natal period up until the child’s date of death. Agencies reviewed all their records for historical context and provided timelines of significant events for the review period, as well as a brief synopsis and analysis of their involvement prior to this date. This information was considered by the panel and provided the opportunity for panel members to raise questions and clarify understanding of the circumstances of the case and of the separate services provided.   The Child Practice Review (CPR) process required agencies to provide a detailed timeline of their involvement with the child and their family within the agreed terms of reference period of the review. Where appropriate agencies have also provided a synopsis of their involvement prior to the terms of reference period to capture any historical information known. This was requested in order to provide context to the learning review process and to help to understand how this historical information was used to inform current practice and decision making. The timelines included a brief analysis and initial hypothesis of their agency’s involvement. The individual timelines were then merged to produce an inter-agency timeline, and this was carefully analysed by the reviewing officer, with the Panel, to inform areas of interest that required further exploration and consideration. The process also allowed for the identification of the key practitioners who had worked with the child and their family and they were required to attend a learning event in order to understand the detail of the single and interagency practice in this case. The merged timeline was used as the basis to inform this learning event.  Engagement with the family  The CPR methodology promotes meeting with the family to ascertain their views on the services provided to them and to use these views to inform the depth of learning. A letter to explain the purpose of the CPR process was sent to the mother and her partner, however due to the ongoing criminal investigation the senior investigating officer made representation that this engagement would potentially jeopardise the ongoing police investigation. However at the conclusion of the process the couple had the opportunity to read the report before publication.  Contextual information known to agencies   This review concerns the death of a 6 week old child who lived with their mother and father. The child was the first child of the mother and the second child of the father. The mother of the child subject to this review was 17 years and the father was 21 years old at the time of their baby’s birth. Agency records relating to the father evidenced that he had previously  4  identified to professionals that he had difficulties with reading and writing; agency records also identified that he had had a statement of special educational needs at school.   The child had a half sibling, who was known to Children’s Social Care services. The child’s father and his new partner had regular contact with his first child which included overnight stays at their home.  Historical involvement by Children’s Social Care Services (CSC)   Child D had not previously been known to Children’s Social Care. The mother had an historical referral from 2013 relating to potential homelessness and relationship breakdown with her mother and the father had a historical record dating back to 2001 regarding a disability which led to no further action.  The day of Child D’s death   Recent Children Social Care involvement with Child D’s parents began on the day of Child D’s death. This was initiated by a referral from Staffordshire Police to the Local Authority’s Emergency Duty Service to inform the authority that an ambulance had been called to the family home address after the child had been found lifeless by its parents. This was confirmed by paramedics on arrival, who when they arrived on scene, had found the mother performing CPR on her child as instructed to do so by the emergency services phone operators.   The police records suggest that father fed Child D in the early hours of the morning and then placed him back in his cot where he reportedly went to sleep. Half an hour later the father self-reported during police interview that he went back into the room as Child D was crying. Father gave Child D a dummy in order to try and help it to calm and settle. An hour later the father stated that he went back into the room and found that Child D was unresponsive. The  father said he had tried to wake up the mother who was lying in the same room as Child D next to the cot. It was noted from ambulance service and police records that the 999 call for an ambulance was not made until fifty minutes after the father found Child D to be unresponsive and lifeless.   At the time the Paramedics arrived, and later at hospital, some small marks were noted on Child D’s face and there were injuries consistent with the emergency treatment Child D had received at the hospital, but no other marks or injuries to Child D were recorded.  Police officers stated that they were concerned that both parents appeared to be under the influence of alcohol at the time of the incident; with the mother described as smelling strongly of alcohol. The doctor at the hospital also reported that both parents smelt strongly of alcohol. Hospital records also indicate that the parents confirmed they had both consumed alcohol that evening and when asked they said they had not taken any illegal drugs. In addition the post death health report on the visit to the family home made reference to the family home smelling strongly of smoke and there was evidence of alcohol having been consumed in the property.  The Learning Event  Attendees:  Daphne Rose (DR) - Child Practice Review (CPR) Independent Reviewer Head of Safeguarding Staffordshire & Stoke-on-Trent Partnership NHS Trust (SSOTP) and CPR Panel Chair  5  Staffordshire Local Authority Targeted Services (Local Support Team)  Staffordshire CSC Family Engagement Service Burton Hospital NHS Foundation Trust  Staffordshire & Stoke-on-Trent Partnership Trust Health Visiting Service Staffordshire Safeguarding Children Board Manager  Apologies /unable to attend:  On the advice of the senior police investigating officer (SIO) the Staffordshire Police Officers and West Midlands Ambulance Service (WMAS involved in attending family home on the night Child D died were unable to participate in the practitioner’s learning event. It was considered attending this event could compromise the parallel criminal investigation process due to the potential that they would be called as witnesses. The practitioners present were asked to consider throughout the learning event, whether there were any questions that they would like the reviewer to pose to the police officers (through the SIO) or to the WMAS representative as part of the review process.   Practitioners attending the event were initially asked to introduce themselves and to describe their professional relationships with Child D and his parents. The merged inter-agency timeline which had been produced through the work of the panel was reviewed by the practitioners present and practice was discussed. Practitioners were advised of the importance of identifying whether there was any significant information held within the timeline which practitioners were perhaps unaware of and if so whether they considered it would have impacted on the delivery of the service they had offered to the family.   The practitioners involved in working with Child D and his family reviewed their contact with the family through considering the merged inter-agency timeline in two key sections. They were asked for each section of the timeline to consider the following questions:  ➢ Did you know everything about that section of the timeline? If you didn’t, why was this? If you didn’t know, what did you need to know? ➢ What was their level of concerns at this time? Were they high, medium or low levels of concern?  ➢ Was what happened OK? ➢ Could things have been done differently? ➢ Should things have been done differently?  ➢ Were there any pressures for you in your workload at that time?  It should be noted that at the conclusion of the learning event none of the practitioners had any specific questions for the police officers or for the WMAS representative who had been unable to attend the learning event.  Review of Section 1 of the Timeline (Summer 2013 – Beginning of 2014)  Section 1: Antenatal period up until Child D’s birth   Engagement with services  It was identified that both parents had engaged with midwifery services and had attended the initial booking appointment together. Furthermore it was reported that both Child D’s mother and birth father attended all but one of the planned antenatal appointments. It was considered by the midwife that the mother was able to express her views and no welfare or safeguarding  6  concerns were identified during this period. It was recorded in CSC records in September 2013 that the parents had an identified need in relation to help with financial support and an appropriate referral in respect of this need was made to the relevant Children’s Social Care (CSC) Local Support Team (LST) to provide this advice and support.    It was identified by the midwife that they would have considered referring this mother to the Family Nurse Partnership intensive health service had it been available in the area. This was due to the young age of the parents, the fact that this was their first child together and because the midwife felt that parents would have benefited from additional support. The midwife advised that there are a number of young, potentially vulnerable parents who cannot access this support as it is a service that’s only available in certain locality areas, the criteria for gaining a place is difficult to meet, referral timescales can be difficult to manage, and spaces are few and far between.   Engagement with Local Authority Targeted Services  (Local Support Team)  The referral from the Community Midwife resulted in the Local Authority Targeted Services  Local Support Team (LST) Family and Engagement Worker having direct involvement with the parents and completing an assessment with them using the Common Assessment Framework (CAF) approach. This assessment focussed primarily on the family’s need for financial support and benefits advice and included appropriate engagement with the professionals involved in working with the family. No other welfare or safeguarding concerns were identified by LST professionals during the course of the assessment process and the couple reportedly engaged well. The LST Family Engagement Worker identified that they were aware the birth father had another child from a previous relationship but was not aware he was having regular contact with his child. Support was offered to the family in relation to rent discretionary benefits and the parents were signposted to the Department of Work and Pensions for a review of all of their benefits. When the couple later moved to another area of the county there was a period where they disengaged with the LST service. Contact was subsequently re-established, and a further visit was made to the family by the LST worker. It is recorded in LST files that at this time the parents had all of the items they needed for their baby and had received appropriate support to meet their identified need. As there were no other needs relating to the family or concerns about the care afforded to Child D, the case was closed by LST services in March 2014.   Engagement with Health Visiting services  From a health visiting perspective it was identified that no contact was made ante-natally with parents as at that time the family had moved to another area of the county for a temporary period and then had moved back to their original location; the health visiting service had been unaware that the couple had moved back. Health visiting visits had been made since the birth of the baby and health records evidence that the health visitor had first met the family at their home for the ‘new birth visit’. No issues were identified and it was noted that the family engaged well during the subsequent three to four home visits made. Child D was considered to be thriving and progressing well developmentally. It was noted there had been one hospital attendance episode due to concerns about Child D’s feeding, but no welfare or safeguarding concerns were identified.    Issues unknown to practitioners  When the practitioners reviewed the merged agency timeline they identified a number of issues they had been unaware of, however they shared a collective view that even if they had known about these issues, it would not have impacted on their service delivery to the family. These issues included:   7  • Not being aware that the mother had changed her surname in 2009 by deed-poll (this issue was identified by panel members and resulted in all agencies re-checking their agency records to seek assurances that no information relating to the mother had been missed. There was no evidence that this was the case.  • All practitioners were unaware of the historical Children’s Social Care contact relating to the father’s child from a previous relationship. The father had not disclosed anything about his contact with his other child to any practitioner. In fact he had implied that he had no contact with the child at the time LST services were undertaking the CAF assessment with them and the reason for this is not known. This resulted in the father’s child remaining invisible to professionals. All practitioners considered that if they had known about fathers other child and the fact that there had been some previous CSC involvement, they would have at least asked him some further questions about his role in his other child’s life and the level of contact he had. The health visitor identified if she had known about the child it would probably have initiated her undertaking an ante-natal visit. Whilst this was not identified as a significant area of concern in this case, it was recognised that it impacted on the depth of the assessments undertaking with Child D’s parents and could have led to professionals not knowing that a child was visiting the family’s home if a concern had been identified. This information could have also helped to inform the assessment of father’s parenting capacity and added to the understanding of the family’s network.  • It should be normal practice for Midwives to ask at the booking appointment, if the woman's partner has had any previous children or any previous involvement with social care, this is documented in the Maternity hand held notes. The Midwife in this case said that she had become more professionally inquisitive since being involved in this case. • The parents had told the health visitor and the LST worker that neither of them had had any previous CSC involvement. Whilst this offered limited information it was considered by both practitioners and panel members that had historical information had been known, then it would have potentially added greater context to understanding parental history and needs. This was particularly pertinent to the birth father who had a statement of educational needs at school. Although the health visitor records do make reference to him having difficulties with reading and writing, it was acknowledged that no agency had sought to understand whether the father understood the written agency information provided to him.   • The maternal grandmother was known by some agencies to be a supportive factor, but the extent of this support was not fully explored.  • The LST worker was aware they moved to another area on a temporary basis but the health visitor didn’t realise it was temporary and thought that the move was permanent. It is noted that despite this confusion it did not impact on service delivery to the family.   Review of Sections 2 of the Timeline (Beginning of 2014 – Spring 2014)  Section 2: Timeline from Child D’s birth to his death  The key areas identified in Section 1 of the timeline were mirrored in the practitioner’s review of Section 2. The following additional information was however identified during the review of this latter timeline:   8  • The LST worker had been unaware of Child D’s birth but she did make attempts to contact mother at the point that the case was being closed to CSC services to ask for a name and date of birth for their new child (the child who is the subject of this review).    Practitioner Learning Event Conclusions  Having reviewed both sections of the timeline the practitioners concluded that there were no pre-disposing factors, known needs or risk factors relating to the family that would have raised concerns to a level that would have led to different level of intervention being offered or undertaken.   The agency contact with Child D and his parents was on the whole unremarkable and consisted of mainly universal routine engagement. LST service involvement was predominantly focussed on the parental need for benefit advice and support as this was the only additional need identified for the family at this time.   During the learning event it was identified that during the period of the review the CSC worker’s team was short staffed, however it was noted this did not affect the work that was undertaken with the family. There were no reported specific work pressures that impacted on the role of the midwife or health visitor during the timeline period.  ANALYSIS: Practice & Organisational Issues Identified   Improving Systems & Practice   In order to promote the learning from this case the review identified the following recommendations for SSCB and its partner agencies to action in order to learn from this review and to strengthen local safeguarding arrangements. It should be noted that some of the recommendations set out below have already been initiated:  The need for information about other children in the family who do not live with the parents  Due to the fact that the father’s child was invisible to agencies despite them having regular contact at the family home, the following recommendations are made : I • Midwifery, health visiting and LST early help assessment records need to be reviewed to ensure that they include a standard section that prompts relevant to practitioners asking questions about whether either parent / carer has any other children and if so the level of contact held with their child/ren. This information needs to be sought as part of standard practice. It should be noted that the existing SSOTP health visiting records (new universal child health records) have already been amended as a result of this local learning. The document now specifically prompts health visitors to ask the question about whether there are any other children and /or significant others living at or regularly visiting the household. This new form was implemented and is now used by all SSOTP health visitors as of December 1st 2014.    The new Staffordshire Early Help Assessment (EHA) (which replaces the previous CAF) now includes a section on the form which prompts practitioners undertaking the assessment to question whether there are any other significant others that need to be considered as part of the EHA process.   9  Routine antenatal visits by health visitors  An ante-natal visit to families should be routine practice. This is now included as part of the universal health visiting service offered to all families but was not the in place during the timeframe reviewed in respect of this case. This should include exploring both parent’s family history and any history of learning difficulties for either parent.  The Family Nurse Partnership   FNP specialist nurses offer intensive support to teenage mums under the age of 19 years old. Each nurse has approximately 25 mothers to work with over a period of up to two years.  Midwives make a professional judgement about whether the mother should be referred and mothers have to consent to receiving the support. It is acknowledged this is considered an expensive resource in the short term, but it can have long term cost effect benefits and there is research evidence of improved outcomes for children.   • It is recognised this service is not available in all localities across Staffordshire. The accessibility and referrals for young teenage or vulnerable parents to the Family Nurse Partnership (FNP) intensive health service needs to be considered by health commissioners and their commissioning colleagues in partner agencies to understand whether there is a gap in this service area for young, first time, vulnerable parents.   The Sudden Unexpected Deaths of Children (SUDC) Process  The chronology completed by Walsall Manor Hospital was submitted late to the review process but was available in time to be used to inform this learning review process. All parties expressed their concern that the non-accidental physical injury evident on Child D at the post-mortem examination was not observed by professionals despite the Walsall Healthcare Sudden Unexpected Deaths of Children (SUDC) procedures reportedly being appropriately followed. The lighting in the room at the time of the examination was considered appropriate and therefore the reasons why the physical injury was not seen by hospital staff remains unclear.   The reviewer is however aware this is not an isolated case where physical injuries have not been identified at the time of death (e.g. Daniel Pelka), and some not until the post-mortem stage. The Reviewer is aware of a discussion between a paediatrician and a paediatric pathologist involved with a case in another area where the pathologist stated “the most important thing is that bruising can become more apparent over time, so it might be very subtle around the time of the death but become more visible by the time of autopsy. Whilst this does not apply to skin breaks (e.g. tooth marks) which should become apparent straight away, there is often a component in bite marks which can again become more apparent with time”    Walsall Manor Hospital also identified that whilst the ambulance crew and paediatric documentation was quite comprehensive, A&E documentation and record keeping was suboptimal and needs to improve. There are no observations noted, details of medication given and clinician notes in the A&E record. It was also recognised that the on call social worker should have been present during SUDC cases to facilitate a comprehensive assessment and this did not happen for the baby who is the subject of this review.  In addition, whilst Staffordshire Police Officers were present at the hospital it was recognised by panel members that there were some gaps in the application of the joint Staffordshire and Stoke-on-Trent LSCB’s Sudden Unexpected Child Death Protocol. A police supervisor was not present at the hospital and it is noted that the nature of the police examination of a deceased child under SUDC procedures requires further discussion and exploration. Although this is an acknowledged practice issue, it is not believed that the investigation suffered as a result of this.   10   The following recommendations therefore apply:  • Walsall Manor Hospital should provide written assurances and evidence to the SSCB and Walsall LSCB on how they are taking internal action to help to address the two quality issues identified as a result of their agency review of this case.   • Staffordshire Police to advise the SSCB of any areas for internal or regional improvement in respect of the SUDC protocol as a result of their further exploration into the actions of police officers in this case.  Promoting information sharing in Primary Care   To improve communication between GPs and health visitor teams the following is recommended:   • In order to improve inter-agency working and communication between the GP and the Health Visitor teams it is recommended that regular meetings take place between them. These meetings would allow for sharing of information about a child and their family where it has been identified that there are safeguarding concerns or an identified need for early help.  The format and frequency of these meetings would be decided between the Practice and Health Visiting teams and would depend upon the geographical area and vulnerability of families locally.  These meetings could also include the Community Midwifery Team where appropriate.   Conclusion  The death of any child is a tragedy but especially so when abuse or neglect is suspected to be a cause of the death, both for the families involved and for the professionals who have worked with the family. Agencies and professionals who were involved with this family were able, through analysing the prepared integrated timeline, to identify areas where practice could be enhanced as part of routine interventions with families. These have been identified in this report. However, it was also identified that even if these initiatives had been in place there is no evidence to suggest this would have resulted in the tragic death of Child D being prevented.  The practitioners involved in this review identified how useful it was to be brought together for the learning event. They felt that this enabled them to reflect on their involvement with this family with the other practitioners involved and they collectively identified the event as a cathartic process in dealing with this tragedy.   It was noted at the beginning of this report that the review was undertaken after advice from the DfE that the criterion for a review was met.  Although some learning has been identified through the process most of this information was identified as areas for improvement following the scoping panel information sharing process. It is therefore suggested that this review could have been achieved through a local SSCB multi-agency learning review approach as opposed to a formal SCR process, which is labour intensive, costly and time intensive. The SSCB would welcome consideration from the DfE in respect of serious child care incidents where the formal criteria may have been met, but the LSCB makes a shared and transparent professional judgment with the endorsement of the LSCB Independent Chair, about the timeliest and most proportionate systems approach to undertake in accordance with their LSCB Learning and Development Framework.   