Death of a 7-week-old baby boy of mixed parentage whilst co-sleeping with mother, who had consumed alcohol and cocaine. Mother was arrested on suspicion of overlay but no charges brought. Child A's older sibling had died when 2-weeks-old from sudden infant death syndrome in 2007. No concerns about the care of the sibling were identified at the time. Mother was known to police prior to her pregnancy with Child A as both a perpetrator and victim of crime. She was supported by domestic abuse services and her ex-partner received a custodial sentence for violence against her. Mother was also known to the Children and Families Practice, who completed a common assessment framework (CAF). Mother also had issues related to: alcohol and drug misuse, including an unintentional overdose when 15-weeks-pregnant; housing; mental health problems; and lack of engagement with professionals. Uses the Significant Incident Learning Process (SILP). Learning includes: professionals working with adults must understand parental behaviour in terms of the impact on the child; risky behaviour in pregnancy should be seen as a potential child protection issue; high support and high challenge is required when engaging with vulnerable families; and threat of withdrawal from engagement should be seen as an indicator of risk. Recommendations include that the Milton Keynes Safeguarding Children Board's Neglect Group should extend its remit to become an early help development group. Highlights examples of good practice including use of multi-agency referral forms and persistence in contacting the mother after missed appointments. Also outlines changes made to local services and practice since the death of Child A.
      
 Title:  Serious case review: Child A: overview report. LSCB: Milton Keynes Safeguarding Children Board  Author: Nicki Pettitt Date of publication: 2016  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.                           Version 29.2.16  1         Serious Case Review CHILD A    OVERVIEW REPORT      Author and Lead Reviewer: Nicki Pettitt Date presented to the MKSCB: 27 January 2016 Version 29.2.16  2  CONTENTS  Summary of the learning       Page 3  Introduction to SILP        Page 5  Introduction to the case       Page 6  Family Structure        Page 6  Terms of Reference        Page 7  The Process         Page 7  Background prior to the scoped period     Page 8  Key episodes         Page 9  Analysis by theme        Page 17  Conclusions         Page 27  Recommendations        Page 30          Version 29.2.16  3  1 Summary of the Learning 1.1 This Serious Case Review (SCR) is in respect of a 7 week old baby who died after being found with ‘no signs of life’ whilst co-sleeping with his mother. She had been drinking and stated she had used cocaine. An inquest concluded that the cause of death was unascertained, with a narrative from the Coroner that it was a sudden unexplained death of an infant. The fact that Mother had been drinking, that the child was sleeping with her and was face down, and that there was a smoky atmosphere in the house, were noted by the Coroner as factors which heighten the risks of such an unexplained death.  Whilst the child’s sad death was not as a consequence of any actions or failures to act by any individuals or organisations, the SCR has identified a number of learning points for the individual agencies involved and for the Milton Keynes Safeguarding Children Board (MKSCB).  When considering in detail the involvement of partner agencies with Child A and his family the following learning has been identified:  Parents who are misusing drugs or alcohol can be very persuasive.  To ensure that potential safeguarding risks are identified, professionals need to seek and consider objective evidence which can be used to confirm or challenge the accounts being given by the parent. ‘Respectful uncertainty’ should be employed, particularly when drug or alcohol abuse is a possibility.    The NSPCC published a report in 2010 called ‘Ten Pitfalls and How to Avoid Them - What Research Tells Us.’ Four of the ten pitfalls in regards to assessing families in the community are relevant to this case. They are:  o An initial hypothesis is formulated on the basis of incomplete information, and is assessed and accepted too quickly. Practitioners become committed to this hypothesis and do not seek out information that may disconfirm or refute it.  o Attention is focused on the most visible or pressing problems; case history and less “obvious” details are insufficiently explored.  o Insufficient weight is given to information from family, friends and neighbours.  o There is insufficient full engagement with parents (mothers/fathers/other family carers) to assess risk.   It is important that all assessments seek an explicit understanding of a child’s lived experiences (or likely lived experience if they are not yet born) combined with a thorough analysis of the known risks and protective factors.    When a service user is pregnant and engaged in risky or worrying behaviour (in this case Mother’s overdose of drugs and alcohol) professionals must consider the behaviour as a potential child protection issue.   A parent with vulnerabilities requires a positive and understanding response from professionals.  When considering their potential to parent the child there should also be robust and honest challenge about the areas and behaviours which would negatively impact on the child.    Professionals attending a TAF meeting need to have a shared understanding of the background concerns and risks as well as consideration of the immediate concerns that led to the meeting.  This will ensure the best plan is devised for a child. If the meeting is part of a longer term process to develop a clearer understanding of the family, including Version 29.2.16  4  any risks and protective factors, this should be clarified with those in attendance and recorded.   It is difficult for professionals to maintain the engagement of a service user who is likely to withdraw their cooperation, or refuse to give consent for information sharing, when they are challenged.  The threat of withdrawal from engagement should be seen as an indicator of risk.   Professionals need to acknowledge that a service user may not be telling the truth. The notion of ‘high support, high challenge’ should be the aim of engagement with families. It is acknowledged that this is a complex and difficult balance, which to do well requires skilled practitioners, reflective practice and effective supervision.    Adult behaviour needs to be understood by professionals, especially those who primarily provide services to adults, in terms of the impact of that behaviour not just on the adult but on their child. This needs to be evaluated accordingly where the adult is about to become or is a parent.  Supervision needs to be available and sought to help professionals challenge themselves, each other and family members when there are concerns about lack of engagement.     Professionals need to understand and clarify the role and status of any volunteers or advocates before disclosing confidential information or including them in meetings.   Information sharing guidance should be a guide to professional practice but not a hindrance to appropriate professional curiosity.   Despite a commitment to ensuring families are aware of the need to adhere to safe-sleeping advice, it is not always possible for professionals to identify a family where there is an un-disclosed culture of co-sleeping.    GPs are a crucial part of the safeguarding system.  Sharing information with them, and seeking the information they hold, should be a standard action in any assessment.    All professionals need to understand, through their own agency and MKSCB training and learning, how to have and understand difficult conversations with other agencies and professionals from other disciplines.     Any new information gained by a professional should always be considered alongside the information already available.    Family members can hold significant information and they should be engaged with and spoken to when making an assessment. As they can also provide important support and care for families, they should be appropriately utilised.   The benefits and difficulties inherent in involving wider families in assessments and plans need to be fully evaluated and understood by professionals.     Assumptions can be made about the implicit protection provided by wider family members to children. Professionals need to be aware of making such assumptions and recognise the risk of doing so.      Version 29.2.16  5  2 Introduction to the Significant Incident Learning Process (SILP) 2.1 The MKSCB agreed that this Serious Case Review (SCR) should be undertaken using the SILP methodology. SILP is a learning model which engages frontline staff and their managers in reviewing cases, focusing on why those involved acted in a certain way at the time. This way of reviewing is encouraged and supported in Working Together to Safeguard Children 2015. 2.2 The SILP model of review adheres to the principles of;  proportionality  learning from good practice  the active involvement of practitioners  engaging with families, and   systems methodology 2.3 SILP reviews are characterised by the completion of Agency Reports followed by a large number of practitioners, managers and agency safeguarding leads coming together for a Learning Event. All Agency Reports are shared in advance and the perspectives and opinions of all those involved at the time are discussed and valued. The same group then comes together again to study and debate the first draft of the Overview Report. All those involved make an invaluable contribution to the learning and conclusions of the review.  2.4 As required by Working Together 2015, this SCR has been conducted as a systems review which;  recognises the complex circumstances in which professionals work together to safeguard children; seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did;  seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight;   is transparent about the way data is collected and analysed; and   makes use of relevant research and case evidence to inform the findings.  2.5 MKSCB recognised the potential to learn lessons from this review regarding the way that agencies work together in Milton Keynes to safeguard children. Working Together 2015 states that serious case reviews should:  Identify improvements in the way that agencies work together for the prevention of death, serious injury or harm to children and to consolidate good practice.  Clearly identify what lessons are to be learned both within and between agencies and within what timescale they will be acted on and what is expected to change as a result.     Version 29.2.16  6  3 Introduction to the Case 3.1 The subject of this review is a child to be known as Child A.  He was a much-wanted child who was happy and thriving. Child A lived with his mother and had extensive contact with his maternal family in Milton Keynes, often staying with them along with his mother due to issues with the family’s housing.  3.2 The father of Child A is not thought to have had any contact with him during his lifetime. His details have not been shared by Mother with her family or any of the agencies involved at the time or during this review.  Mother had another child who was born in 2007.  That child died when it was 2 weeks old due to sudden infant death syndrome. 3.3 The professionals involved with the family during Child A’s life were the police, domestic abuse professionals, midwives, a health visitor, a CONI coordinator1, children’s services (the referral and assessment team (R&A) then the Multi-Agency Safeguarding Hub (MASH)2 after 1 September 2014), children and families practice workers,3 GPs, housing officers, and a victim support advisor providing personal support to Mother. Prior to his birth, Mother also had contact with professionals working in her local hospital and in adult mental health services.   3.4 The child’s mother was initially arrested on suspicion of overlay after the death of Child A, but no charges have been bought. 4 Family Structure 4.1 The subject of this review is to be referred to as Child A. When referred to, Mother’s previous child will be called Sibling.  4.2 The parents of the child are referred to in this report as Mother and Father. Other family members will be referred to by their family title e.g. Maternal Grandmother.  4.3 Child A was of mixed parentage. Mother and her parents are white British. Their only language is English. Father is thought to be of black African/Caribbean origin. This information appears to have been accurately recorded on agency records. Child A had no known physical disabilities. Mother was not working during the timeframe of this review.   4.4 Mother’s previous partner, who was involved with partner agencies during the scope of this review, will be referred to as Ex-Partner in this report. He is not the father of Child A.                                                       1 The CONI programme (Care of the Next Infant) is a care package offered to parents expecting a baby where either parent has previously suffered the sudden unexpected death of a child under the age of 2 years of age. In Milton Keynes the CONI team is made up of staff from the Health Visiting service and is managed within this service. 2 Multi-Agency Safeguarding Hub. The Milton Keynes council website states that it ‘brings together professionals from partner agencies to deal with safeguarding concerns, where someone is concerned about the safety or wellbeing of a child. Information from partner agencies is collated within the MASH to assess risk and decide what action to take. As a result, the agencies are able to act quickly, in a coordinated and consistent way, ensuring that vulnerable children and families are kept safe. 3 Milton Keynes Council website states ‘Children and Families Practices offer early help services for families with additional or considerable needs. These teams are based in local areas to ensure that support is more accessible to children, young people and their families’. Version 29.2.16  7  5 Terms of Reference 5.1 It was agreed that the scope of this review would be from the time that professionals became aware of Mother’s pregnancy with Child A until the date of his death.   5.2 Relevant information prior to these dates was also considered. This included some information that is known to agencies about the death of Sibling, and about Mother between the two pregnancies.  6 Process 6.1 Mother and the maternal grandparents were contacted in order to meet with them to ensure their views were considered and heard as part of the review. A representative of the MKSCB initially visited both Mother and the grandparents to explain that an SCR was being undertaken. They were then visited by the Lead Reviewer and the representative of the Board to explain the process and ask them if they had any views on the agencies involved with the family regarding the way they worked together to protect Child A.  Their views will be shared throughout this report. Best endeavors were made to identify Child A’s Father, but it was not possible in this case.  6.2 The Department for Education (DfE) expects full publication of SCR overview reports, unless there are particular serious reasons why this would not be appropriate.  Working to that requirement, some confidential historical family information will not be disclosed in this report. It is written in the anticipation that it will be published, and contains all of the information that is relevant to the learning established during this review.  The family will be contacted again prior to publication to ensure they are aware of the conclusions of the review. 6.3 The decision to undertaken an SCR was made by the then Chair of the MKSCB and the review was planned at a scoping meeting held on 23 June 2015. Agency reports were requested, along with a chronology of agency involvement.  A briefing meeting for agency report authors was held on 28 July 2015, to clarify expectations. The SILP model requires engagement with staff involved at the time, and therefore two events were held to enable the Lead Reviewer to engage with staff. A Learning Event was held on 24 September 2015, and a Recall Event was held on 12 November 2015. Practitioners and first line managers attended and engaged in both events and received all reports. The Overview Report was presented to the Milton Keynes Safeguarding Children Board on 27 January 2016.    6.4 The Lead Reviewer in this case is Nicki Pettitt, an independent child protection manager and consultant who is an experienced chair and author of SCRs, and a SILP associate reviewer. She is entirely independent of MKSCB and its partner agencies.   7. The background prior to the scoped period 7.1 Mother and her family are well established in the Milton Keynes area. Mother attended school locally and although she has moved away in the past she sees Milton Keynes as her home.  7.2 Milton Keynes Council Children’s Services (CS) were not aware of Mother prior to her pregnancy with Child A.  When she became pregnant with Sibling she lived in another part of the country and returned to Milton Keynes before the birth.  Version 29.2.16  8  7.3 Midwifery and health visiting services were involved with Mother and Sibling in 2007. No concerns were identified at the time or when Sibling died at the age of 2 weeks.  7.4 Little is known about the death of Sibling.    The Police were involved, as they are in all cases of unexpected death, but limited records are available.  There is no evidence that there were any concerns about the care of Sibling or that the death was preventable. 7.5 Mother was relatively well known to Thames Valley Police prior to her pregnancy with Child A, as both a victim and perpetrator of crime. She has a history of offending and anti-social behaviour and the police have recorded concerns about her alcohol and drug misuse, and associations with those thought to deal drugs. Mother has been a victim of domestic abuse with more than one partner. Most recently, from June 2013, she was identified as at high risk of domestic abuse from Ex-Partner and was subject to the MARAC4 process.  7.6 In between the pregnancies Mother had a number of personal challenges, as described in the GP Agency Report. These were summarised as an ‘inability to work, a previous neonatal death, domestic abuse, personal safety concerns, housing issues and mental health problems.’ There is also reference to ‘long standing anxiety and stress related problems’. 7.7 In 2013 Mother was treated in hospital for a suspected mixed overdose of benzodiazepine5 and alcohol. Mother denied taking the overdose intentionally, but spoke of the breakup of her relationship with Ex-Partner, who had been abusive to her. She admitted taking drugs and drinking vodka. Mother was not asked if she would agree to toxicology tests being undertaken, so the review cannot be clear about what drugs she digested. It was noted that Mother responded well to Narcan6, which is a strong indicator that she had taken opiates. Mother was referred to her GP for support with her anxiety following this incident. No role for secondary mental health services was identified.   7.8 Mother has been a customer of Milton Keynes Housing Services for a number of years, and they were aware of domestic abuse from 2012.  7.9 In 2013 Mother referred herself to MK-ACT, the domestic abuse service for Milton Keynes, but she failed to engage.  7.10 The South Central Ambulance Service had also been called on a number of occasions prior to the pregnancy with Child A, predominantly due to injuries sustained during domestic abuse incidents (often after heavy drinking), anxiety and panic attacks, and the overdose mentioned above.   7.11 Allegations of domestic abuse from Ex-Partner started in 2013. Mother was assessed as high risk due to the serious allegations and the extent of the injuries she sustained. Mother’s cooperation with attempts to prosecute were inconsistent, however criminal proceedings were initiated and Mother made a statement which led to a successful prosecution. She was well supported, was provided with a personal attack alarm7 and a TECSOS8 mobile phone, and was referred for a MARAC.                                                   4 Multi-Agency Risk Assessment Conference 5 Benzodiazepines are a type of medication known as tranquilizers. Familiar names include Valium and Xanax. They are commonly prescribed in the UK.  6 Narcan is a drug used to prevent or reverse the effects of opioids.  7 These are primarily used in domestic abuse cases where a system is installed at a victim’s address with a panic button in the address. This is monitored by the company who alert police with a unique alarm number upon activation. 8 A device which enables a user to push a central button and activate immediate contact with the emergency services, providing details of the location from the handset and triggering an immediate recording of all activity in the vicinity of the device. Version 29.2.16  9  7.12 The staff at the Learning Event who knew Mother before the timeframe of the review confirmed that they were aware of her history of domestically abusive relationships. Some reported that she was often sleepy or drowsy when they saw her and that they thought she was being prescribed diazepam for depression. It was clarified at the Learning Event that this was not a prescribed medication, although professionals assumed it had been. She was also thought to drink to excess, often smelling of alcohol when visited.  8. Key Episodes 8.1 The time under review has been divided into four Key Episodes. Key Episodes are periods of intervention that are judged to be significant to understanding the work undertaken with a child and family.  They are key from a practice perspective rather than to the history of the child. The term ‘key’ emphasises that they do not necessarily form a complete history of the case but represent the key activities that occurred, and include the information that is thought to be most helpful in informing the review.   Key Episode 1:   8.2 This episode will look at the two months of agency involvement when a number of professionals involved with Mother were alerted to her pregnancy, which was ‘booked’ at 8 weeks.  8.3 The Community Midwife who first saw Mother noted that she was a victim of domestic abuse and that she was due to be a witness in the court case against Ex-Partner. The previous neonatal death at 2 weeks of age was noted along with previous postnatal depression. This information was shared with the relevant Health Visitor through the use of ‘confidential communiqués’9. The identity of the baby’s father was not recorded, as Mother stated he was not involved.  She was clear however that Ex-Partner was not the father.   8.4 When she was 15 weeks pregnant with Child A, an MK-ACT worker rang Mother and noted she was very drowsy. MK-ACT had recently been told by Maternal Grandmother that Mother may be misusing valium. The MK-ACT worker could hear a panic alarm going off in the background and could not communicate clearly with Mother. Acting swiftly MK-ACT staff called an ambulance and Mother was taken to the Emergency Department of her local hospital with an alleged overdose of tranquilisers, alcohol, and possibly opiates. It is recorded that this was following an argument with her ‘partner’.  It is also recorded in hospital records that Mother had stated that Children’s Services had told her they would take the child away from her when it was born, which led to the overdose. (It is noted that this was not the case as there had been no previous involvement with Children’s Social Care in Milton Keynes.)  The hospital records state that the ambulance crew reported two empty wine bottles at the home. The Police were also in attendance and it was confirmed during this review that neither service noted any evidence of drug use, which they stated is unusual when a person admits taking drugs. Like with the previous overdose, Mother responded to the use of Narcan. No toxicology tests were undertaken to establish exactly what substances Mother had consumed. A&E staff did not contact the GP or the Midwives to discuss Mother and unborn Child A.  8.5 Mother was insistent that this was not an intentional overdose, that she had taken extra tablets to relax, and she was adamant that there was no risk of reoccurrence. She was seen                                                  9 A confidential information sharing record used by midwives and health visitors in Milton Keynes.  Version 29.2.16  10  by a Speciality Doctor10 and Mental Health Nurse. They noted that Mother had a history of depression and a baby that had died. They were made aware of the domestic abuse and the impending court case. The mental health workers were told that the hospital emergency department was making a referral to the Referral and Assessment Team (R&A). They agreed to refer Mother to the ASTI11 for assessment and treatment for anxiety and to the service’s perinatal lead.  The GP was also asked to refer Mother for counselling.  8.6 Around a week later Mother made a 999 call asking for ‘NHS Direct’ due to her being pregnant and bleeding. It was the view of the police operator who spoke to her that she sounded intoxicated. She would have been given the number for 111 (the replacement for NHS Direct) and her details taken, but she hung up. This information was only identified when the Police agency report author checked contacts from Mother’s telephone number to aid this review. This information was not readily available so was not shared at the time.  8.7 Two MARAC meetings were held where Mother was discussed during this period. One was before and one shortly after professionals became aware of Mother’s pregnancy. The first meeting considered an incident around 6 weeks previously where Ex-Partner had pushed Mother down the stairs. The second meeting noted that Mother was pregnant but decided that it was not an appropriate referral to MARAC on this occasion as Ex-Partner was in prison and there was no new incident, just a belated report of an old allegation.  8.8 This is a key episode because professionals were aware of Mother’s pregnancy and had concerns about the historic domestic abuse, the need for her to give evidence against Ex-Partner, and her on-going anxiety. Mother took a drug overdose with alcohol which was stated to be unintentional, but provided evidence of the use of alcohol and tranquilisers which were not prescribed during the pregnancy.  Key Episode 2:   8.9 During the next month the R&A team received two referrals, using the MARF12, about the unborn child. Firstly from the hospital emergency department following the overdose, then from the Police Domestic Abuse Investigation Unit (DAIU) after agreeing with MK-ACT that it was more appropriate for them to make a referral. The Health Visitor, who had not yet met Mother and had no direct involvement until later in the pregnancy, also contacted R&A to discuss the concerns at this time, and had a conversation about the case and advising R&A that Mother was still in hospital.  This is good practice.  The referral from the DAIU included the information that Mother ‘had presented on numerous occasions as being quite lethargic and having just woken up, having slurred speech and to a degree, incoherent’. Police records show that officers were sceptical about Mother’s denial of on-going drug use. The recorded concerns from the referrals and subsequent conversations were in regards to Police and MK-ACT concerns that Mother may be addicted to prescribed drugs (as also asserted by Grandmother), that she was at high risk of domestic abuse, was very anxious about the up-coming court case against Ex-Partner, and her general anxiety following the death of Sibling.  8.10 A number of attempts were made by the R&A team to contact Mother by telephone and by letter, but they were unable to speak to her. They spoke to a Midwife and to MK-ACT. Information sharing between R&A and MK-ACT was good.                                                    10 A doctor in A&E who undertakes psychiatric assessments as well as medical assessments. (CNWL-MK MHHLT) 11 Assessment and short term intervention team for mental health.  12 Multi-Agency Referral Form.  Version 29.2.16  11  8.11 The CSC records state that during a telephone conversation between the R&A Social Worker and the Midwife it was understood that the if Mother did not engage with the R&A assessment, the Midwife and MK-Act should continue to support Mother, and that if Mother still had anxiety after the court case there may need to be a further referral to R&A and an assessment to see if she could meet the baby’s needs when born. There was no further communication with the health visitor who had contacted the R&A team after Mother’s overdose.   8.13 No contact was made with the GP by any of the professionals involved at this time, and the GP did not make contact after receiving notification of the overdose. The R&A team stated that in their case this was because there was no consent from Mother to share information with the GP.  Mother’s previous GP attended and engaged with the SCR learning events, however the GP involved with Mother during her pregnancy did not attend and it is not clear why she did not make further enquiries after receiving the notification. There was limited consideration among professionals about liaising with the GP in this case, because they stated there was no reason for any of the agencies to question whether or not Mother was being prescribed the medication she was thought to be using at this time.   8.14 There is evidence that a number of attempts were made by the R&A team to speak to Mother, including in the presence of the MK-ACT worker, but this was not successful. There does not appear to have been an attempt to gain Mother’s consent for agency checks via those agencies she was seeing, and it is not clear if this would have included the GP. The agencies involved later reported that Mother appeared more positive and that support was in place. She was refusing a place in a refuge, but wanted to be re-housed.  8.15 Mother made a 999 call to the Police stating she was 6 months pregnant, that she had been drinking overnight with friends, and that her mobile phone had been stolen. She was later suspected of causing criminal damage outside the house of the ‘friend’. The case was not pursued criminally, and the possibility that Mother had been drinking while pregnant was not assessed and nor was the information shared.  8.16 As Mother had stated to MK-Act that she did not want support from Children’s Services, it was decided by the R&A team that a transfer to a Children and Families Practice was not possible, as it relies on consent. The Children’s Social Care agency report states that when assessed using the Levels of Need (at that time the 2nd Issue October 2013), the outcome was that unborn Child A’s case was classified as Level of Need 2 - Additional: “Targeted response alongside universal services using the Common Assessment Framework (CAF) to identify need.”  The case was therefore closed to the R&A team. At the time the main focus seemed to be Mother’s anxiety about the court case and the release of Ex-Partner. The concerns about her presentation, the allegations of possible drug abuse from Maternal Grandmother, and indications she may have been drinking while pregnant were not treated as significant.  The Police DAIU did not receive any response to their MARF referral and did not follow it up. There is no record that a letter was sent to Mother to inform her of the closure of the case.  Meanwhile there was no clear discussion between the agencies who were working with Mother regarding whether there should be a coordinated multiagency response to meeting the needs of this young woman and her baby. It was not clear if the work required going forward should be through a CAF based process or through some similar multi-agency assessment and engagement process with Mother and agreement to a support plan.  Version 29.2.16  12  8.17 Things were more positive over the next few weeks. Mother did not have to give evidence due to a change of plea by Ex-Partner. Mother was allocated a new flat in Milton Keynes, despite the reservations from housing professionals regarding the on-going risk to her and her baby of staying in the town. On the day that she moved in however she recognised the neighbours as associates of Ex-Partner and became very anxious. Ex-Partner was then released unexpectedly at the start of a bank holiday weekend. This was due to the amount of time he had spent in prison on remand. Probation originally arranged for him to live in approved premises13 within walking distance of Mother’s new flat, as they were not aware of her change of address. When this issue was established he was quickly moved to other premises in another town.  The involvement of a Probation Officer who knew the case from MARAC ensured a swift resolution of the matter.  8.18 MK-ACT made a further referral, via a MARF, to R&A a month later stating their concerns about the on-going risk of domestic abuse from Ex-Partner, Mother’s anxiety about her neighbours links to Ex-Partner, and the fact that he had been recalled to prison following staff in the bail hostel overhearing a phone conversation between him and Mother. Significantly, at this time Mother was stating that she wanted support. She had gone to stay with her parents due to her concerns, and intended to stay there until she was again re-housed. The outcome of the referral was that the case was classified as Level of Need 3 – “Considerable”: The referral was transferred to the Children and Families Practice (CFP) which covered Maternal Grandmother’s address in another part of Milton Keynes.  Information from the previous referrals was included, with the exception of the referral from the DAIU which was unintentionally omitted. However the information was known to the CFP manager as they appear to have read the records.  8.19 The CFP recorded that the priority at the time was planning for Ex-Partner’s release.  Mother was visited by a duty worker from the CFP who noted the issues as housing, her fear of Ex-Partner, and the death of Sibling.  Mother adamantly denied that she used alcohol. She was not questioned about her drinking at the time of her overdose, or the concerns shared that her speech was often slurred. A CFP worker was allocated to unborn Child A and had contact with both Mother and Maternal Grandmother. During the contact Mother stated she was opposed to both drinking and drug use. Mother decided that she had enough support however and stated she did not need to work with the CFP. She told the CFP worker that her main motivation at the time was to be re-housed near to Maternal Grandmother. Mother’s request was accepted and the case was closed. MK-ACT, as the original referrer, was informed.  8.20   The ASTI (Assessment and Short Term Intervention Team) tried hard to meet with Mother, who missed a number of appointments, then stated she was no longer in need of the service as she had arranged counselling. The ASTI discussed the case with the Perinatal Lead, who agreed with the decision to discharge Mother from secondary Mental Health Services. Around the same time a referral had been made to IAPT14 by the GP, and a telephone assessment was undertaken, followed by another contact a week later.  The assessment concluded that Mother was feeling low in mood, was unmotivated, isolated, and was                                                  13 Approved Premises offer residential provision for people leaving custody in order to provide enhanced levels of protection to the public and reduce the likelihood of further offending.  14 Improving Access to Psychological Therapy (IAPT) which is a free, NHS service providing psychological treatment for depression and anxiety disorders. Version 29.2.16  13  suffering from on-going fears and anxieties. Mother denied using drugs and alcohol to manage these issues. An agreement was made to refer her to a Psychological Wellbeing Practitioner for cognitive therapy. Mother did not respond to the request to make an appointment however and her case was closed. The GP was informed in both cases of the closure of the case, but not the details of the assessment. The information was not shared with the midwives or Health Visitor.  It is presumed that the counselling Mother stated she was receiving was from her previous Victim Support Worker, who at this time continued her involvement on a private basis. This may have prevented Mother from engaging with the other public services being offered. 8.21 Mother had used her personal attack alarm on a number of occasions during this key episode, all inappropriately. She told the police officers responding that she had concern about noise disturbances in the street and about an unknown person heard banging on her door, that she was checking the alarm was working, and that she accidentally activated the alarm.  Ex-Partner was in prison on each of the occasions the alarm was used. This has led to the Agency Author from Thames Valley Police questioning in her report if alarms should be removed when perpetrators are in prison. The author concluded that it is accepted practice for the victim to keep the alarm when they are anxious and vulnerable, as Mother was assessed to be. As in this case, there are also times when an offender is unexpectedly released from custody. It was also raised by Mother when she was spoken to as part of this review, that she remained concerned that Ex-Partner would send other people to intimidate her on his behalf while he was in prison.  8.22 This is a key episode because issues were identified that could pose a risk to the unborn child, including potential domestic abuse from Ex-Partner (who had been temporarily released from prison and had been in telephone contact with Mother), Mother’s anxiety and presentation, and the unassessed concerns from Maternal Grandmother about Mother’s use of prescription drugs.  An attempt to provide support from the CFP was twice refused by Mother, on the second occasion after she was seen by two CFP workers. A Police DAIU (Domestic Abuse Investigation Unit) Case Investigator and IDVA (Independent Domestic Violence Advisor) from MK-Act remained involved until after the conclusion of the court case against Ex-Partner, but were closing the case at this time.   Mother did not engage with psychological services offered, the midwives and housing remained involved, and the Health Visitor was aware of the case.   Key Episode 3: 8.23 In the next few months Mother appears to have been living between her own accommodation and her parent’s address. She also missed a number of appointments with the midwives, either due to stated illness, because she forgot appointments, and on one occasion because she requested a change of midwife. Mother had been to see her GP who had concerns about the growth of the baby. Mother then missed a further appointment and did not respond to the GP’s attempts to contact her. The GP liaised with the midwives and an ultrasound was organised. Mother had changed GP and therefore the health visitor early in her pregnancy. There was a swift transfer of records, however the transfer was undertaken electronically, so the receiving Practice were not specifically made aware of the many long standing maternal vulnerabilities and the impact they may have for the unborn child.  Version 29.2.16  14  8.24 MK-ACT closed their involvement due to Ex-Partner’s custodial sentence. Mother continued to receive support from her previous Victim Support volunteer, who began work with Mother in an unofficial capacity. She is a trained psychodynamic counsellor. She worked on Mother’s behalf to get her re-housed and supported her at key meetings, for example with Probation regarding Ex-Partner’s release. 8.25 The midwives continued to be concerned about Mother’s lack of engagement, leading to a discussion with a supervisor around 4 weeks before Child A was due. It was agreed that a referral to the MASH would be made if Mother did not engage with appointments and antenatal care.  There was no attempt made to have a conversation with the MASH and no direct liaison with the Health Visitor.  8.26 Mother’s engagement improved and she had an ultrasound scan which confirmed unborn Child A’s growth was normal. During the appointment Mother said she had been on Diazepam and anti-axiolytic15 medication but had not used them during her pregnancy.  8.27 The Health Visitor undertook an antenatal visit to Mother due to the history of infant death and the information that was being shared by Midwifery. These visits are offered to all families where there may be a need for additional and targeted support. The Health Visitor discussed the death of sibling with Mother, who agreed to a referral to the CONI programme. Domestic abuse was also discussed and Mother’s mood, which was described as ‘up and down’.  8.28 The CONI coordinator visited Mother. Mother agreed to participate in the programme and to accept additional support around the prevention of infant death. The Midwife, Health Visitor and GP were advised of this. Equipment, including a movement monitor, was provided, and basic life support was demonstrated. Both Mother and Grandmother told the Lead Reviewer that they did not consistently use the monitor, particularly after Child A was two weeks old (the age that Sibling was when they died).  8.29 The week before Child A was born Mother missed another appointment with the Midwife, who then called at the house. The door was answered by man who said he was Mother’s cousin and said Mother was ill in bed with a ‘hangover’. When the Midwife insisted on seeing her, Mother stated that the Midwife was being rude and she did not want to see her again. Midwife noted a strong smell of cigarettes and left the house. She communicated the event to the Health Visitor via a Confidential Communiqué, which stated there were ‘several’ men in the house at the time. There was also a conversation held with the Health Visitor, which led to the health visiting service making a decision to visit in pairs. No consideration was given to the impact on Child A of the concerns identified during the visit.   He was born a week later.  8.30 This is a key episode because the midwives were challenged in their attempts to meaningfully engage with Mother, Mother’s housing situation remained of concern to her and her family, and there were further issues identified about Mother’s lifestyle by the Midwife and Health Visitor, which could potentially have an impact on Child A. These issues did not lead to a discussion in safeguarding supervision or with the MASH which was now in place in Milton Keynes, which would have been expected in the circumstances.                                                    15 Type of prescription medication used to treat symptoms of acute anxiety.  Version 29.2.16  15   Key Episode 4: 8.31 No concerns emerged about Child A at the time of his birth or immediately afterwards, although it was recorded by staff on the postnatal ward that Mother’s behaviour was ‘challenging’. Further information has been sought regarding this recording, but it has not yet been possible to clarify what was meant by this statement. Mother and Child A went to stay at the grandparent’s home after discharge in order for Mother to receive support from them, and due to concerns about the housing situation. The Community Midwives remained involved until Child A was four weeks old.  There is some evidence within the maternal post-natal notes that a management plan was put in place regarding the risk factors surrounding Mother’s anxiety, her potential for depression, and the death of her previous baby.   8.32 When Child A was 10 days old Maternal Grandmother called the Police in the early hours of the morning to state that Mother had been drinking at a family party, and that Grandmother was concerned that she was going to leave with the baby. The police visited and informed Mother that if she did not allow her mother to provide child care that evening Police Protection16 would be taken. The officers described Mother as “drunk”.  The incident was recorded as a domestic incident with limited information, and not a child protection incident. This had an impact on what was shared with the MASH, who were unaware that alcohol had been involved or that the row had involved who would care for Child A, who was present at the time. The MASH had requested more information about the incident, but this was not provided. This appears to be because the Police Officer involved completed their report as a domestic incident, not as a potential child protection incident, which involves a separate report that should have been completed. The Health Visitor and the GP were not informed about the domestic dispute at all. A recommendation has been made in the TVP (Thames Valley Police) Agency Report to ensure processes are more robust going forwards.  8.33 The following day Mother left the grandparent’s home and returned to her own home with Child A.  8.34 The Health Visitor had a planned visit to Mother the next week, and prior to her visit she telephoned the MASH to check if there had been any recent concerns or incidents, and she was told the case was not open. She was not informed of the domestic incident the previous week, as the way it had been shared with the MASH by the Police meant it was not recorded on their system. Soon afterwards the 6 week check was completed by the GP who noted nothing of concern, with the GP stating that Mother appeared to be coping very well and Child A was fine other than some snuffles.   8.35  A MARAC meeting was held shortly after the birth of Child A. The incident between Mother and Grandmother regarding the care of Child A was not discussed. A MAPPA17 meeting was also held regarding Ex-Partner’s release and safety planning for Mother and Child A was considered.  8.36 The MASH was contacted by Probation after the MAPPA meeting regarding the risk Ex-Partner posed to Mother and Child A once he was released. This included the risk to Child A                                                  16 Section 46 of the Children Act 1989 gives the Police the power to remove children to or keep them in a safe location for up to 72 hours to protect them from "significant harm". 17 Multi-agency public protection arrangements. Which are multi-agency processes in place to ensure the successful management of violent and sexual offenders. Version 29.2.16  16  when Ex-Partner realised he was not his father.  Mother gave her permission for a referral to the MASH. The duty worker spoke to Mother, to the Health Visitor, and to the previous victim support worker who was now working with Mother on an informal basis. The case was classified as Level of Need 3 – ‘Considerable’18 and opened to the relevant CFP. The CFP worker spoke to housing on Mother’s behalf, liaised with others working with Mother, and completed a CAF.  8.37 A team around the family (TAF) meeting was held shortly before Child A died. It was well attended by those involved. Adult mental health services were not invited to attend, and no information from them was considered, although it is acknowledged that they were not involved with Mother at the time of the meeting. Mother attended. The focus of the meeting was predominantly housing, and ensuring the safety of Mother and Child A, as Ex-Partner was due to be released from his custodial sentence.  Wider issues such as Mother’s mental health and any issues with alcohol and drugs were not discussed, including the alcohol-fuelled domestic incident at Grandmother’s home, the details of which were not known to those at the meeting. It is possibly significant that the CFP involved at this time were not aware of the information contained within the referral in key episode 2 from DAIU about the observations of Mother’s behaviour and the suggestion this could indicate a possible addiction to prescribed medication. This is due to the information from this referral not being summarised on the referral from MASH to the CFP. While it was contained in records on the wider data base, these were not accessible to the CFP Practitioner.  8.38 The TAF meeting agreed that there were no issues with Mother’s care of Child A, and they were reassured that Mother had no intention of having any contact with Ex-Partner. Housing attended and agreement was given to re-house Mother and for her rent-arrears to be written off to ensure a swift resolution.  A further safety meeting was held the next day to plan support Mother may require when Ex-Partner was released, which included the Police DAIU Case Investigator, the IDVA from MK-Act and Mother’s counsellor. A further TAF meeting was to be held the following month. The Lead Reviewer was told that further information about Mother and Child A would have been considered at the second TAF meeting, the date of which had been set.  8.39 Child A died two days later. Mother was visiting a male friend where she drank alcohol and took what she thought was cocaine. Child A was said to have been put to bed in a Moses basket, but Mother’s friend stated to the Police and the Inquest that in the night the baby was in bed with Mother and was later found to not be breathing. Mother told the Lead Reviewer that she was not co-sleeping with Child A when he died.  8.40 This is a key episode because the focus of professionals was on the risk posed to Mother and Child A from Ex-Partner, and information on previous and more recent concerns about Mother’s behaviour was either not available, not shared or not reconsidered at this stage.                                                        18 “Practitioners have serious concerns; Family is socially isolated; Experiencing unsafe situations.”  (Level 3)  Version 29.2.16  17  9 Analysis by Theme  9.1. From the information deduced from the agency reports, from the discussions at the Learning Events, and from the meetings with the family, several key themes have emerged.  These can be summarised as:  Mother’s vulnerabilities   Focus on the child  Multiagency meetings  Lack of engagement  Co-sleeping   Information sharing, consent and evidence  Family engagement  Each theme will be considered below, with any learning clearly identified.   Mother’s vulnerabilities: 9.2 The following potential risks were evident in this case:  domestic abuse   drugs and alcohol   mental health / anxiety  housing issues 9.3 Mother had significant issues that were likely to impact on her parenting of Child A.  These included her anxiety and depression, the previous relationship with Ex-Partner that continued to have an impact both practically and emotionally, her apparent use of drugs and alcohol, and her more general life-style. A Serious Case Review enables all of the information known to agencies to be seen in one place, often for the first time, and this case is no exception. The benefit of both hindsight and the full information enables the reviewer to see that there was evidence of risk prior to the incident. However, with improved sharing of information and more challenge both of Mother and between professionals, the risks in this case to both Mother and Child A would have been more evident at the time.     9.4 The Health Visitor or CFP Workers did not observe any signs that Mother may have been using drugs or alcohol on their visits, although a number of the visits were undertaken at Grandmother’s home. Engagement remained poor, and Mother continued to miss appointments with a number of professionals, such as with IAPT, Probation, and midwives.   9.5 The overdose when Mother was 15 weeks pregnant was considered by those involved as an understandable reaction to having to give evidence in court the next day. Mother stated clearly that she did not intend to take an overdose, which allayed professional fears for her safety. The fact that she took unprescribed drugs and drank alcohol while pregnant, which was not an attempt to overdose, was not thoroughly considered as a potentially reckless misuse of substances that could be harmful to her unborn child. Most of the professionals involved had been informed that she had taken an overdose of alcohol and sleeping tablets. The overdose of opiates does not appear to have been as widely known, although a number of agencies were aware of it.  In agency records, and in the Children’s Social Care and Children & Families Practices Agency Report prepared for this review, this incident was referred to as an ‘accident’ where Mother took too many of her tablets to relax. This was the shared understanding at the time, and was not sufficiently challenged.  At the Version 29.2.16  18  Learning Event a number of those involved agreed that they had seen it as an adult protection issue rather than a child protection matter at the time.  9.6 In regards to the concern expressed by Maternal Grandmother that Mother could be misusing valium, there is no evidence this was ever discussed with Mother. The R&A team did not directly discuss the concerns with Grandmother. There was also a dilution of the information over time leading to a shared professional view that Mother may have used valium ‘to relax’ in the past. They accepted Mother’s claim that she had not used any prescription drugs since the overdose earlier in her pregnancy. Grandmother’s allegation, the concern of some professionals that Mother was often drowsy and incoherent when spoken to, and the fear shared by the Police that Mother may be addicted to ‘prescription’ drugs, were not rigorously considered by any of the professionals involved. The GP was not contacted to see what drugs Mother had been prescribed. There was no consideration that the regularly missed appointments and the difficulties in contacting Mother may have been a sign that she may be misusing drugs or alcohol.  9.7 The view shared at the Learning Event was that there was no evidence at the time of any risk to Child A from Mother’s use of drugs, however there was no focused assessment of the concerns or clarification of the potential evidence that was available. Child A did not show any signs of drug withdrawal at birth. Although the professionals involved in this case demonstrated a wider awareness of the risk that parents who are abusing drugs or alcohol will be dishonest about the extent of the issue, in this case it did not impact on their interventions with Mother.  9.8 In key episode 2 those involved felt there was no need to challenge Mother or to question if she was being honest about her use of drugs and alcohol. Mother may have been unwilling to share the probable extent of her drug use at this time due to a concern about what it would mean for her continuing to care for her unborn child, or because of her own needs. Research tells us that ‘for those who have experienced long histories of using substances or where the use has provided significant emotional support, facing the possibility of examining their pattern of substance misuse can be particularly stressful.19’  A drugs and alcohol assessment was not requested or undertaken. MK-ACT discussed it with Mother, but she refused to consider any input of this type, stating she had no current issues with drugs or alcohol.  9.9 Mother received a psychological assessment and offers of therapeutic input after the overdose, but she chose not to engage. The assessment noted some concerns about Mother’s low mood and anxiety, which again were thought to be linked to the on-going risk of abuse from Ex-Partner and, to a lesser extent, to the death of Sibling. However the GP held information that depression was a longer-term issue for Mother, which was likely to have an impact on her care of Child A.  9.10 Housing was an on-going concern for Mother, her family, and the professionals involved who were appropriately worried about the risk to Mother and her child when Ex-Partner was released from prison. This concern appears to have dominated professional engagement with Mother, and large amounts of professional energy were put into finding a solution within tight timescales. The concerns in this case were seen as domestic abuse and housing, and this led to inadequate consideration being given to the other risk factors evident.                                                   19 Parental Substance Misuse and Child Welfare Brynna Kryll and Andy Taylor (2002) Version 29.2.16  19  9.11 The identified learning:  Parents who are misusing drugs or alcohol can be very persuasive.  To ensure that potential safeguarding risks are identified, professionals need to seek and consider objective evidence which can be used to confirm or challenge the accounts being given by the parent. ‘Respectful uncertainty20’ should be employed, particularly when drug or alcohol abuse is a possibility.    The NSPCC published a report in 2010 called ‘Ten Pitfalls and How to Avoid Them - What Research Tells Us.21’ Four of the ten pitfalls in regards to assessing families in the community are relevant to this case. They are:   An initial hypothesis is formulated on the basis of incomplete information, and is assessed and accepted too quickly. Practitioners become committed to this hypothesis and do not seek out information that may disconfirm or refute it.   Attention is focused on the most visible or pressing problems; case history and less “obvious” details are insufficiently explored.   Insufficient weight is given to information from family, friends and neighbours.   There is insufficient full engagement with parents (mothers/fathers/other family carers) to assess risk.  Focus on the child: 9.12 It is always important for practitioners to understand the lived experience of a child, and to consider the situation from the child’s perspective. The importance of gaining a picture of a child’s lived day-to-day experiences has been consistently highlighted in SCRs.  In this case a lack of awareness of Mother’s lifestyle at the time means no real consideration was given to what Child A’s experience was going to be growing up in his family. Child A was very young when he died. Much of his lifetime was spent with his Mother living in his grandparent’s home. After Mother chose to return to her own accommodation following a drunken row with her mother, there is little known about what Child A’s lived experience would have been. It is clear that he continued to be well cared for physically, and that his Mother was loving and attentive to him when professionals were present. On the evening that he died Child A was with his mother at a friend’s house. She was drinking, believed she had used drugs, and she did not heed the advice she had been given about safe sleeping.   9.13 Child A was a much loved child. Mother and Grandparents speak of him with affection and pride. The many photographs of his short life show a thriving and smiling child. Both his mother and his grandparents had well maintained and comfortable homes, and the grandparents were willing and able to care for Child A and support Mother as required. On the occasions when Child A was seen by professionals they had no concerns.  Mother’s immediate needs were the priority, and the professionals involved felt they were best meeting Child A’s needs by helping Mother.   9.14 The identified learning:                                                   20 Lord Laming. Enquiry into the death of Victoria Climbie. 2003.  21 Dr Karen Broadhurst, Professor Sue White, Dr Sheila Fish, Professor Eileen Munro, Kay Fletcher and Helen Lincoln. NSPCC 2010 Version 29.2.16  20   It is important that all assessments seek an explicit understanding of a child’s lived experiences (or likely lived experience if they are not yet born) combined with a thorough analysis of the known risks and protective factors.    When a service user is pregnant and engaged in risky or worrying behaviour (in this case Mother’s overdose of drugs and alcohol) professionals must consider the behaviour as a potential child protection issue.   Multi-agency meetings: 9.15 A number of professionals from different agencies met to consider the case on occasion, with MARAC, MAPPA and TAF meetings held.  The focus of all these meetings was the risk posed by Ex-Partner and Mother’s related housing issues. The risk of further domestic abuse to Mother, and the predicted risk to Child A himself when Ex-Partner realised the child was not his, dominated the discussions and plans. The meetings held did not identify and consider the wider risk factors. In the case of MAPPA and MARAC this focus is understandable and the timing of the TAF meeting led to a similar focus. This led to the continued shared professional understanding of what was perceived to be the main issues and risks. As stated in the agency report ‘from the perspective of the Health Visitor, mother’s main issue was being very scared because of the impending release of her ex-partner from prison and where she would be housed.’  The lack of shared information about continuing and concerning elements of Mother’s lifestyle led to these elements not being considered as relevant.  9.16 The focus of the TAF meeting was housing and safety planning for the release of Ex-Partner. This ensured the cooperation and attendance of Mother. She was described as reluctant to attend but appears to have been prepared to attend and engage with professionals who worked to her defined priorities.  9.17 There was good attendance at the TAF meeting which was held three days before Child A died. It included Mother, the CFP Practitioner and Senior Practitioner, the Health Visitor, Officers from DAIU, the MK-ACT Worker, Housing Officers, a Probation Worker and the previous Victim Support Worker who was now supporting Mother independently. Maternal Grandmother did not attend but looked after Child A. The meeting discussed the risk posed by Ex-Partner to Mother and Child A and the housing situation.  It was noted Mother had been given a baby monitor, but hadn’t felt the need to use it as she had been living at her parents’ home. This was not rigorously challenged at the meeting, and Mother did not state that she had returned to her own flat. The meeting started a ‘Mapping’ exercise22 which considered the risk posed by Ex-Partner and the need for re-housing. As alcohol or drug use had not been identified as significant issues, and Mother was being supported by the previous Victim Support Worker, her wider needs and any risk from these to Child A were not considered.   9.18 Good attendance at the meeting and attempts to engage with Mother over the timeframe of this review show that the agencies involved appeared to have worked well together to address the concerns about domestic abuse and housing. However the focus of the work was primarily limited to these areas, and there was limited awareness of Mother’s vulnerabilities, which meant a robust assessment and planning around Child A was not                                                  22 Part of the ‘Signs of Safety’ model. Where professionals consider what is working well, what is of concern, and what needs to be done. Version 29.2.16  21  identified as a need at this time.  Housing stated that they were not aware of any concerns about Mother’s use of drugs or alcohol despite attending a number of meetings about the case prior to the death of Child A. The CFP were clear however that this meeting was used to discuss the immediate concerns, and there was an intention to extend the remit of their involvement at the next meeting.   9.19  MARAC meetings in Milton Keynes are held monthly and involve all of the key agencies. They look at incidents which have occurred up to 6 weeks previously due to the cut off date for referrals for MARAC. However, agencies generally undertake a number of tasks and assessments between the date of the incident and the meeting. The reason for the meeting is to check relevant information held across agencies, to share updated information, and to problem solve. The inclusion of Mother’s case in the meetings did lead to improved information sharing, however the confusion about whether she should have been discussed at the second meeting where her pregnancy was confirmed has led to a question being raised with the relevant agencies about the process and recording of meetings that is being pursued.  9.20  The learning identified:  A parent with vulnerabilities requires a positive and understanding response from professionals.  When considering their potential to parent their child there should also be robust and honest challenge about the areas and behaviours which would negatively impact on the child.    Professionals attending a TAF meeting need to have a shared understanding of the background concerns and risks as well as consideration of the immediate concerns that led to the meeting.  This will ensure the best plan is devised for a child. If the meeting is part of a longer term process to develop a clearer understanding of the family, including any risks and protective factors, this should be clarified with those in attendance and recorded.  Lack of engagement: 9.21 Despite the risks, with the support available from her own family and from professionals, there is no reason to believe that Mother could not have successfully parented Child A. However, Mother’s lack of engagement with a number of professionals led to a lack of relevant assessments and limitations in the impact of the support offered. Maternal Grandmother’s help was valuable, but Mother did not always accept or seek her support unless she could see the benefit of doing so.  Mother was also happy to accept professional support, for example with housing, but this had to be on her own terms. She did not cooperate when her own behaviour was questioned.  9.22 There were a number of indicators that Mother was resistant to professionals, but this was generally seen as understandable. It was accepted she was very anxious because she was a victim of serious domestic abuse, involved in the difficult court case against ex-partner, and fearful that her child would be removed from her care. The midwives described Mother as ‘jumpy’ when they questioned her, and said she was clearly nervous around them.  This could be because of a genuine fear of professionals intervening in her life, or because she did not want her choices being exposed and questioned.  Version 29.2.16  22  9.23 Mother’s lifestyle was described as ‘chaotic’ at the learning event, including when she was pregnant. Witness Care at the criminal court recorded Mother as ‘notoriously difficult to get hold of.’ This was a view that all professionals at the learning events could relate to.  9.24 The ‘rule of optimism’ in safeguarding decision-making was first identified by Dingwall Ekeelaar and Murray in 198323.  They acknowledged that those in the helping professions may be inclined towards positive interpretations of what is going on, and the propensity to see the best in those they are working with. In this case Mother tended to cooperate with professionals just enough to reassure them that she was compliant. After the overdose in key episode 1 Mother minimised both what had happened and her intent, and reassured professionals that the crisis was a one-off linked to the court case and would not reoccur. Her version of events became the accepted story both at the time and since.  There were occasions when she showed disguised compliance, stating that her anxiety after the death of Sibling led her to be nervous around professionals, and that she wanted to cooperate. While there was likely to be some truth in this, the situation was more complex and the acceptance of her reluctance to engage as understandable allowed Mother to avoid difficult conversations about her lifestyle.  9.25 Mother did not respond well to challenge, as the midwife found when she questioned Mother about missed appointments and whether she had been drinking.  Anxiety about challenging the service user may stop the recognition or exploration of difficult issues by professionals, such as the potentially problematic drinking and drug use in this case.  The health visitor made a decision to visit Mother in pairs due to a concern that Mother was not always truthful. This leads the review to question the otherwise accepted view that Mother was generally honest with professionals.   9.26 Those working with Mother in regards to the domestic abuse expressed their concern about Mother’s vulnerability and the impact contact from social workers from the R&A team would have on her at the time of the criminal trial. They also voiced concern about the impact on their on-going relationship with her when she became aware of them referring their concerns about the potential misuse of prescribed drugs. While this is understandable, it could set a precedent of putting Mother’s needs before the need to consider any potential risk to the unborn child.  Those involved however were clear that they did not ask that Mother was not contacted, rather that any contact was made in a sensitive way.  The R&A deputy manager decided there would be no further action from CS in relation to the referral as other agencies were supporting Mother and she had stated that she did not want support from CFP. It was stated that there was no evidence that Mother was misusing drugs, so CS did not believe they had the authority to undertake any further enquiries without Mother’s consent. They also did not consider any other evidence that might be available, including a clarifying discussion with Grandmother. It is the Lead Reviewer’s view that there was enough concern at this time to justify further enquiries about the issue.   9.27 Limited support was offered to Mother from community health professionals involved during the pregnancy beyond standard health interventions. Mother stated during this review that it is very hard to get hold of the midwives and that she did try to contact them a number of times and was not called back. When she did see them she stated they did not seem interested in her. The agency report for midwifery services states that there was ‘no                                                  23 The protection of children: state intervention and family life. 1983 Version 29.2.16  23  evidence that consideration was given to the support available to Mother, especially in light of the concerns about her previous child dying, her abusive relationship/s, and her anxiety’. A referral was not made to the bereavement midwife. The postnatal plan made reference to Mother’s history of domestic abuse, depression and anxiety and the need for more regular post-natal visits.  However, ‘minimal visits occurred and the records for those visits predominately make reference to the medical activities and not the emotional or social needs’. (Agency Report).  It is also noted that staff on the post-natal ward did not discuss with Mother the concerns that were known previously with regard to drinking, smoking and drug taking.  9.28 The GP and the midwives identified Mother’s habitual non-compliance with antenatal care. This led to a conversation with the Named Safeguarding Midwife to discuss a potential referral to the MASH, which was decided against. The information held about Mother’s ongoing depression, anxiety and limited engagement was shared with the Health Visitor but no referral was made to the R&A team / MASH, and there was no liaison or sharing of information with other non-health agencies involved with Mother such as victim support and MK-ACT.   It has not been established why this decision was made.  9.29 The probation victim liaison unit had a number of telephone conversations with Mother, wrote to her and then attempted to meet with her. She did not attend any of the meetings arranged however. They considered Mother to be ‘chaotic, rather than not bothered or choosing to actively not engage.’ (Agency report.) Victims have no obligation to engage so no further action was taken.  9.30 The GP was aware that Mother had missed a number of appointments with the midwives, and after a concern had been identified about the size of unborn Child A she missed an appointment with the GP. The GP agency report states that the missed appointments ‘should have been addressed more assertively to ensure the health needs of the unborn child were being fully met’.  The rationale relating to the decision not to refer to MASH following the GP’s discussion with the Safeguarding Midwife is not documented within the maternal GP records. 9.31 Mother was regularly accompanied by her counsellor, who had previously been her Victim Support Worker. The counsellor would often speak for Mother at meetings and attended the MAPPA professionals meeting despite it not being appropriate for her to do so, as the meeting is for agency professionals only. There was a lack of professional curiosity about this individual’s role, and it is of concern to the review that the involvement of this individual may have led Mother to refuse the support being offered by agencies. This issue is being pursued outside of this review.  9.32 The identified learning:  It is difficult for professionals to maintain the engagement of a service user who is likely to withdraw their cooperation, or refuse to give consent for information sharing, when they are challenged.  The threat of withdrawal from engagement should be seen as an indicator of risk.  Professionals need to acknowledge that a service user may not be telling the truth. The notion of ‘high support, high challenge’ should be the aim of engagement with families. It is acknowledged that this is a complex and difficult balance, which to do well requires skilled practitioners, reflective practice and effective supervision.   Version 29.2.16  24   Supervision needs to be available and sought to help professionals challenge themselves, each other and family members when there are concerns about lack of engagement.     Professionals need to understand and clarify the role and status of any volunteers or advocates before disclosing confidential information or including them in meetings.   Adult behaviour needs to be understood by professionals, especially those who primarily provide services to adults, in terms of the impact of that behaviour not just on the adult but on their child. This needs to be evaluated accordingly where the adult is about to become or is a parent. Co-sleeping: 9.33 An investigation of the extent to which Mother’s actions on the evening of Child A’s death might be considered criminally negligent has been undertaken by Thames Valley Police and it has been concluded by the Crown Prosecution Service that there is insufficient evidence for a prosecution.  Child A’s death cannot be directly attributed to any actions taken or not taken by his Mother, however her life style, her consumption of alcohol, and her intention to use drugs are known risk factors for sudden unexpected death in infancy and are likely to have played a part.  No agency or professional could have prevented the death had they acted differently however. Mother was given appropriate advice regarding co-sleeping, and Mother understood the added risks of drinking/drug use, of overheating, and of roll over if sleeping with her baby.   9.34 Co-sleeping was specifically discussed with Mother and Grandmother a number of times, including at the new birth visit. She was also given the safe sleep leaflet. The CONI nurse visited and provided advice about avoiding sudden infant death, and the risks of co-sleeping. It is noted in the GP agency report however that while the death of Sibling was discussed by Mother with her GP, safe sleeping arrangements discussions were not documented in any of the medical notes reviewed.   9.35 When speaking to Maternal Grandmother as part of this review it was clear that within the family co-sleeping was common. She spoke of the family staying up at night and taking turns to hold the baby while he was sleeping, rather than putting him down to sleep in his crib. Their anxiety, which was due to Sibling dying alone in their crib, appears to have led to this practice. There is no evidence that this information was shared with professionals involved at the time. A child who is not used to sleeping alone is likely to be unsettled at night when placed in a cot or crib, leading to the increased risk of co-sleeping when their mother is caring for them alone. This appears to have been the case here.  9.36 The identified learning:    Despite a commitment to ensuring families are aware of the need to adhere to safe-sleeping advice, it is not always possible for professionals to identify a family where there is an un-disclosed culture of co-sleeping.         Version 29.2.16  25  Information sharing, consent and evidence:    9.37 Communication and information sharing is an issue that is regularly highlighted in SCRs, and this review is no exception. As stated in Learning Lessons from Serious Case Reviews24 ‘for most families a great deal of information was known but it was not coordinated and evaluated until the serious case review was completed.’  This report has made reference to inter-agency communication in this case, much of which is positive, such as information sharing between MK-Act and the R&A team and the Police DAIU. However there were also some problems. They include the limited information sought from and by the GP, the R&A team not informing either the midwife or health visitor about the case being closed to them in key episode 2, the Police not sufficiently sharing information about the incident between Mother and Grandmother, and the limited information shared with the involved housing professionals regarding Mother’s potential misuse of drugs and alcohol. Limited communication with Maternal Grandmother was also an issue.   9.38 The GP was potentially a key contact, particularly as they held a lot of information in regards to the identified anxiety and depression and knew what medication Mother had been prescribed. There was little engagement or information sharing with the GP. This may be because the GP was not proactively engaged or because other professionals do not seek to engage GPs in the day-to-day management of cases. The issue of consent was also an issue. Professionals reported during this review that their understanding is that they are unable to contact GPs without the explicit consent of the client. To ensure optimum information is available for assessments and case management GPs should always be contacted. If explicit consent is not given or is not available due to lack of engagement by the parent, but there are concerns about the impact on a child of a parent’s health or use of medication (as in this case), consideration should be given to requesting information without this consent. This is a fully defensible and legal approach. The government recently published information sharing guidance which emphasises that data protection legislation is a support and not a barrier to the effective safeguarding of children25.  Information sharing guidance should be a guide to professional practice but not a hindrance to appropriate professional curiosity.   9.39 There is a clear understanding of thresholds and levels of need in Milton Keynes. They are well publicised and it is acknowledged that a response under level 426 is only undertaken in the most serious cases. None of the individual referrals or the information shared with the R&A team in this case led to a Level 4 response in this case. This appears to have been accepted by the professionals involved at the time as there was no use of the escalation procedure for professional disagreements. Workers from R&A/MASH were clear during the review that had the information which was known by other agencies been shared with them this would have resulted in a Social Work assessment under level 4. However the lack of curiosity about what was shared, such as Grandmother’s concerns and the information from Police about Mother’s presentation in key episode 2, should have led to a more robust assessment by a social worker.                                                    24Ofsted 2008 – 9.  25 Information Sharing Advice for Safeguarding Practitioners. Department for Education. 26 March 2015. 26 Specialist services intervention coordinated through statutory process alongside universal services. Version 29.2.16  26  9.40 There was a need to consider each new concern alongside the known history. Past experiences have a critical impact on present and future behaviour, so the understanding of a person's history must always inform any assessment being undertaken by the professionals working with children and their families. This should lead to a professional assessment of the wider picture, not just what evidence there is of risk from single issues or events. In this case the need to keep Mother on board, the need to address serious concerns about Ex-Partner, and the need to keep Mother and child safe from domestic abuse appears to have led to a focus on the here and now. It also diverted professional attention from risky behaviour, and led to a limited consideration of what else might be important.  9.41 Other issues such as the access by CFP to the client data base used by the R&A team, the use of confidential communiqués in place of conversations on occasion, the need for timely sharing of information from the MARAC with those working with the families (such as housing staff), the lack of information sharing by the Police after the incident at Grandmother’s home, and the lack of detailed information sharing between IAPT and the GP were also highlighted in the agency reports.  However it was stated clearly at the Learning Events that information sharing in Milton Keynes is generally very good, that professionals do communicate and do share information appropriately with each other and with the MASH.   9.42 The learning identified:   GPs are a crucial part of the safeguarding system.  Sharing information with them, and seeking the information they hold, should be a standard action in any assessment.     All professionals need to understand, through their own agency and MKSCB training and learning, how to have and understand difficult conversations with other agencies and professionals from other disciplines.     Any new information gained by a professional should always be considered alongside the information already available.   Family engagement:  9.43 The grandparents of Child A were very involved in his care during his short life. Maternal Grandmother spoke regularly to a number of professionals in housing and domestic abuse services. She shared her concern about Mothers use of drugs, but she was not asked for more information in regards to this, despite her knowledge and the probability that discussing this issue must have been very difficult for her.  She was not assertive about her concerns, and they were largely overlooked.  The information she may have had regarding her daughter was underutilised in the assessments undertaken and decisions made in this case. The Review was told that audits of CS records generally show very good involvement of family members in assessments and subsequent plans however.    9.44 This review has concluded that despite different reports from Mother to agencies involved at the time, it remains unclear who Child A’s Father is. Therefore it has not been possible to consult with them as part of this SCR.   9.45 The learning identified:   Family members can hold significant information and they should be engaged with and spoken to when making an assessment. As they can also provide important support and care for families, they should be appropriately utilised.  Version 29.2.16  27    The benefits and difficulties inherent in involving wider families in assessments and plans need to be fully evaluated and understood by professionals.     Assumptions can be made about the implicit protection provided by wider family members to children. Professionals need to be aware of making such assumptions and recognise the risk of doing so.    10    Conclusions 10.1. The death of Child A was a tragedy, but it appears that Mother’s lifestyle may have had an impact on the turn of events, as the Coroner stated at the Inquest into the death.   10.2. While it appears that the professional interventions in this case have had no bearing on Child A’s death, this SCR was agreed by the MKSCB as they identified that learning could be gained from the degree of scrutiny an SCR provides. The review has attempted to avoid hindsight bias which “oversimplifies or trivialises the situation confronting the practitioner and masks the processes affecting practitioner behaviour” (Woods et al27).  It has consulted with those involved at the time and has sought to understand why actions were taken and decisions were made. 10.3. This SCR has identified statements of learning which were developed from the themes considered above, and have been listed at the start of this report.   10.4. It is also important to learn from the good practice identified during the course of this review. It is acknowledged that there was good practice across a number of agencies in the following areas:  Communication and information sharing.   Recording.  Management oversight.   Timely and coordinated responses to concerns.   The use of multi-agency referral forms.   The persistence of a number of professionals to see Mother when she was missing appointments or not answering her door. The review was assured that this is standard practice within Milton Keynes and recognises the value of this.   10.5. The other agency specific good practice which the review has identified is:  When Mother was seen in hospital after the overdose the staff recognised the risk to the unborn child and made a referral to Children's Social Care and contacted the maternity unit.  The mental health assessment identified Mother’s history in relation to the “toxic trio” of depression, drug and alcohol misuse and domestic abuse.   Police and the CPS put a plan into place for Mother to give evidence via video link from a police station in the trial of Ex-Partner.                                                   27 David D Woods et al. Behind Human Error. 2010. Version 29.2.16  28   The emergency response to Mother’s overdose by MK-ACT, the police and ambulance service.    The flexibility of the housing service regarding providing accommodation for Mother and Child A.  The CFP staff attempted unannounced as well as planned visits in this case.  The CFP Practitioner became involved in a timely way and arranged a TAF meeting to address Child A and Mother’s safety before Ex-Partner was released from prison.  10.6. It is also acknowledged that there has been a high degree of cooperation and engagement from agencies with the SCR process, which the Lead Reviewer has appreciated.  10.7. There have been some changes within partner agencies of the MKSCB since the death of Child A. This reflects the fact that some of the “best learning from serious case reviews may come from the process of carrying out the review” 28 Other changes have happened which were unrelated to the death of Child A but show the continuing improvement culture in Milton Keynes.  10.8. The changes are as follows:  The Milton Keynes MASH has an approach to information sharing about lower need cases that is different to that previously applied in the R&A team. This means the information sharing issues that arose around key event 2 are less likely to happen again as the “information package” within the MASH firewall would include health worker liaison with the GP.   There has been a change in practice for the Lead Midwife roles for Perinatal Mental Health and Domestic Abuse from being advisory and supportive to case holding midwives to case holding women who are identified as high risk according to the developed risk matrix.   The health visiting service has updated service guidance regarding receipt of Confidential Communiqués.  Following a change of structure within the housing service all officers within the Moving Home Team have now received additional training in safe guarding (‘MKSCB Everybody’s Business’.)     As part of the Housing Options Assessments, case files will be submitted to a Senior Officer or Housing Services Manager for review and agreement of assessment.   The three CFPs have the same systems and processes and work in the same way. Previously there was slight variation.   CFP policies have been reviewed, including: o A Non-Engagement Policy is being developed.                                                   28 Brandon et al.  Lessons from Serious Case Reviews.  2012 Version 29.2.16  29  o A protocol covering the transfer of cases between CSC and CFP, to support smooth transition of cases at the appropriate time, is in place and is currently being reviewed.  CFP’s work focuses on cases assessed as Level of Need 3. They no longer work with cases assessed as Level of Need 2, which are now supported by co-ordinated universal services.   Management of the CFPs is now within the Children’s Social Care management structure.   Health professionals are now located within the MASH.   The MASH reports an increased use of the consultation they provide to partner agencies who wish to discuss a case. They also report a healthy culture of debate.    For cases which are considered by the MASH to be Level of Need 3, but with a high level of concern, a contingency plan is included in the referral to CFP. For example, if there is a lack of engagement or progress, within a given timescale, the case should be referred back to MASH.  Since September 2014 all case recording is located on the Early Help system used by CFPs, unless the case is open to Children’s Social Care or subject to child protection investigation. This allows more access to historic details on a case by staff in CFPs.   In April 2015, Milton Keynes Mental Health Commissioners established a Perinatal Mental Health Collaborative group to review and improve perinatal mental health pathways. This will have a significant impact on the work of CNWLMK Mental Health Services in terms of the support they will be able to offer perinatal women and effectively ensure the safety and welfare of children.  With the formation of the MASH new processes for Thames Valley Police (TVP) have been introduced, such as the Triaging of Domestic Abuse referrals to Children’s Social Care, including twice weekly multi-agency meetings.   Niche Record Management System has been introduced by TVP. This involves new methods of recording including the use of Risk Management Occurrences - a standalone record to detail all the ongoing risk management activity for a domestic abuse case.  Development of a process where DAIU staff are expected to create a Child Protection occurrence report in line with front line officers attending domestic abuse incidents and discovering potential child protection concerns.  All GP practices now have an identified named GP lead for safeguarding.  Additionally the Designated professionals and Named GP run quarterly safeguarding forums for GP leads and Practice Managers to support with safeguarding arrangements within each practice and to update on learning from SCRs.    GP practices are being encouraged to hold Monthly Multi Disciplinary Team meetings within their practices to discuss any safeguarding concerns identified. These include the HV and Midwife.  Version 29.2.16  30   An electronic template has been created to embed into System One (the clinical computer system used by all GP Practices within Milton Keynes) to support GP’s in identifying and sharing information relating to known vulnerabilities and/or safeguarding concerns when a patient/ family transfers to a new GP Practice. 11    Recommendations 11.1. The final report was discussed at the MKSCB Board meeting and the following recommendations were identified as the key areas of focus arising from the learning: 11.2. It is recognised that actions have already been taken in relation to some of the individual agency's identified learning. In addition the agency reports included some recommendations which had largely been completed by the conclusion of the SCR.  11.3. The purpose of providing additional recommendations is to ensure that the MKSCB and all professionals in the partner agencies of the Board are confident that any areas identified as of concern in this review are addressed.  The MKSCB has considered the conclusions and learning from this review and after consulting with the Lead Reviewer have identified the overall significant learning points for the partner agencies of the MKSCB and made recommendations. These recommendations are designed to apply the learning from undertaking this SCR in such a way as to achieve the best outcomes for other children and their families in terms of informing and improving practice: 11.4. Overall Learning Points:  a. Professionals who mainly work with adults need to be able to understand the adult’s behaviour in terms of the impact it has on that adult’s child/children, evaluate it accordingly and act appropriately in order to ensure that the child/children are appropriately safeguarded. They in particular need to do so when concerns do not meet the threshold for intervention at level three of the MKSCB Levels of Need. They also need to see beyond the immediate or presenting issues; see the situation in the round; assess the context and the child’s as well as the adult’s needs effectively; understand and thoroughly address identified and assessed risks and ensure any plans appropriately address the whole situation on a multi-agency basis. To do this they need to understand the child’s lived experience, involve the wider family fully and recognise the risks inherent in doing so.  b. Staff across all agencies need to confidently and competently exercise “high support; high challenge” when engaging with adults; use respectful uncertainty in their interactions; recognise when engagement or its’ absence is creating risks for a child and ensure that empathy for an adult’s own challenges does not obscure a rigorous focus on those affected by those challenges.  c. All those agencies working with adults as well as children need to ensure frontline staff are properly supervised and good management oversight is in place to ensure that professionals retain objectivity, are able to have difficult conversations, challenge each other and constantly review their interactions with adults and their children in the light of changing circumstances and information    Version 29.2.16  31  11.5. Recommendations to address those learning points: a. That the MKSCB Neglect group extend their remit to become an early help development group.  Jointly working with MKSAB members, the group will develop tools to assist practitioners working with adults to better understand early help services for adults and children, and develop clear pathways for assessing a range of adult and children’s needs at the same time (a family focussed model of intervention). The toolkit will facilitate engagement that is holistic and assertive, based on a sound assessment of the whole context for that family, their strengths and those areas of risk that need addressing, and resulting in a plan for support and change.  b. The learning from this SCR is widely disseminated through learning events in each agency as well as through material provided by MKSCB. In addition MKSCB works with partners to develop common learning materials for each agency to utilise which provide tools, research evidence, intervention methodologies and standards for working in a “high support/high challenge” way with vulnerable adults who are also parents.  c. In addition partner agencies assure themselves, through their own quality assurance systems, that they have effective systems in place to ensure front line professionals receive appropriate supervision and management oversight, based on the multi-agency standards set by MKSCB 11.6 The outcomes the MKSCB want to see as a result: a. A clear framework for professionals working with both vulnerable adults and children who need early help that ensures adults know what is expected of them when they receive support, what needs to change and why, and that ensure children’s needs are central to decision making when meeting their parent’s needs.  b. A shared multi-agency set of tools and methodologies for family focussed restorative practice with vulnerable, challenging or hard to engage parents. This should lead to clear evidence from what those adults and their children tell us, that whilst they may not like everything they hear, they feel supported and are clear about what is expected of them.  c. Evidence from audits and reviews of practice that Milton Keynes has confident, competent and well supported front line professionals who work with adults as well as children; who engage in good disagreements; have difficult conversations and understand how to engage with and support families through high support and high challenge; and where the plans in place clearly improve children’s life chances and outcomes effectively and safely.     