Serious head injury of a 6-month-old baby boy in December 2010. Examination revealed that Bobbie suffered permanent hemiplegia as a result of his injuries. Mother's partner was given a custodial sentence in relation to the incident. Mother was 19-years-old when Bobbie was born and initially concealed her pregnancy. Bobbie was seen by a number of medical practitioners in the weeks before the incident for various injuries. Identifies key learning points and emerging issues, including: need for greater professional awareness of issues related to concealed pregnancies; and need to ensure that childminders receive support and child protection training. Makes various recommendations.
      
 Title:  Serious case review: in respect of Family S4. LSCB: Dorset Safeguarding Children Board Author: Ghislaine Miller Date of publication: 2014  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.                           Family S4 Serious Case Review Overview Report             Serious Case Review  Overview Report for Publication In Accordance with the Requests of Working Together 2010    In respect of   Family S4     Review Initiated: February 2011 Criminal Proceedings: December 2010 – July 2013 Review Published: 13 January 2014       Report Author: Ghislaine Miller BA MA CQSW AASW   Family S4 Serious Case Review  Overview Report   Page2  CONTENTS              Page    OVERVIEW REPORT    1. Introduction, Terms of Reference and Serious Case Review process 3-8   2. Genogram 9   3. Family and Professional Context 10-13   4. What Happened? History of Professional Involvement    13-21 5. Analysis of Practice   21-40 6.  Key Learning Points and Emerging Issues 40-46   7. Conclusions 46-48        8. Overview Report recommendations 48-50   9. Report Addendum: what actions have been taken in response to the findings? 51-52    All names within the report have been changed in order to protect the identity of the people involved. Pseudonyms have been used for the family.         Family S4 Serious Case Review  Overview Report   Page3  OVERVIEW REPORT  1.0 INTRODUCTION   1.1  Two days before Christmas, Bobbie was admitted to Hospital 1 after being first taken to GP Practice 1 that morning. Jemima and her boyfriend, Stephen were concerned that Bobbie was floppy and unresponsive and had been ill during the night with sickness and diarrhoea. The GP did not at that point identify any signs of non-accidental injury, but there was a query about meningitis.      1.2  Shortly after admission to Accident and Emergency at Hospital 1 Bobbie had a small seizure and continued to have several more that day. Throughout the day tests were carried out on him, and late that evening arrangements were made to transfer him to Hospital 3 after a CT scan had shown abnormal results.   1.3  On Christmas Eve the CT scan results were reviewed by a medical professional and it was considered that they showed a subdural bleed. A differential diagnosis that included the consideration of a non-accidental injury was made, and a skeletal survey was undertaken. The hospital informed Children’s Services Out Of Hours Service (OoHS) who in turn informed the Police Child Abuse Investigation Team (CAIT).    1.4  The following day, a meeting involving the two CAIT Police Officers and two medical professionals from Hospital 3 took place. Jemima and Stephen were interviewed at home later that day by the Police.   1.5  The following day, the Paediatric Neurologist at Hospital 3 concluded and recorded that the injury was non-accidental. The family was not previously known to Children's Services Social Care (CSSC).  1.6  Three days later, a strategy meeting took place at the hospital. This was the first normal working day after the Christmas holidays.  1.7  It was later established that Bobbie had suffered permanent hemiplegia. He was taken into care (section 20) following his discharge from Hospital 3 and was placed with foster carers. Care Proceedings were initiated and included the new baby (half sibling to Bobbie). Both children are now subject to Care Orders to the local authority. Jemima and Stephen have since ended their relationship. Stephen is currently serving a custodial sentence in relation to the injuries Bobbie sustained.  Following an assessment undertaken whilst Jemima and both the children lived in a foster placement, Jemima has now returned home and both the children are living at home with her under the Care Planning, Placement and Case Review (England) Regulations 2010.    Family S4 Serious Case Review  Overview Report   Page4  Terms of Reference 1.8  To establish the events and circumstances relating to Bobbie, and to review the information known to Local Safeguarding Children Board (LSCB) agencies and actions taken by them. This should include the period from the confirmation of the pregnancy to the date of admission to Hospital 3.  The terms of reference were extended by five days following a discussion at the Serious Case Review Panel  (SCRP) where it was agreed that matters surrounding notifications following Bobbie’s injury and subsequent strategy meetings, needed further exploration. Where relevant historical information outside of the identified timeframe is available and pertinent to the review, this should also be included.  1.9  To establish the history of agency involvement with Bobbie and/or his  parents/ carers in order to understand the family circumstances. Specific consideration should be given to the following areas where applicable: • Information sharing - inter-agency and inter-disciplinary and including between GP surgeries • Quality/robustness of assessments undertaken - including whether mother’s learning difficulties were taken into account • The information that was known about/assessed relating to mother’s partner • Consideration of whether safeguarding issues were considered as part of the diagnosis and if so, whether the action taken was therefore appropriate • Timeliness of referral to other agencies – specifically to the police and social care • Accuracy and quality of record keeping  1.10  To determine if practice was sensitive to the racial, cultural, linguistic and  religious identity and any issues of disability of the child and family, and  determine whether they were explored and recorded.  1.11  To take account of findings of each agency’s IMR, and review how inter- agency working accorded with the inter-agency safeguarding procedures.  1.12  To take account of any relevant lessons from research (including the biennial overview reports of serious case reviews) and any relevant recommendations from previous serious case reviews.  1.13  To consider the cultural and organisational climate of the agency and the extent to which this affected practice within and between agencies, leading to an understanding of why actions were or were not taken.  1.14  To ascertain to what extent each agency fulfilled its statutory Responsibilities to safeguard and promote the welfare of children, highlighting examples of best practice as well as areas of concern.  1.15  To provide feedback to a senior manager of a specific agency about any important issues which arise from the overview process, which may not  Family S4 Serious Case Review  Overview Report   Page5 have been known or addressed in the individual agency review report.  1.16  To establish whether the inter-agency safeguarding procedures were adhered to and whether any changes are necessary in relation to these or in the guidance or training associated with them.  These should be divided into two categories: � Non adherence to practice guidelines contained within the inter-agency safeguarding procedures � New areas for policy development   The Serious Case Review Process 1.17  The case was referred to the SCRP by the Designated Nurse Consultant for Safeguarding Children. The SCRP met within the timescale laid down in Working Together and concluded that “given the severity of the injuries to Bobbie and the concerns about inter-agency working that the criteria for conducting a SCR were met and that a recommendation should be made to the LSCB Chair that a serious case review should be conducted”. The recommendation of the SCRP was endorsed by the LSCB Chair and an Independent SCRP Chair appointed on the same day.   1.18  Terms of reference were agreed by the SCRP members and were used as a key document at a briefing for IMR authors.     1.19  Panel membership consisted of: Jane Wonnacott, Independent Chair Safeguarding Manager, Children’s Services Business Manager, Local Safeguarding Children Board Detective Superintendent, Police Principal Inspector for Inclusion, County Council (attended meetings between April and July 2011 and then withdrew due to retirement).  Designated Nurse Consultant (Health Overview Author) Consultant Community Paediatrician, Hospital 2.  1.20  Ghislaine Miller, Independent Consultant and Director of Ghislaine Miller Consultancy Ltd. was commissioned as Overview Author and attended all subsequent meetings with a remit to question, understand and challenge.  1.21  The Overview Author qualified as a social worker in 1976 and has an MA in Social Work and an Advanced Award in Social Work. She has significant experience in the work of Local Safeguarding Children Boards and Serious Case Reviews and is an accredited Overview Author, accredited in October 2010 by the Tavistock Consultancy, London Safeguarding Children Board and Department for Education. She is also a trained Lead Reviewer for Learning Together SCIE (Social Care Institute for Excellence) reviews, which adopt a systems methodology. The author is completely independent, having never worked in or for the local authority, and with no prior knowledge of or involvement in this case.     Family S4 Serious Case Review  Overview Report   Page6 1.22  IMR reports were commissioned from the following: • NHS Dorset • Dorset Community Health Services • Dorset County Hospital NHS Foundation Trust • NHS Bournemouth and Poole GP services • Dorset County Council Children’s Services: Integrated services: Early Years (children’s centres)* • Dorset County Council: Children’s Services Social Care** • Dorset Police** • Borough of Poole** • Southampton General Hospital**  • Poole Hospital **  *At an early meeting of the SCRP it came to light that an IMR was needed from the Early Years Service as the baby had been cared for by a childminder for four hours one morning a week for a period of three months.  An IMR was commissioned by the SCRP chair from the Early Years Service the following day.   **At a subsequent meeting of the SCRP it was agreed that a report for information would be requested from CSSC and the Police in relation to events surrounding the five day period commencing on Christmas Eve with a telephone call to Local Office 1 by the child protection nurse from Hospital 3 and her subsequent telephone call to the OoHS and their telephone call to the Police Child Abuse Investigation Team (CAIT). A report from CSSC was received by the SCRP and this, combined with verbal information from the Police was discussed at the next SCRP meeting. It was agreed that the issues concerning the notifications (to the OoHS by Hospital 3 and to the Police and CSSC by the OoHS) and the subsequent strategy meeting warranted further exploration and that the terms of reference for the SCR should be extended by five days (the date of the strategy meeting). The reason for this was to ensure that appropriate action had been taken to safeguard the baby at that point. The impact of this was that four additional IMR reports needed to be commissioned from the Police, CSSC, the Borough managing the OoHS), and Hospital 3.       1.23  The SCRP met on nine occasions from February 2011 onwards. The original deadline for completion of the review was 18 August 2011 but it was agreed at the meeting on 24 May 2011 that this submission date should be revised to 29 September 2011. The submission date was revised twice more, at meetings on 24 August 2011 (revised submission date of 16 December 2011) and 9 November 2011 (revised submission date of 1 March 2012).  The reason for this was that whilst it had been the intention throughout to involve the parents in the SCR process (they had been written to by the SCRP Chair on 7 June 2011) it was agreed that it would not be possible to visit them until the SCRP had clarification on any possible criminal proceedings. A definitive position statement from the Crown Prosecution Service (CPS) had been expected in July 2011 but this  Family S4 Serious Case Review  Overview Report   Page7 was delayed to September 2011 and then November 2011.   1.24  The Overview Report and Executive Summary were endorsed by the LSCB on 1 March 2012 and submitted to Ofsted the following week on 8 March 2012, with the caveat that the Overview Author had been unable to see the parents and include their views in the report but that once the criminal proceedings were concluded they would be invited to meet with the author and their views would then be presented to the LSCB.   1.25  Quality Assurance has been built into process through:  • Briefing for IMR authors by the SCRP Chair that clarified the terms of reference and ensured that authors were clear about the task and what was expected of them regarding the terms of reference, Working Together and Ofsted descriptors, and setting clear timescales.    • In most cases IMR authors presented their reports to members of the SCRP and other IMR authors, which enabled panel members to ask questions regarding omissions, discrepancies in information and provided an opportunity for emerging issues to be discussed.  This discussion provided an early opportunity to identify lessons for learning that could be used to improve practice.  • At SCRP meetings members conducted a quality assurance exercise on each of the IMR reports to identify whether the report met the standard outlined by the Ofsted indicators and highlighted areas that needed amendment, or further clarification. Further work (for example clarification, further exploration of particular issues, ensuring that the recommendations flowed from the analysis and were SMART) was requested by the SCRP on the following reports: Early Years (childminder and children’s centre involvement), (OoHS), Hospital 3, Police, NHS Dorset, County Hospital, Dorset Community Health Services, Poole Hospital and Children’s Social Care. This additional work was completed within the requested deadlines.   • All IMRs were quality assured and signed off by the Chief Executives of the respective organisation before submission to the SCRP.   Family Involvement    1.26  The Independent SCRP Chair wrote to Jemima and Stephen on 7 June 2011 notifying them that a SCR had been commissioned and that the Overview Author would contact them at a later date to seek their views. It was agreed by the SCRP that there would be no contact with them until after the criminal proceedings had been completed as the Police had requested “no interviews are carried out with the parents until the criminal investigation is complete.  Family S4 Serious Case Review  Overview Report   Page8  1.27  Both Jemima and Stephen were written to after the criminal proceedings had been concluded. There was no reply from Stephen, but Jemima did reply and was seen at her home by the Overview Author and a senior manager from Children’s Social Care on 14 August 2013.   1.28  She described how difficult the time of the criminal proceedings was for her and her family, but that all charges against her were dropped before the matter went to court.  On reflection she wishes professionals had been more challenging with her about the injuries to the baby, which she viewed as a series of unconnected incidents. She said she was unaware of the concerns of professionals.  1.29  Attempts have been made to contact Stephen by letter and telephone, to offer him an opportunity to meet with the Overview Author, but there has been no response.  1.30   Legal Services have tried unsuccessfully to make contact with Bobbie’s putative father.    Family S4 Serious Case Review  Overview Report   Page9 2.0 GENOGRAM (as of the time of writing)                   Maternal Grandmother Maternal Grandfather Mother Mother’s Sister Mother’s Sister Mother’s Ex-Boyfriend Half Sibling Putative Father Bobbie  Family S4 Serious Case Review  Overview Report   Page10   3.0 FAMILY AND PROFESSIONAL CONTEXT    Family Context 3.1  Jemima was nineteen when she became pregnant with Bobbie. The  pregnancy was described as “concealed” as Jemima did not  have it confirmed until she was approximately 33 weeks pregnant, having told her mother about it a few days previously.  She told the Overview  Author that she knew she was pregnant, but living in a small village,  wanted to keep it to herself for as long as possible. However, one day someone came into the shop where she worked and asked her when the baby was due and she said she realised that she now needed to tell her  mother. She is White British and at that time was living with her parents  and two younger siblings. Little appears to have been known or recorded about the family history and home circumstances.   3.2  For the first five months following Bobbie’s birth, Jemima continued to live in the family home, joined at some point by Stephen (she later told the  Police she had met him through an Internet dating site). Jemima had lived  all her life in this small village in Area 2.  Jemima moved out of the family home for the first time, at the age of  twenty, with Bobbie and Stephen when they were rehoused in Area 1, a  larger village 7/8 miles away. This was her first move away from her parental home, into a new village, with the added stress of a new baby and a new relationship. Nothing is known about the support systems she had in Area 1, or the on-going support she received from her family after she had moved out of the family home.   Professional Context Health 3.3  Jemima was known to two GP surgeries. She had been registered with GP Practice 1 since she was a child and it was there that she had her concealed pregnancy confirmed.   3.4  She received antenatal midwifery care from the midwives employed by Hospital 2, but delivered the baby at Hospital 1. The health visiting service was based at GP Practice 1 and consisted of one health visitor, and a health visitor assistant.  3.5  When Jemima, Stephen and Bobbie moved to Area 1 they did not immediately register with the GP Practice 2 and continued to visit GP Practice 1. The only occasion they visited the GP Practice 2 was when they took Bobbie and asked for him to be seen by a doctor as he had been found in his cot that morning with “blood all over his pillow”. Bobbie was seen by the Locum GP following registration with the practice. Neither Jemima nor Stephen were registered with the surgery, despite taking the  Family S4 Serious Case Review  Overview Report   Page11 forms to complete.    Children’s Services (which includes Children’s Services Social Care, the Early Years Service and the Out of Hours Service) 3.6  Children’s Services had had no involvement with this family prior to the telephone call from Hospital 3 on Christmas Eve.  Bobbie spent a morning a week with a childminder from the age of three months until the injury; a period of about three months. The Early Years Service had some responsibilities in relation to childminders, so the childminder would have been known to EYS.    3.7  Jemima had attended two children’s centres: one where she attended antenatal appointments with the midwife on two occasions and the other where she attended a young parents’ group with Bobbie on two occasions. These children’s centres were managed by the EYS.  Childminding 3.11 The Early Years Directorate of Ofsted, the Office for Standards in Education, took over responsibility for the registration and inspection of childminders in England in 2001. Prior to this, this was the responsibility of the local authority through their Under 8’s service (previously under 5’s).     3.12 The childminder in this case was originally registered in 1983 and would have therefore originally have been registered and inspected by the County Council Under 8’s service by their Under 8 Officers. Their function was fulfilled through making unannounced visits to registered childminders every six months as well being available and accessible to offer advice and support. She had also previously been a foster carer.  3.13 The Ofsted Inspection process that has been in place since 2001 is that registered childminders (those who take children under 8 and are registered on the Early Years Register) are inspected once every 3-4 years. The childminder in this case is registered to care for up to six children under 8 at any one time. She was inspected by Ofsted in 2005 and 2009 and was graded as “good”.   The Role of Children’s Services, Early Years Service in Relation to  Providing Support and Training for Registered Childminders   3.14 Childminders in Dorset are supported by the local authority Early Years and Childcare Service Team (EY&CCS), and by the local branch of the National Childminding Association, as a commissioned service. Children’s Centres also have a remit to offer support for childminders. Between 2001- 2007 European Social Fund financial support enabled the establishment of the local Childminding Association; a third sector organisation. This provided, through its employed advisers, support visits to childminders every few months, as well as regular training and support sessions. The childminder in this case did receive this support between 2001 and 2007 and was part of the local childminding network during that time.   Family S4 Serious Case Review  Overview Report   Page12 3.15 Since 2007, the authority’s EYS has worked in conjunction with the National Childminding Association (NCMA) to provide packages of support through the local Quality Improvement Scheme (DQIS). All local childminders are part of the DQIS unless they “opt out”. Currently the authority’s EY&CCS staff support childminders when they are first registered. The National Childminding Association sees childminders who attend DQIS sessions or training, but their responsibility to childminders is ring fenced to those who have received a “good” or “outstanding” grading from their Ofsted Inspection, or those who choose to become quality assured. At this point a NCMA Childminding Co-ordinator visits them to establish their suitability and then subsequently makes home visits to assess their practice and agree a programme for their professional development. Support visits to the childminder would be a minimum of 1 “contact” with the childminder per year (this could be a telephone call) plus 1 visit in the 6 months prior to the childminder’s next Ofsted Inspection (every 3-4 years). Other childminders who do not achieve the status of “good” or “outstanding” are supported by the local Early Years Team.      3.16 If the childminder elects not to take up the opportunity to become Quality Assured, then they do not receive the minimum annual contact, but are still offered the chance to have a home visit in the 6 months prior to their next Ofsted inspection.  The childminder in this case decided not to become Quality Assured as she felt “that there was too great an emphasis on paperwork” (Early Years IMR, paragraph 9.40). She also decided not to take up the support available from her local children’s centre. She last attended Safeguarding Training provided through the EYCCS in July 2008 and that is within the expectation of attending training every 3 years. This would have been a two and a half hour training course (see section 5.76 on Management and Supervision issues in relation to the childminder).      Children’s Services:  Out of Hours Service 3.17 The OoHS in this authority is provided through a service commissioned in conjunction with two other neighbouring authorities. It is a service commissioned “to provide emergency cover and access to essential social work services outside of the main local office/daytime services working hours” (Joint Agreement between the three authorities dated January 2011).     3.18 “OoHS social workers are recruited as qualified and experienced practitioners who can function at a senior practitioner level. They have delegated responsibility for decision making on cases, which in daytime services might fall to senior practitioners and team managers. They are required to refer higher level decisions and serious incidents to senior operational managers in day time services and have contact details to do this. “ (OoHS IMR, paragraph 7.26)     Police 3.19 The local arrangements for investigating safeguarding concerns (children,  Family S4 Serious Case Review  Overview Report   Page13 adults and domestic violence) are via a co-located Safeguarding Referral Unit and two geographically based Child Abuse Investigation Teams (CAIT).   4.0 WHAT HAPPENED? HISTORY OF PROFESSIONAL INVOLVEMENT   Professional Involvement during the Antenatal Period  4.1  When Jemima saw GP 1 at Practice 1 to have her pregnancy confirmed the GP described it as a “concealed pregnancy that was fairly well advanced”. The GP also noted that Jemima had told the maternal grandmother of the pregnancy a few days before. Jemima was 19 years and 10 months old at this time.  4.2  When Jemima had her first appointment with Community Midwife 4, Area 5, linked to GP Practice 1 blood samples were taken, an ultrasound was booked for the next day and a social screening questionnaire was completed. No information was recorded about the baby’s father or the reason for the concealed pregnancy.  4.3  The following day Jemima had an ultrasound at Hospital 1 Maternity Unit that showed her to be approximately 33 weeks pregnant.   4.4  One month later Jemima was seen again by Community Midwife 4 at GP Practice 1. She also saw the health visitor at GP Practice 1 that day. Jemima was accompanied by maternal grandmother. Jemima told the health visitor that she would inform the baby’s father about the baby after the baby was born.  4.5  Jemima was seen on a weekly basis by the midwives involved. On two occasions she attended the ante-natal clinic that was held at Children’s Centre 3.     The Birth and Post Delivery Professional Involvement 4.6  Bobbie was delivered by emergency caesarean section due to foetal distress. He had initial trouble breathing and was given “rescue breaths”, but he “was subsequently well enough to go to the postnatal ward with his mother”. He was initially breast-fed but by the following afternoon his breathing was causing concern (fast and shallow) and he was transferred to the Special Care Baby Unit (SCBU). The Consultant Paediatrician took blood tests and cultures and the differential diagnosis was sepsis, or pneumothorax. Bobbie was given intravenous antibiotics and his respiratory symptoms settled. He remained on the SCBU for 3 days until he was transferred back to the main unit. The results of the blood tests and cultures were negative.          4.7  The following day a student midwife requested a medical review of Bobbie as she noticed he had become more floppy and sleepy during the evening. The examination showed that he had had mild jaundice, but was well apart  Family S4 Serious Case Review  Overview Report   Page14 from that.  4.8  The following day Jemima requested to be discharged home, and that was done, following her medical review being completed by the Senior House Officer.   4.9  Jemima and Bobbie were seen at home by a community midwife the day after discharge, who recorded that the jaundice was improving, the baby was feeding well, although Jemima expressed concern about breast feeding and was given “further advice” although it was not specified what this was. Jemima was seen the following day and two days after that by community midwives. By the last of these visits it was noted that Jemima was supplementing breast feeds with bottle feeds, but was using baby formula that was not suitable for newborn babies. The midwife advised her of a more appropriate formula to use.      4.10  Three days later the health visitor from GP Practice 1 made her primary post delivery visit to Jemima and Bobbie, and observed good bonding between them. The health visitor recorded the home circumstances: that Jemima and the baby were living with her parents and sister. The house was described as “well lived in, but all the basics are in place”. Jemima and Bobbie had their own room and Jemima said she wanted to continue living with her family. She told the health visitor that the baby’s putative father (not Stephen) had not been aware of the pregnancy and that he had moved away and changed his number. Jemima was encouraged by the health visitor to attend a young parents’ group.  4.11  The following day, the final midwifery visit was made. Bobbie was described as being “alert and thriving” and they were discharged to the care of the health visitor, who had visited the day before.  4.12  The health visitor continued to visit Jemima and Bobbie on a regular basis. During the visit when Bobbie was 6 weeks old, Jemima told the health visitor that she wanted to return to work for a few hours a week and that maternal grandmother would look after Bobbie. (In fact the combined chronology details that Jemima and maternal grandmother had already visited the childminder and made arrangements for Bobbie to go there).   4.13  Two days later, Jemima and Bobbie visited GP Practice 1 for the 8-week check. The GP recorded that the baby was having a mixture of bottle-feeding and breast-feeding, and that contraception was discussed. Thirteen days later, Bobbie received his first immunisations at GP Practice 1.     4.14  When Bobbie was 12 weeks old, the health visitor did a home visit. This was not a routine visit, but a “support visit” triggered by the health visitor’s concern that Jemima had returned to work so early after the birth of Bobbie (Dorset Community Health Services IMR, paragraph 5.7).  Jemima told her  Family S4 Serious Case Review  Overview Report   Page15 that she was feeling “crowded” by the current housing arrangements. She had returned to work and maternal grandmother, her boyfriend and the childminder were sharing the care of Bobbie. It would appear that the boyfriend had already moved into the family home at this point, but this was not made explicit until the following week when the health visitor wrote a letter to the local Housing Partnership, supporting an application for re-housing by mother. The letter described that Jemima, her boyfriend and Bobbie all shared a bedroom in the family home.     4.15  Bobbie was 12 weeks old when he received his second set of immunisations at GP Practice 1. That same day, Jemima took him to a young parents’ group at Children’s Centre 1 for the first time. The Children’s Centre is managed by the Early Years Service. Jemima was reported as being quiet, but attentive and responsive to Bobbie and his needs. She attended again three weeks later and the centre manager wrote a letter to the Housing Partnership, to support Jemima’s housing application. Bobbie was 15 weeks old at this time.    4.16  The following week, Bobbie received his third set of immunisations at GP Practice 1. This was in line with recommended timescales. On the same day the health visitor saw Jemima, Bobbie and Stephen at the surgery for the Bobbie’s four-month check. It was noted that they were still living with maternal grandparents and that the cramped home conditions were causing them stress. Jemima and Bobbie were reported to be attending the young parents’ group on a regular basis (they had been twice). Bobbie’s development was recorded as age appropriate. About three weeks later Jemima, her boyfriend and Bobbie were re-housed to Area 1.   4.17  A few days later, Bobbie, (now 20 weeks), arrived at the childminders with a bruise on his cheek. The explanation given, and recorded in the childminder’s diary, was that he had fallen forward and hit his head on a toy. This explanation was accepted by the childminder. The childminder also recorded “Baby is fine in himself”.   4.18  Ten days later, Bobbie was taken to the GP Practice 1 and seen by GP 1. He had a slight bloody discharge from his nose. The GP diagnosed a slight infection and prescribed some cream.   4.19  Four days later, when Bobbie was taken to the childminder’s, she noticed faint bruising to the side of his face. Jemima’s explanation for the injury was accepted by the childminder and recorded in the childminder’s diary, although she did not record what Jemima’s explanation was. Bobbie was 22 weeks old at this time.       4.20  Jemima did tell the childminder about the baby having a bloody discharge from his nose and she gave the cream to the childminder to apply to Bobbie’s nose. She also told the childminder that she had moved house.    Family S4 Serious Case Review  Overview Report   Page16 4.21  One week later, Bobbie was taken to the Accident and Emergency Department at Hospital 1. He had a large haematoma on his left temple. Jemima’s explanation was that the mobile hanging above the cot had fallen down into the cot and hit Bobbie on the head. She said she had not witnessed the event but heard him cry and then went to him. It is not clear who examined the baby. The hospital notes record “he was glanced at” by a Senior House Officer. It is recorded that Bobbie was alert and bright and responsive with no vomiting or lethargy, but it is not clear who made this assessment. It was then recorded that “Mum happy to take him home as department busy”. Jemima was given a leaflet on head injuries and told to return if she had any concerns. They had waited over an hour to be seen as the department was busy but were seen for a total of only 15 minutes.       4.22  Three days later, the GP at GP Practice 1 received a letter outlining the visit to the Emergency Department. It outlined that no investigations had been performed, and the diagnosis was that of a head injury. This letter was not passed on to the health visitor who was based in the same building.     4.23  The following day, Jemima collected Bobbie early from the childminders. She was tearful and unwell and was critical of the lack of support from Stephen. The childminder offered to keep Bobbie for longer to give Jemima a break, but she declined.   4.24  Three days later, the health visitor from GP Practice 1 went off sick. She was the only health visitor in the surgery (there was a health visitor assistant). She was off work for several weeks. In the meantime, cover for her post and her duties was provided partly through a voluntary arrangement with other health visitors based at other surgeries and partly by the health visitor assistant. The impact of this was that there was no one to deal with notifications from Accident & Emergency (see below) or run the baby clinic.     4.25  A few days later, the health visiting service at GP Practice 1 received a notification from Accident & Emergency about the Bobbie’s attendance ten days earlier. This was a separate notification to the one sent to the GP.  In the absence of the health visitor, the health visitor assistant date stamped the notification but there was no response to the issue raised by the notification and it was not responded to until the health visitor returned a few weeks later.    4.26  A few days later, when Bobbie was at the childminder’s, two of his bottles of milk (brought in by Jemima) curdled when heated up. The childminder contacted Jemima who was requested to bring in two more bottles, which she did.    4.27  At the age of 26 weeks old, Jemima and Stephen took Bobbie to GP Practice 2 in the morning. They said they had recently moved into the area  Family S4 Serious Case Review  Overview Report   Page17 and asked for Bobbie to be seen by a GP as Jemima had found him with blood on his face and over his pillow when he had woken that morning. They registered the baby as a patient at the practice and he was then seen by the Locum GP. The Locum GP later confirmed in interview that he examined Bobbie thoroughly and that Jemima’s explanation for the cut to the tongue which had caused the bleeding was that she thought the Bobbie had “likely chewed on a toy or something similar” and that this explanation was not questioned, although the GP said later in interview that his “gut feeling” told him that something was not right. He thought the baby might be underweight and advised Jemima to see the health visitor the following week to have the baby weighed and to bring him back as soon as possible if there was any further bleeding from his tongue. Jemima did not tell the Locum GP that she had taken the Bobbie to see GP1 at Practice 1 a few weeks earlier with a bloody discharge from his nose, nor that he had been taken to Accident and Emergency three weeks earlier with a head injury, that they said had been caused by his mobile falling on him in the cot.       4.28  Three days later, Bobbie was taken early in the morning to GP Practice 1 by Jemima and Stephen and was seen by GP 1. The GP IMR outlined that this would have entailed “a journey of 8 miles down an icy/snowy road to Area 1” when in fact GP Practice 2, at which the baby was now registered, was “approximately 350 yards away” from where they lived. Given that they said that he had been ill during the night, it would have been easier and quicker to take the baby to GP Practice 2 when it opened at 8.30am that morning.    4.29  Jemima and Stephen told GP 1 that Bobbie had been well the day before but had been unwell during the night and had vomited several times. They mentioned that he had fallen off the sofa a few days before but “seemed fine”. When the GP examined Bobbie, she found him to be dehydrated and he could not hold his head up. She arranged for him to be admitted to Hospital 1 and Jemima and her Stephen agreed to take him there straight away. Jemima told the Overview Author that her father was with them and he had a 4x4 vehicle and given that there was a lot of snow on the ground, it was agreed by all (including the GP) that the best course of action was for Bobbie to be taken to hospital in this vehicle. There was concern that an ambulance would not be able to get through to them, given the snow.  4.30  Bobbie was seen by a Consultant Paediatrician at Hospital 1. He had a seizure lasting 1 minute. Jemima had said that Bobbie had been fed four times during the night but had vomited during each feed. Since midnight his head had been turned to the right and he was more floppy than usual. For the past hour his right arm had been in the flexed position. Bobbie underwent a variety of tests and a CT scan. By the afternoon the consultant had contacted a Consultant Paediatric Neurologist at Hospital 3. Jemima, Stephen and maternal grandparents were all at the hospital with Bobbie, who had several more seizures during the evening and was transferred to Hospital 3 late that night.   Family S4 Serious Case Review  Overview Report   Page18 4.31  The following day, (Christmas Eve), the CT scan results were reviewed by the Consultant Paediatric Neurologist at Hospital 3 and it was considered that they showed a subdural bleed. A differential diagnosis that included the consideration of a non-accidental injury was made, and a skeletal survey was undertaken.   4.32  Just after midday on Christmas Eve the child protection nurse from Hospital 3 telephoned CSSC Local Office 1 and spoke to the duty administrator as the duty team manager and social worker were both involved in other child protection matters and were not available. She wanted to inform them of the Bobbie’s admission to hospital, enquire whether the family were known and ask what arrangements were in place if this case developed into a child protection matter given that it was Christmas Eve and the CSSC offices were closing at 1pm. The call was logged by CSSC Local Office 1 as a “contact” and the outcome was “no further action”.   4.33  Approximately half an hour later, the duty social worker from Local Office 1 telephoned the child protection nurse at the Hospital 3 to confirm that the family were not known and how to contact the OoHS during the holiday period. The duty social worker then sent a handwritten fax from Local Office 1 to OoHS, alerting them about the telephone call and that it had been “closed as a contact”. It contained the personal identification number allocated to the case on the basis of the telephone call, which would enable OoHS to access the electronic records created on RAISE (the electronic database). The fax itself did not give any reason for the telephone call from Hospital 3.      4.34  The child protection nurse from Hospital 3 telephoned the OoHS a few hours later and spoke to Social Worker 1. Social Worker 1 then telephoned the nurse in charge of the intensive care unit at the Hospital 3. On the basis of these two telephone calls, that had provided additional information about previous incidents involving the baby, a faxed referral was sent to the OoHS by the child protection nurse at the Hospital 3. This fax constituted a formal s47 referral and included a request for an s47 strategy meeting “after the Bank Holiday”.  4.35  Following receipt of this faxed referral, the OoHS Social Worker 1 checked the electronic records and ascertained that there had not been any previous involvement with CSSC. She completed the paperwork to enable the referral to be logged as a Child Protection Enquiry.   4.36  Shortly afterwards OoHS Social Worker 1 contacted the Police CAIT and spoke to DS CAIT Team. He conducted Police checks on Jemima and Stephen and confirmed that they had no previous records. A discussion took place between OoHS Social Worker 1 and DS CAIT Team that concluded that as the nature of the baby’s illness had not been confirmed (that is whether it was meningitis or a non-accidental injury) that no action  Family S4 Serious Case Review  Overview Report   Page19 would be taken by them at this time. It was agreed that they would telephone Hospital 3 for an update the following day. This discussion and decision making was not recorded as a strategy discussion. Shortly afterwards, the Police formally allocated the case to the CAIT.  4.37  The next morning, (Christmas Day), the Police incident log was updated. The Police had agreed that the case would be dealt with under the Sudden and Unexplained Death in Infants procedures (SUDI), “on the basis that the child was in a critical condition” and they would need to secure evidence in case the baby died. Later that day, they requested that a strategy meeting was convened that day, to include the Paediatric Consultant, the Police and CSSC (Police IMR, paragraph 7.11). There is evidence from the Police IMR that at this stage, they thought that the SUDI protocol and S47 Enquiries were running in tandem at this point and that the strategy meeting would be under section 47.      4.38  Shortly afterwards, DS CAIT telephoned OoHS Social Worker 2 and informed him that the Police were planning to follow the SUDI procedures. They agreed that the OoHS social worker would contact Hospital 3 and then give feedback to the Police.  4.39  OoHS Social Worker 2 then telephoned Hospital 3 and spoke to the Paediatric Consultant. The OoHS Social Worker 2 was told and recorded that “initial view is that this is not a classic presentation of non-accidental injury, but this cannot be ruled out” (OoHS IMR, paragraph 6.12). The Consultant agreed to review the notes and contact OoHS later that day. The OoHS Social Worker 2 faxed a report outlining all of this to DS CAIT.    4.40  DS CAIT then telephoned OoHS Social Worker 2 and informed him that CAIT officers would visit the hospital (that day) for a strategy meeting with medical staff and to interview Jemima and Stephen. The OoHS IMR states that it was agreed that this would be done as a single agency approach, as they understood this to be following SUDI procedures, but the reason was not recorded. The Police IMR states that the Police had requested a CSSC representative attend the meeting, but “OoHS explained that they were unable to attend” (Police IMR paragraphs 7.14 and 7.17). The inference is that it became a single agency enquiry as a result of CSSC being unable to attend, and that this is something the CAIT officer involved had agreed to.     4.41  On the afternoon of Christmas Day, a meeting took place at the hospital, attended by Police and medical professionals. The Police had hoped that this would be a strategy meeting, but as there was no CSSC representative from OoHS present it could not be. There was no record of the meeting. After the meeting, the Police and one of the medical professionals “interviewed” Jemima (Police IMR paragraph 7.21). There is evidence that at this point, the medical professional “explained that he felt the injury was now even more likely to be non-accidental injury” (Police IMR, paragraph 7.21). Jemima was later seen by the Consultant and DS CAIT.     Family S4 Serious Case Review  Overview Report   Page20 4.42  DS CAIT later contacted OoHS Social Worker 2 to update him with this information. A CSSC “Record of a Strategy Meeting” was completed by OoHS Social Worker 2 on the basis of this discussion and recorded the action by the Police and this suggests that they did regard it as a section 47 Strategy Meeting, albeit, one they were unable to attend.     4.43  On the morning of Boxing Day an internal Police meeting took place that decided that Jemima and Stephen would be treated as “significant witnesses” rather than suspects at that time. DS CAIT telephoned OoHS Social Worker 3 later that day. He informed her that the Police had decided to video interview Jemima and Stephen at home, which they had agreed to. At this point there was no further action for OoHS and DS CAIT agreed to contact OoHS when there was a further role for them.  4.44  That same day health professionals at Hospital 3 recorded that they had reached the conclusion that Bobbie had “almost certainly been the victim of non-accidental injury”. This was based on the results of a skeletal survey and an ophthalmology review (carried out on Christmas Eve) and the absence of results, suggesting the baby’s condition was due to an infection.    4.45  They did not notify CSSC or the Police that they had reached this conclusion, although the Police had been given a sense that medical opinion was moving more in this direction at the meeting that had taken place the previous day (Christmas Day). However, there is no evidence that the Police shared this with the OoHS service when they telephoned them after the meeting to give them an update.  4.46  The paediatric neurologist informed Jemima that Bobbie had sustained extensive brain damage and “will have a movement disorder along the lines of cerebral palsy and a visual disorder as well” (integrated chronology). 4.47  The following day, DS CAIT telephoned the OoHS and spoke to Social Worker 4 to request a strategy meeting on the first working day after the Christmas break as he considered there was (now) sufficient concern about non-accidental injury.     4.48  At 7.11 am on the first working day after the Christmas break the OoHS sent a 13 page fax report to CSSC Local Office 1, outlining “OoHS involvement over the holiday period, to inform them of action taken and action needed” (OoHS IMR, paragraph 6.18). The report included a request that a social worker attended a strategy meeting at Hospital 3 that day. However, the fax machine had run out of paper and this went unnoticed until 11am.Once this was rectified, the duty team at Local Office 1 then became aware that attendance at a strategy meeting at 3pm had been requested. Due to resource shortfall issues, the team at Local Office 1 were unable to respond to this request and the case was transferred to a social worker in Local Office 2, as they had the resources to deal with the  Family S4 Serious Case Review  Overview Report   Page21 case and provide someone to attend the strategy meeting. (The resource issue was due to a reduction in staff because of annual leave, during the holiday period between Christmas and New Year).    4.49  That same morning, the Police had telephoned Local Office 1 to discuss the strategy meeting that afternoon. The response given by Local Office 1 to the Police was that they were “unaware of the case and they were unable to attend the strategy meeting” (Police IMR, paragraph 7.25). It seems the fax problem had not yet been resolved, so they were unaware of the developments in the case over the holiday period and the request for someone to attend the strategy meeting that afternoon. The Police made several calls to other CSSC offices and were later advised that someone from another area office would be attending the meeting (Police IMR paragraph 7.28).   4.50  The strategy meeting took place at 3pm that afternoon and was attended by the Police CAIT representative, the Consultant Neurologist from Hospital 3, the child protection nurse from Hospital 3 and the social worker from Local Office 2. The Police and CSSC agreed a plan of action that involved a formal joint section 47/criminal enquiry that was to be conducted.  5.0 ANALYSIS OF PRACTICE IN RELATION TO THE TERMS OF REFERENCE: ADDRESSING THE WHY? QUESTIONS    The Voice of the Child: what was daily life like for Bobbie? 5.1 There is evidence that Bobbie experienced a difficult delivery and respiratory distress in the first few days of his life. He was delivered by emergency caesarean section because of foetal distress. He was described as being in “poor condition at birth, requiring some resuscitation, but with a good response and a good early feed” (Maternity records, integrated chronology). The following day he again experienced difficulty breathing and was transferred to the SCBU. Blood tests, cultures (for infection) and neo natal x-rays were conducted and he was given antibiotics.  The test results came back negative 48 hours later and the antibiotics were stopped. There was evidence of normal lung development.    5.2 Bobbie was initially breast fed, but there is evidence that Jemima experienced some difficulties with this and so bottle fed to supplement his milk intake. However, she was using formula that was not suitable for newborn babies and was advised to change to a suitable formula and did so promptly. She was given “additional advice” about breast-feeding. There was evidence of “good bonding” between Jemima and Bobbie (health visitor’s first home visit) and that Bobbie was “alert and thriving” (midwife subsequent home visit).  5.3 By the time Bobbie was 12 weeks old, he was being cared for by multiple carers (Jemima, maternal grandmother, Stephen, the childminder and a  Family S4 Serious Case Review  Overview Report   Page22 friend of maternal grandmother), as Jemima had returned to work as a retail assistant.  There is no evidence that this had a negative impact on Bobbie. Jemima told the Overview Author that she had little choice but to return to work as soon as possible, as “money was tight”.        5.4 The childminder was the one professional who had the most contact with Bobbie and her records provide an insight into Bobbie’s daytime experiences. She described Bobbie as a “very laid back, relaxed baby, who tended not to get fretful or stressed, wasn’t nervous or easily startled (e.g. when other children were playing near him) and didn’t get upset or grouchy" (Early Years IMR paragraph 8.16). These are conveyed as positive attributes. However, a picture also emerges that evidences signs of neglect. She described how “Bobbie always smelt of cigarette smoke from the first time he attended and that his clothes were not dirty, but felt un-aired. It wasn’t unusual for Bobbie to need a feed or a nappy change when he arrived”. (Early Years IMR paragraph 8.15). There is evidence of a deterioration in the care he received after Jemima, Stephen and Bobbie moved out of the family home into their own accommodation, “she (the childminder) identified that although Bobbie’s responses didn’t change, his care appeared to deteriorate, for example, on one occasion when Jemima came in saying that Bobbie hadn’t fed since 10pm the night before, and when she’d bring him in with a nappy which looked like it hadn’t been changed since the evening before” (Early Years IMR, paragraph 8.17).    5.5 When Jemima was seen by the Overview Author in July 2013, she was angry about these comments made by the childminder, who had given evidence in the Care Proceedings. Jemima said that the childminder had told her “not to worry” if she did not have time to feed or change the baby in the morning before taking him to her (the childminder), as she would be happy to do these things once he had been dropped off.   How Jemima Presented Herself and was Perceived By Professionals 5.6 There is evidence that Jemima was perceived to be straightforward and reliable. However, there was a query about why she took the baby to GP1 when he sustained his serious injury. She had originally registered with GP1 at GP Practice 1 and then later registered Bobbie with GP Practice 2 when she moved into new housing with Bobbie and Stephen. However, when Bobbie was taken to the GP just before Christmas with what transpired to be a serious head injury, they took him to see GP 1 at GP Practice 1 and not the GP at GP Practice 2, where he had been seen by the Locum GP three days before. This would have involved a longer and more difficult journey, given the winter snow and a delay in getting the baby seen. Mother’s response to the Overview Author when asked why they took the baby to GP1 rather than GP2, was that GP2 had been rude to her when she had visited a few days before and that she liked and trusted GP1.  5.7 There is evidence that Jemima was selective in the information she shared  Family S4 Serious Case Review  Overview Report   Page23 with professionals when she sought medical advice about Bobbie’s injuries. For example, when she took Bobbie to the Locum GP at GP Practice 2 she did not tell him about the fact that they were already registered with GP Practice 1 and that she had taken Bobbie to see GP 1 at that practice when he had a bloody discharge from his nose. When she took Bobbie to see GP 1 at GP Practice 1 at Christmas she did not tell the GP about the visit to the Locum GP at GP Practice 2 or the visit to Accident and Emergency at Hospital 1 with a head injury.    What was Known By Professionals About Stephen? 5.9 Little was known about Stephen and that in itself is significant. It conveys a lack of professional curiosity on the part of professionals from universal health services and may be indicative of organisational cultures in those services that may see the role of fathers of babies as being incidental to the situation. There is evidence that Jemima was not forthcoming in her limited contacts with various health professionals and this may have been an additional barrier to gathering information about Stephen, her relationship with him, his relationship with her and more importantly with Bobbie.    The Quality and Robustness of Assessments Undertaken 5.10 Appointment with GP1 at GP Practice 1: Jemima’s pregnancy was confirmed at this appointment and routine health processes triggered, such as referral to the midwife. However, given that it was identified as a late and concealed pregnancy there was no gathering of information about the circumstances, the identity of Bobbie’s father and relationship issues that might have an impact on the pregnancy or Jemima’s health and emotional wellbeing. There is some evidence from the GP IMR that factors that contributed to this were the fact that maternal grandmother was present and that GP 1 saw it as the midwife’s role to gather this sort of information and assess the social situation.  5.11 Antenatal Assessment by Midwifery Service: the community midwife saw Jemima at GP Practice 1 on two occasions in the period following confirmation of the pregnancy. In between this she was seen at the maternity unit at Hospital 1. Despite this being a concealed pregnancy that was confirmed at 33 weeks gestation and despite Jemima telling GP 1 that she was scared of maternal grandmother, there is no evidence that an assessment of her vulnerability took place, the circumstances of her unplanned pregnancy, the identity of Stephen, the baby’s father and the nature of her relationship with him, the post-natal support she might need and any possible safeguarding risks to the baby.  5.12 Antenatal Appointment with the Health Visitor at GP Practice 1: an assessment was undertaken by the health visitor, when she saw Jemima during the antenatal period. There is evidence that she used the Assessment Framework model. However, despite this, there was still only a scant social and family history taken and outline of home circumstances.  Family S4 Serious Case Review  Overview Report   Page24 5.13 Post Natal Checks at GP Practice 1: assessments were made when Jemima was seen by at GP Practice 1 for her post- natal checks on three occasions. She was seen by a different GP on each of these three visits and on each occasion they discussed contraception, although there was still no information about Stephen or her relationship, or the relationship of Stephen with Bobbie. On the third visit, she was seen by GP 1 and said she was feeling tired. GP 1 “determined she was not depressed” (GP IMR, paragraph 6.3.4) but there is no evidence that there was any exploration of any stress factors that were having an impact on her physical and emotional wellbeing, such as the stress of parenthood, from returning to work and child care arrangements, or stress in her relationship.  5.14 Appointment with Locum GP at GP Practice 2: the Locum GP was disadvantaged because this was the first time that he had met Jemima, Stephen and Bobbie, because he did not have information to hand about any previous medical matters. Jemima withheld information about the visit to GP 1 at GP Practice 1 a month before when Bobbie had bleeding from his nose and the visit to Accident and Emergency two and a half weeks before with a head injury.    5.15 The Locum GP thoroughly examined Bobbie and thought him to be underweight and not only advised Jemima to bring him in to see the health visitor the following week to be weighed, but also emailed the health visitor the same day to arrange this appointment.   5.16 The quality of the assessment was limited in that it did not explore a  differential diagnosis that might include non accidental injury despite the  fact that the Locum GP later acknowledged a “gut feeling” that something  was not right. With hindsight it may be that the comment about Bobbie’s  weight and the advice about seeing the health visitor the following week  was a response to underlying child protection concerns, that if the Locum GP had been able to identify and acknowledge at the time, may have  resulted in a different outcome. For example, he may then have  telephoned GP Practice 1 and established the facts about the visit to GP 1 with the bloody nose and the visit to Accident and Emergency at Hospital 1 (the notification form had been logged on Bobbie’s file by the health  visitor assistant by this time). The matter was not helped by the  fact that there is no guidance available for GPs on bleeding in the mouth in non-mobile children.           5.17 The quality of the assessment may also have been influenced by the way Jemima and Stephen presented themselves. It is clear with hindsight that they were withholding information from the Locum GP, despite their apparent concern for Bobbie’s health. It is possible that they came across as reasonable and concerned parents and that the explanation given for the injury appeared plausible.    5.18 Visit to Accident and Emergency at Hospital 1: there is evidence that the  Family S4 Serious Case Review  Overview Report   Page25 assessment of Bobbie was inadequate, especially given that the staff in the department had specific guidance on head injuries in non-mobile children. There is evidence that the Accident and Emergency department was busy. Nevertheless, given that Bobbie had been taken with a head injury he appears to have received scant attention by medical staff. Over an hour after arrival the baby was seen by a staff nurse who took “a very brief history” that included the explanation given “appears his mobile fell onto his head, cried but not witnessed by mother”. The time of the incident was not recorded, nor any further details. There is a record that the examination showed a “large haematoma on the left side of the temple” but there are no further details of the examination or who conducted it, other than a reference in the records to “glanced at by the Senior House Officer, mum happy to take home as department busy”. He was discharged home after being seen by medical staff for a total of 15 minutes.    5.19 Visit to GP 1 at GP Practice 1 at Christmas: as the GP IMR analysis outlined this was “the final opportunity for assessment of Bobbie’s situation and any risk that might be present”. There is evidence that GP 1 examined Bobbie thoroughly. There is evidence from the interview with GP 1 by the IMR author that GP 1 had not thought at that time that there was evidence that Bobbie had been non-accidentally injured, but that she thought that “in retrospect, his presentation did fit with injury, but this is with the benefit of hindsight”. There is evidence that the appointment was tense because of a sense of urgency about getting Bobbie to hospital. GP1 would have been aware that she had previously seen Bobbie with a bloody nose and that he had been taken to A+E previously with a head injury. GP 1 was not however aware that Bobbie had been taken to GP Practice 2 three days before and was not aware that he was registered at another surgery. With hindsight it is clear that Jemima and Stephen withheld this information. They did however mention that Bobbie had fallen off the sofa a few days before (this was not something mentioned at the visit to the Locum GP at GP Practice 2 a few days earlier) but there is no evidence that GP 1 considered that as part of a differential diagnosis that included the possibility of non-accidental injury.          5.20 Admission to Hospital 1 and Transfer to Hospital 3 at Christmas: there is evidence of good information gathering on admission to the hospital, in terms of who had parental responsibility and that there had been no previous involvement with Children’s Social Care.  There is also evidence that Bobbie was quickly seen by a Consultant Paediatrician and that during the course of the day, all necessary tests were carried out to find out what was wrong with him and manage his care. There is very little information about what the parents’ response was to events, other than that they were at the hospital, along with maternal grandparents.    5.21 It was on Christmas Eve when the CT scan was reviewed by the Consultant Radiologist at Hospital 3 that an acute subdural bleed was identified and a differential diagnosis of non-accidental injury was  Family S4 Serious Case Review  Overview Report   Page26 tentatively made. The Consultant Paediatric Neurologist from Hospital 3 telephoned the Consultant Paediatrician at Hospital 1 to discuss the diagnosis and the latter then telephoned the named nurse for safeguarding children Hospital 3, who notified OoHS.     Were Safeguarding Issues Considered as Part of the Diagnosis and if so, were the Actions Taken Appropriate? 5.22 The childminder observed signs of neglect in Bobbie; constantly smelling of cigarette smoke and un-aired clothes, often needing feeding and changing when brought into her premises, with evidence that he had not been fed or changed since the previous evening. An incident occurred when two bottles of baby milk were brought to the childminder curdled and there were signs of possible non-accidental injury (two incidents of facial bruising within a fortnight). However, the childminder did not consider the differential diagnosis of non-accidental injury and did not seek advice from the appropriate safeguarding adviser in the Early Years Service.  5.23 GP 1 at GP Practice 1 saw Bobbie when he was taken with some blood discharging from his nose and he had a cold. The GP had no concerns about Bobbie at this time and prescribed ointment for what was diagnosed as an infection. She did not consider any safeguarding issues and she did not strip Bobbie when she examined him. The health overview author cites some research where nasal bleeding is said to be unusual in the first year of life and may be linked to child abuse in this age group, but there is a lack of evidence to support this view. The NICE Guidance 2009 (When to Suspect Child Maltreatment) links nasal or oral bleeding with an apparent life threatening episode and the health overview author concludes that   “there is nothing to indicate this was the history of (this baby) at this time, and therefore this episode of care appears to have been managed reasonably” (Health Overview Report, paragraph 7.7.10) .     5.24 When Bobbie was taken to the Accident and Emergency Department of Hospital 1, the differential diagnosis of non-accidental injury was not considered and the Paediatric Head Injury Guidance was not followed. The Health Overview author lists areas where there was a shortfall in practice (Health Overview Report, paragraph 6.3.2) and they include: failings in history taking, the baby was not stripped for full examination, failure to follow child protection policy (the 5 questions to be considered that may indicate risk to the child) and specific paediatric head injury guidance, no evidence that a paediatrician was asked to assess the baby.  The IMR author had identified “a departmental wide lack of knowledge and significant omissions in practice” and the Health Overview author commented that this was surprising “in the light of the case of “Baby Peter” and the subsequent scrutiny of safeguarding children arrangements in health organisations, including Accident and Emergency Departments” (Health Overview Report, paragraph 6.3.16).         5.25 However, on a positive note, the learning from this has quickly been put  Family S4 Serious Case Review  Overview Report   Page27 into action and the Accident and Emergency Department has since conducted an audit of child attendance with a head injury and scrutinised child protection assessments in the department and this has resulted in the immediate implementation of actions aimed at improving practice.   5.26 Bobbie was taken to GP Practice 2 with a cut to his tongue and dried blood over his face. There is evidence from the relevant IMR that the Locum GP did consider a differential diagnosis of non-accidental injury and fully examined Bobbie naked as a consequence. However, the Health Overview author comments that his actions did not go far enough as he did not challenge Jemima about her explanation for the injury (that he had chewed on a toy); challenge his own internal response to the situation (when interviewed by the IMR author he said that his “gut feeling” had told him that “something was not right” about the situation) or contact GP 1 at GP Practice 1 to see what information they had about the family. GP Practice 2 has since changed their policy so that if a baby/child is now taken to the practice with an injury and is a new patient the GP will immediately contact the previous GP. This information is also included in the Locum pack. This demonstrates that the learning from this SCR has been used to effect change aimed at improving practice.          5.27 Bobbie was taken to the GP Practice 1 at Christmas with a serious head injury.  GP 1 did not consider a differential diagnosis of non-accidental injury. Her main expressed concern was to get Bobbie to hospital as she could see that he was very ill. The rationale for asking Jemima and Stephen to take him in their car is open to challenge because of the risk of a road traffic accident, given the poor weather conditions and the stress they must have been experiencing. However, Jemima provided the Overview Author with additional information that may shed a different light on the matter (see 4.29).   5.28 Bobbie was admitted to Hospital 1 that day following a referral by GP 1. Although her referral did not contain all available information about Bobbie, there is evidence from the IMR that professionals involved did consider a differential diagnosis of non-accidental injury and noted both potential risk factors and protective factors. This remained a differential diagnosis and no action was taken in response to it as CT scan findings “indicated alternative explanations” (possible meningitis). This seems an appropriate response.  5.29  Bobbie was transferred to Hospital 3 on Christmas Eve. There is evidence that they did consider a differential diagnosis of non-accidental injury, although they awaited the results of further tests to rule out/in the possibility of meningitis. They recorded on Boxing Day that they had reached the conclusion that the injury was non-accidental, but they did not inform OoHS who had sought information from them earlier that day.    5.30 Information Seeking and Sharing: inter-agency and intra-agency The crucial point relating to information sharing in this case is that, with  Family S4 Serious Case Review  Overview Report   Page28 hindsight, there is evidence of an emerging pattern of neglect and non-accidental injuries to this baby during the weeks after they (Jemima, Stephen and Bobbie) moved out of the home of the nuclear family and into their own accommodation that was not identified or acted upon because information was not shared between professionals.   5.31 If information had been shared appropriately in compliance with the inter-agency safeguarding procedures and had been sought more rigorously then it is more likely that this emerging pattern of injuries would have been identified, triggering a S47 enquiry.   5.32 There had been two incidents when Bobbie was taken to the childminder and facial bruising was noticed, but the childminder did not notify her safeguarding adviser in Early Years and if she had this may well have triggered a visit from the health visitor to Jemima and may have resulted in a referral to CSSC.      5.33 In between these two incidents Bobbie had been taken to GP 1 at GP Practice 1 with a bloody discharge from his nose. The differential diagnosis of non-accidental injury was not considered and so child protection enquiries were not made, which may have triggered a response when other concerns came to light.   5.34 The following week, Bobbie was taken to Accident and Emergency at Hospital 1 with a large haematoma on his left temple. A notification form was sent to GP 1 at GP Practice 1 and another separately to the health visitor at GP Practice 1, but it took 10 days to arrive by which time the health visitor had gone off on sick leave. If GP 1 had discussed the Accident and Emergency notification with the health visitor at GP Practice 1 when she received it, there is a strong likelihood that the health visitor would have visited the family and assessed the situation and considered the possibility of non-accidental injury and it is possible that a referral to CSSC and a section 47 strategy discussion would have been triggered.     5.35 Six days later, Bobbie was taken to a different GP Practice (GP Practice 2) with a cut to his tongue and the explanation that he had chewed on a toy. The sharing of information by the Locum GP about the incident was limited to the health visitor in his Practice and went no further. If he or the health visitor had sought information via a telephone call to GP Practice 1, they would have discovered information about the “bloody nose” incident and the visit to Accident and Emergency and it is more likely that they would have considered a differential diagnosis of non-accidental injury and made a referral to CSSC.      5.36 Information sharing at the point of Bobbie’s admission to Hospital 1 three days later and subsequent transfer to Hospital 3 a day later was limited. The referral to the Hospital 1 made by GP 1 GP Practice 1 did not provide information relating to some key incidents, such as the Accident and  Family S4 Serious Case Review  Overview Report   Page29 Emergency visit and Jemima’s comment to GP 1 that Bobbie had fallen from the sofa a few days earlier, information that may have enabled both the Hospital 1 and Hospital 3 to consider a differential diagnosis of non-accidental injury at an earlier stage. The same issue of incomplete information being given in a referral was raised in a previous SCR in 2008.  5.37 Faxed Messages: When Local Office 1 sent a faxed alert to the OoHS on Christmas Eve, some basic information was missing from the document, such as the reason for concern, Bobbie’s ethnicity and religion.   There was a subsequent over-reliance on the use of a faxed thirteen-page update (from OoHS to the Local Office 1 when the case was transferred back to them after the Christmas holidays) as the only means of sharing information about what had happened. It transpired that the fax machine in Local Office 1 had run out of paper over the holiday period and there was therefore a delay in the local team receiving the information. It would have been better if OoHS had also alerted Local Office 1 via a telephone conversation about what had happened.       5.38 On Boxing Day, Hospital 3 recorded that they had concluded that the injury to Bobbie had been caused non-accidentally and was not the result of meningitis. There is no record that they shared this information with CSSC (OoHS) and the Police, although there is some evidence from the Police IMR that this was discussed at the meeting on Christmas Day (which OoHS did not attend), but there is no written record of this meeting.  5.39 There are some good examples of good information sharing:  • Between Hospital 3 and the OoHS on Christmas Eve. This consisted of two telephone conversations and a faxed referral from the hospital to the OoHS which outlined all the crucial information about Bobbie and his family circumstances and known history (see OoHS IMR paragraph 6.5) • On the first working day after the Christmas break when the case was allocated to the senior practitioner in CSSC Local Office 2. The CSSC IMR details the actions taken by the senior practitioner and there is evidence that she contacted key professionals within health and the Police and there was good quality information sharing that enabled her to attend the strategy meeting that afternoon fully equipped to contribute to the discussion, even though she had only been allocated the case earlier that day.  Seeking Information: Enquiries of the Designated Manager 5.40 One of the reasons the child protection nurse at Hospital 3 telephoned the Local Office 1 on Christmas Eve office was to enquire if the family was known. Implicit in this was an enquiry about whether this baby (or any siblings) was subject of a child protection plan. The inter-agency safeguarding procedures for this authority are clear that such enquiries should be made to the Designated Manager in the Safeguarding Unit.  Family S4 Serious Case Review  Overview Report   Page30 However, there is evidence from the CSSC IMR that there is confusion about this within Children’s Social Care and other agencies, with some professionals trying to acquire this information from their local CSSC office, rather than from the Designated Manager. The SCR has also highlighted the fact that Hospital 3 works to several LSCBs and the procedure varies, and that, in enquiring of the local team, they were not aware, nor were they made aware at the time, that this was not the procedure in this authority.       Communication and Divergent Views 5.41 There is evidence from the respective IMRs of the four agencies involved during the five day period from Christmas Eve onwards, that there was some differing understanding of how the inter-agency procedures were being applied.   5.42 Hospital 3 contacted the Duty Social Worker at Local Office 1 to “inform Social Services of the family in case Social Services needed to be involved” (Hospital 3 IMR chronology). This was seen by both agencies as a straightforward request for, and sharing of, information.   5.43 When Hospital 3 contacted OoHS later that day (Christmas Eve) a formal child protection referral was made, and accepted by the OoHS. Implicit in this acceptance of the referral as child protection is that the section 47 threshold had been met.  5.44 A differing understanding of events then emerges although at the time, there was no apparent impact on the management of the case and it is only with hindsight, through the SCR process, that the divergence of view has emerged.     5.45 Hospital 3 and OoHS had agreed (late on the afternoon of Christmas Eve) that a strategy discussion was required with the Police, and that the plan would be for a further multi-agency strategy meeting to be held after the Bank Holiday.  5.46 The OoHS and the Police then in effect held a strategy discussion (although not recorded as such by OoHS) where the agreement was to wait for further update from the hospital on Christmas Day and make further decisions then.   5.47 It is here potentially that the divergence in understanding begins.  The Police IMR (paragraph 7.6) records “was a strategy discussion, as S.47 threshold met, with a need to consider commencing a joint investigation asap”.  5.48  The OoHS IMR, however, makes no mention of such a joint investigation, more simply that they are waiting further information before a decision about the way forward can be made. (Borough of Poole IMR paragraph 6.10). However, implicit in the acceptance of the referral as child protection  Family S4 Serious Case Review  Overview Report   Page31 is that the s47 threshold had been met. 5.49 On Christmas Day morning, the Police decided appropriately that since a potential serious crime had taken place, they needed to take urgent action to secure the best “evidence” available, including early witness statements that might have informed a future criminal case. The Police decided then to conduct their criminal investigation under the SUDIC Protocol (Police IMR paragraph 7.13) and communicated this decision to OoHS. The Police planned to go to Hospital 3 later that day for a strategy meeting with hospital staff which they state “OoHS were unable to attend, due to lack of staff.”    5.50 However, whilst there was clearly a sense of urgency from the Police perspective (to secure evidence) it appears that OoHS did not have the same urgency to act. The reason for this was perhaps because Bobbie was secure at Hospital 3 (and thus there were no immediate safety concerns) and secondly because they were awaiting confirmation from the Hospital 3 that the injuries were non-accidental (Borough of Poole IMR paragraph 7.17).  5.51 The issue therefore appears to be, not at which point the threshold for a S.47 investigation was judged to be met, but the urgency each agency ascribed to addressing the developing situation.   5.52 Serious situations may be urgent and require speedy actions by the Police to secure the scene, interview witnesses and accumulate evidence.  However, the same situation may not require such an urgent response from CSSC although the case is nonetheless seen as serious.  5.53 In this case, all the actions that were required by each agency were taken, Bobbie was adequately protected and there was no adverse impact on the outcome. However, with the benefit of hindsight, divergent views about what process or procedures were being followed have emerged.    5.54 The need for communication to be explicit rather than implicit is therefore at the heart of this issue, and for this communication to be accurately recorded at the time. Clarity and greater understanding about each other’s roles in child protection situations and in the purpose and recording of strategy discussions is clearly also an issue here.   5.55 The key functions of a strategy discussion as detailed in the Inter-Agency procedures are:  • Agree the conduct and timing of any criminal investigation • Decide whether S.47 enquiries should be initiated. • Plan how the S.47 enquiry should be undertaken • Agree what actions required immediately to safeguard the child  The Police role and responsibility is to conduct criminal investigations. The Local Authority role and responsibility is to conduct S.47 enquiries.  Both  Family S4 Serious Case Review  Overview Report   Page32 roles are separate and distinct but may be conducted jointly: a joint investigation.    5.56 In this case, the Police IMR takes the view that such a joint investigation should have taken place, hence the police identification of the issue about OoHS availability/resourcing to attend the meeting on Christmas Day.   5.57 The OoHS IMR however, holds an opposite view (OoHS IMR paragraph 7.17). This also implicitly confirms that the original plan agreed with Hospital 3 on Christmas Eve to hold a strategy meeting after the Bank Holiday was appropriate, and would determine how the S.47 enquiry was to be conducted. The IMR identified no such resource issue in the OoHS recording of events (although this appears to have been the case), rather that they agreed a single agency response at that time with the Police, that is, to progress the criminal investigation.   5.58 In retrospect, it was entirely appropriate that the Police attended Hospital 3 “urgently” to begin the process of conducting their investigation, and equally appropriate that OoHS decided (by implication) to leave the planning and conduct of the s47 investigation to the day time services. The inter-agency procedures (paragraph 2.60) state:  “Where a situation arises which is not in normal working hours, a  strategy discussion will take place between the Children’s Services out of hours service and the police to discuss immediate protective action. The outcome of this strategy discussion and any action taken will then be passed to the appropriate staff in Children’s Services and the police the next working day”.  5.59 Given the complexity of the case however, it may have been helpful if there had been a telephone conference involving OoHS in the discussion that took place in the meeting held on Christmas Day at Hospital 3. This would have helped to facilitate good information sharing and avoided subsequent differing interpretations about the process of investigation.   5.60      5.61 Cross Border Issues  There was cross border involvement of agencies in various aspects of this case, including the provision of midwifery services, the OoHS provided through a service agreement with a neighbouring authority and the involvement of the Hospital 3, based in another area.   An issue has emerged in relation to the IMR requested and produced by Hospital 3, in that it has highlighted the challenges for IMR authors who work to a number of different LSCBs with differing expectations. It is important for the LSCB commissioning the IMR to be clear with authors, through the terms of reference and in authors’ briefings, exactly what it expected of them. In this case, a contributing factor was that the IMR was one of the four commissioned when the SCR was already underway (see paragraph 1.28) and the authors’ briefing had already taken place. Thought  Family S4 Serious Case Review  Overview Report   Page33 needs to be given by the SCRP about how the SCR Panel Chair could make expectations clearer when organisations are brought in halfway through the process, particularly when there are cross border issues.   5.62 Another cross border issue that has emerged is that arrangements for making enquiries about whether/not a child is subject of a child protection plan vary between authorities and some organisations, such as Hospital 3, work to several LSCBs with different procedures. It is important that they are supported by the LSCB to understand the procedures in relation to this authority. However, it should be noted that the requirement for each Local Authority to appoint a Designated Manager who is responsible for “ensuring enquiries about children about whom there are concerns or who have child protection plans are recorded” is contained within Working Together to Safeguard Children 2010 (paragraph 5.152).     Did Staffing and Professional Availability during the Christmas Holiday Period have an Impact on Practice and Outcomes? 5.63 There is evidence that the duty team in Local Office 1 was under considerable pressure when they received the telephone call from the child protection nurse from the general hospital at 12.30 hours on Christmas Eve. The team manager and duty social workers were all involved in ongoing section 47 matters and the office was due to close. The child protection nurse should have been advised to telephone the Designated Manager in the Safeguarding Unit to enquire whether the family were known to Children’s Social Care but was not and there is no evidence to confirm that this was because the duty administrator and the duty social worker were under pressure or whether they were not aware that such enquiries should be made to the Designated Manager in the Safeguarding Unit, as opposed to the local area office.  Although this is a matter of good practice and compliance with the procedures, in this particular instance it did not have an adverse impact on the outcome of the case, as the Designated Manager’s records would have shown that there had been no enquiries made about Bobbie and that he was not subject to a child protection plan.  5.64 There is evidence that the OOHS duty social workers were under pressure during the 5-day period they were involved but there is evidence that this did not impact on the quality of the service they provided. There is however a divergent view expressed in the Police IMR that states that it was resource issues that prevented an OOHS duty social worker attending the strategy meeting at the hospital on Christmas Day. The OoHS IMR states that it was not a resource issue and that Police had agreed a single agency approach.      5.65 There is evidence that resource issues impacted on the ability of CSSC to provide someone from the local office to attend the s 47 strategy meeting on the first working day after the Christmas break.  However, the case was quickly transferred to another area office and there is evidence that the  Family S4 Serious Case Review  Overview Report   Page34 allocated Assistant Team Manager made sure she was quickly and fully up to speed with the case by the time she attended the meeting that afternoon. She made a written plan of who she needed to speak to and engaged other professionals in information gathering that enabled her to attend the meeting and contribute effectively.  She was a senior practitioner so her attendance at the meeting was entirely appropriate and in line with the inter-agency safeguarding procedures which state that “the strategy discussion should be convened by CSSC and those participating should be sufficiently senior and able to make decisions on behalf of the agency. In CSSC this will normally be a manager, assistant manager or senior practitioner” (Inter-Agency Safeguarding Procedures, paragraph 3.2).   Timeliness of Referrals to the Police and Children’s Social Care. 5.66 Pivotal to any analysis of this is the definition of a referral. There is evidence that the child protection nurse from Hospital 3 made timely telephone contact with the Local Office 1 at lunchtime on Christmas Eve. The purpose of her telephone call was not to make a referral and so it was appropriate that it was recorded as a contact. However, she did wish to make an enquiry about whether the family was known (as well as inform CSSC of the baby’s admission to hospital and to seek clarification about out of hours arrangements) and so should have been re-directed to the Designated Manager in the Safeguarding Unit.   5.67 The referral from the OoHS to the Police on the afternoon of Christmas Eve, following the formal written referral from the general hospital was made in a timely manner and this was made after further information had come to light about previous incidents (during conversations between the OoHS Social Worker 1 and medical professionals from Hospital 3).   Accuracy and Quality of Record Keeping 5.68 There are some examples where improvement in the quality of record keeping is indicated:   • There is evidence that the records in the SCBU did not contain any information about the social and obstetric history, including the fact that this was a concealed pregnancy and a late booking. This would have “informed the observations” of the staff on SCBU of the mother/baby relationship. This is an issue that arose in a previous SCR (2010) and resulted in policy and practice changes, but it is of concern that these matters have arisen again in this SCR and may indicate that policy and practice changes have not been embedded.  • The Accident and Emergency notification forms sent to GP Practice 1 should have had all sections of the form completed. In this case, the “attendance at Emergency Department” notification form sent by Accident and Emergency to GP Practice 1 in relation to Bobbie’s visit had nothing written in the section entitled “the following treatment and advice was provided”.   • The standard of record keeping by the childminder fell short of that  Family S4 Serious Case Review  Overview Report   Page35 laid down in her own procedures and the inter-agency safeguarding procedures in that although she noted the two incidents of facial bruising she did not record the reason given by the Jemima for the bruising on one of the two occasions. • The discussion between the OoHS Social Worker 1 and the DS            CAIT on Christmas Eve should have been recorded as a              strategy discussion, but it was not. • There is no record of the meeting that took place at the hospital on Christmas Day, involving the Police and medical professionals, during which, according to the Police IMR (paragraph 7.21) the medical opinion had shifted more towards a differential diagnosis of non-accidental injury.  Diversity: Racial, Cultural, Linguistic and Religious Identity 5.69 There are no known issues of significance relating to race, language and religion.        Disability 5.73 There are no known impairment issues in this case prior to the head injury sustained by Bobbie.  Management Oversight and Supervision Health Visiting Service at GP Practice 1 5.74 There were no formal sick cover arrangements for the health visitor when she was off sick and no apparent management oversight of what was happening to the functions she normally undertook, such as dealing with Accident & Emergency notifications, and running the baby clinic. The issues are outlined in the Health Overview report in paragraph’s 8.1.20 and 8.1.26. The Health Overview author is clear that “It is the responsibility of the manager to ensure safe levels of care are provided when health visitors are absent for extended periods of time”.     Childminder 5.75 The changes to the registration, inspection and support to childminders since 2001 are outlined in paragraphs 3.11-3.16 above. For the childminder in the case these changes appear to have a significant impact on her. She had previously enjoyed the experience of having an inspection, support and training service that was locally based in the Under 8’s Service, and then had to adapt to the more arms length and less frequent inspection by Ofsted, combined with a local support and training service that appears to be more complex, difficult to understand and less personal. There is evidence that this was a contributory factor in her becoming isolated and this in turn appears to have affected her professional practice, resulting in her failure to follow her own and the inter-agency procedures in relation to safeguarding Bobbie.   5.76 There is no criticism of the Early Years and Child Care Service Team as there is evidence that they fulfilled their function in relation to this  Family S4 Serious Case Review  Overview Report   Page36 childminder. In opting out of the Quality Assurance opportunity she in fact lessened the opportunity for support. However, what it points to is that the current system has the potential, as it did in the case, to result in childminders becoming isolated and not receiving the training and support they need. The childminder had a clear understanding of the child protection procedures and her safeguarding responsibilities but her own isolation impacted on her ability to discharge those responsibilities. This is a systemic issue that needs to be addressed and forms a significant lesson to be learnt from this SCR.     Compliance with the Inter-Agency and Single Agency Procedures   5.77 Examples of compliance:   • The child protection nurse from the Hospital 3 did comply with the inter-agency procedures when she made a written referral to the OoHS on the afternoon of Christmas Eve. • The OoHS Social Worker complied with procedures when contacting the Police about this referral later on the afternoon of Christmas Eve. However, their telephone discussion was not formally recorded as a strategy discussion and should have been, and so did not comply with procedures in this respect.    5.78 There are examples outlined below where procedures were not complied with, but it has not been possible in all cases to give a reason why the individuals involved did not comply with the procedures.   • There is evidence that the childminder did not comply with her own safeguarding and the inter-agency safeguarding procedures in not fully recording the instance where Jemima told her about Bobbie having a bloody nose bleed, the two instances of facial bruising and the occasion when Jemima arrived to collect Bobbie and was in a distressed state and indicated that she was under pressure to look after him and was not receiving any support from Stephen.   • The childminder did not report these incidents or seek advice from her safeguarding adviser, and the IMR author concludes “had she complied with her safeguarding procedures, it is likely that she would have taken advice, which may have made a difference to the final outcome in this case” (Early Years IMR, paragraph 9.16). Her approach seems to have been adult rather than child focused. As identified elsewhere in the report the childminder had become isolated and had cut herself off from the support offered by the local authority. These may be factors that contributed to her failure to comply with her own procedures. • Professionals in the Accident and Emergency Department at the Hospital 1 did not comply with the guidance “Head Injuries in Not Independently Mobile Children” when Bobbie presented with a large haematoma on his left temple. • GP 1 in GP Practice 1 did not give adequate information when  Family S4 Serious Case Review  Overview Report   Page37 referring Bobbie to the Hospital 1 at Christmas. She did not mention the fact that Jemima had told her that Bobbie had fallen off the sofa a few days before, the nosebleed incident a few weeks earlier, the visit to Accident and Emergency, or the fact that this was a concealed pregnancy. The fact that she was dealing with an emergency situation that must have been very stressful may have contributed to her not fully completing the referral form. • When the child protection nurse telephoned Local Office 1 on Christmas Eve one of the reasons for her call was to make an enquiry about whether the family was known to CSSC. The caller should have been re-directed to the Designated Manager in the Safeguarding Unit. The fact that the office was about to close for Christmas was likely to be a contributory factor in this.  • The telephone conversation between the OoHS duty social worker and the Police on the afternoon of Christmas Eve (following the written referral from Hospital 3 to the OoHS) constituted a strategy discussion but was not recorded and written up as one. • The meeting between the Police and medical staff at Hospital 3 on Christmas Day should have been recorded. The Police and OoHS should have been informed that the conclusion of non-accidental injury had been reached on Boxing Day.    Culture and Organisational Climate within and Between Agencies    5.79       5.80       5.81      5.82      5.83   Health  There is evidence that in GP Practice 1, there was a culture that took a very narrow view of the role of the GP. For example, GP 1 did not see that it was her role to enquire about the concealed pregnancy, the home circumstances or the identity of the baby’s father. She saw this as the role of the midwife and health visitor.    There is also evidence that this role separation impacted on communication between the GP and the health visitor. For example, the GP received a notification about the visit to Accident and Emergency within a matter of a few days, but there was no verbal communication with the health visitor about this.   There is evidence of a lack of professional curiosity and challenge on the part of various health professionals, about the injuries to Bobbie and the explanation for these injuries by Jemima. A culture of “respectful uncertainty” is likely to have resulted in better outcomes for Bobbie.  There is evidence from the Health Overview report of some misalignment of view between the Accident and Emergency Department at the Hospital 1 and the named professionals in the use of a risk assessment pathway to be used to identify possible risk in children attending the hospital.  There was additional concern expressed by the Health Overview author in  Family S4 Serious Case Review  Overview Report   Page38 relation to Accident and Emergency in that “the advice of the Safeguarding Children Team, particularly that of the Named Nurse, whose role is to advise the organisation on safeguarding children matters, was not accepted in the Accident and Emergency Department”.         5.84 Childminder There is evidence that despite her years of experience as a childminder and as a foster carer and her being graded as “good” by Ofsted, the childminder had become isolated and disenchanted. A contributing factor to this seems to have been the change in the relationship between herself and CSSC, where there is now a much more “arms length” relationship rather than the more “hands on” approach that existed in the past. The Early Years IMR Addendum outlines and analyses with clarity the issue that contributed to the childminder’s isolation.                     Examples of Good Practice 5.85 There are some examples of good practice,: • Health Visitor in Practice 1: she consistently provided a professional and high quality service to Jemima and Bobbie. For example, she conducted her primary post delivery home visit the day before the final home visit by the midwife. She noted the home circumstances and encouraged Jemima to attend a young parents’ group, which she did. She also made a “support visit” when she was concerned about Jemima returning to work so early. This was not a scheduled routine visit, but was made in response to the health visitor’s concerns. She also wrote a letter to support Jemima’s application to be re-housed, as she was aware of the impact of the overcrowded living conditions in the home. • Childminder: when Jemima arrived at the childminder’s house in a distressed state, and was critical of the lack of support from Stephen, the childminder offered to keep Bobbie that afternoon so Jemima could have a break (in the event she declined the offer).  • When the baby’s bottled milk curdled when heated up at feeding time, the childminder acted appropriately by insisting that Jemima prepare and deliver two replacement bottles, thus ensuring that she took responsibility, rather than doing it for her. • Professionals at Hospital 3: in the liaison between medical staff and the child protection nurse and between the child protection nurse and Local Office 1 and the OoHS duty social worker on Christmas Eve. •  OoHS Duty Social Workers: during the 5 day period they were involved in the case, in liaising with health professionals and the Police and ensuring that Bobbie was being cared for and was safe, as well as monitoring the developing situation in relation to investigating child protection concerns.   •  Police: during their five-day involvement over the Christmas period they showed diligence and a sense of urgency in carrying out their role in investigating child protection concerns and in seeing the  Family S4 Serious Case Review  Overview Report   Page39 family and medical professionals at the earliest opportunity and liaising with the OoHS.      5.87 There are some examples where practice could and should have been better and in line with the recent Ofsted evaluation of SCRs. Where practice fell short of what was expected this was due to a “failure to take the necessary action and implement good practice rather than an absence of the required framework and procedures for delivering services”.1 Examples of this are given in the section on non-compliance with procedures (paragraph 5.78). In all these cases practice could have been improved if practitioners had used agreed procedures.     Learning from Previous Serious Case Reviews and Links with This Case 5.86 The Overview Author has looked at the executive summaries and training synopses from three previous SCRs undertaken by the DSCB between 2008 and 2010. Two of these reviews also related to a physical assault including head injury to a young baby as in this case. In both the other cases the baby in question was younger than Bobbie who was 6 months old when the injury occurred (both were 10 weeks old). In one of these cases the baby died from the injuries sustained.   5.87 In previous SCRs there are issues that should have been dealt with through the recommendations and action plan, but that have re-occurred as issues in this case: • The issue of inadequate information at the point of referral to Hospital 1 by GP 1 was an issue and recommendation in the 2008 SCR • The issue of poor communication between GPs and health visitors was an issue in the 2008 SCR • The lack of assessment of the relationship between Jemima and maternal grandmother and any possible issues of dominance was an issue in the SCR in 2010.     5.88 In this case the family had not been known to CSSC or subject to any statutory intervention and Jemima and Bobbie were known only to universal services, primarily those from health, such as GP, midwifery and health visiting Services. In the previous two SCRs referred to above, the cases had been known to CSSC, through involvement with half-siblings or siblings, but in both cases there was no statutory involvement relating to the baby in question and the case was not open to CSSC at the time of the injury. As with this case, the parents and baby were known only to universal services, primarily health.       5.89 In terms of learning from these two previous SCRs and resonance with the                                                  1 Learning Lessons from serious case reviews 2009-2010, Ofsted, October 2010, reference no: 100087  Family S4 Serious Case Review  Overview Report   Page40 current case, all three cases re-enforce messages from the 2008 review of SCRs2 in relation to interacting risk factors indicative of increased risk to the child, and the importance of clarity about the assessment of protective parenting factors and the impact this may have on safeguarding the child. This is the third physical assault case on a baby under a year old in three years and this warrants a targeted focus on some of the messages from research about the characteristics of these cases.   .      5.90 Fundamental to this case and the others was the need for a comprehensive social history to be gathered and shared by those from the universal services. In this case there was a notable absence of sufficient professional curiosity about the birth father of Bobbie and more importantly mother’s boyfriend, Stephen. The Community Health Services IMR author notes that when Jemima was living at home there were two men living in the household: her father and her boyfriend, Stephen. Apart from being referred to on the front of the health visitor notes, they do not feature in conversations that took place and Stephen was only seen once, at the four month visit, which took place in the surgery. The IMR author noted “This gives the impression of them being background figures whose presence is incidental”. In the other two SCRs reviews, there was evidence that information had been gathered about both birth parents, but that it was not pulled together in a way that could assess the interacting risk factors and any additional stresses on the family, such as in one of the cases, the prematurity of the baby.  6.0  KEY LEARNING POINTS AND EMERGING ISSUES  Vulnerable Babies: Physical Assault and Head Injuries 6.1  In the 2008 review of Serious Case Reviews3 47% of the children in the total sample (161) who died or sustained a serious injury were under the age of 1. Of the 47 “intensive cases” studied, 17 involved a physical assault on the baby, 8 of these involving a head injury.    6.2  The research highlighted that the families of very young children who were physically assaulted (including those with head injuries) tended to be in contact with universal or adult services rather that children’s social care.   6.3  A key learning point from this SCR is the need for a targeted focus on vulnerable babies amongst professionals as this is the third case in this authority of a physical assault resulting in a head injury on a young baby since 2008.   6.4  The research points out that these injuries are difficult to predict but that an increased awareness of the interacting risk factors present can aid                                                                                                                                                         2 Brandon, et al (2008) Analysing Child Deaths and Serious Injury through Abuse and Neglect: What Can We Learn? London: DCSF    3 Brandon, et al (2008) Analysing Child Deaths and Serious Injury through Abuse and Neglect: What Can We Learn? London: DCSF  Family S4 Serious Case Review  Overview Report   Page41 identification and understanding:  “Prevention of child death or injury through abuse or neglect is uppermost in the minds of practitioners or managers working with children and families. However, the complexity of family circumstances means that even if the “whole picture” of family circumstances had been known, it would not always have been possible to predict an outcome for most of the children. To have a better chance of understanding the risks of harm the children face, practitioners should be encouraged to be curious and to think critically and systematically. Being aware of the way in which separate factors can interact to protect from harm or cause increased risks of harm to the child is a vital step in this process”4           6.5  In looking at cases of physical assault and head injury to young babies the research identified a profile that is similar to those cases where neglect was a feature, but some additional distinguishing features, namely:  • The presence of volatility, coupled with a history of previous injury • Illness or admission to Accident and Emergency for the baby or child  • Less contact with Children’s Social Care, or involvement for briefer periods of time, and greater involvement with services for early needs or universal services  6.6  The research lists factors linked to the profile and history of the child’s carers that can be used to aid identification of risk. In the case of Bobbie one of the significant issues was that so little information was gathered about Jemima and Stephen. Promoting professional curiosity with the aid of such risk factors could be a means to enhancing understanding and practice generally, but particularly in the universal health services.  6.7  The research identified factors linked to the children who were physically assaulted and suffered head injuries:  • Some were born prematurely and spent their early days or weeks in Special Care Baby Units • Some had additional medical or emotional needs that presented challenges to those caring for them • A number of young babies already had a history of admission to hospital for illness or accidents that in retrospect were linked to abuse (e.g. a mistaken diagnosis of meningitis, rolling off a chair etc). • Some had a higher number of contacts than average with primary health care services, for example, visits to the GP  This profile does fit with what we know about Bobbie and his experiences and could be used to promote understanding and awareness in the future.                                                                                                                                                          4 Brandon, et al (2008) Analysing Child Deaths and Serious Injury through Abuse and Neglect: What Can We Learn? London: DCSF, page 7.  Family S4 Serious Case Review  Overview Report   Page42  6.8  The research also looked at the profile of the engagement of the families of the babies who were physically assaulted or suffered head injuries and found that:  • Families had more contact with low-level services other than Children’s Social Care. • Some families had high levels of contact with various health professionals, especially mental health practitioners • Many families were “difficult to engage” when pre-arranged appointments would be missed or cancelled • When reluctant engagement was coupled with frequent moves, records would be sketchy or inaccurate and practitioners would not be aware of the sequences of events and behaviour which revealed serious risks to the child, such as attendance at Accident and Emergency   6.9  The critical issue emerging from this SCR is that, with hindsight, there was an emerging pattern of injuries to Bobbie that went unrecognised by the professionals who came into contact with him. This was due to lack of professional curiosity, non-compliance with their own and inter-agency safeguarding procedures and lack of robust information gathering and sharing. If these things had been in place and the pattern of injuries recognised, then in all likelihood there would have been a better outcome for Bobbie.  The Voice of the Child 6.10  Bobbie was six months old when he incurred the head injury that resulted in permanent impairment and his removal from his mother. Although Bobbie was not mobile and could not express himself in words there were incidents in the weeks prior to this that point to possible neglect and non-accidental injury; constantly smelling of cigarette smoke and unaired clothes; two incidents of facial bruising within a fortnight seen by the childminder but not acted upon; curdled milk in two of his bottles taken to the childminder; a visit to Accident and Emergency with a large haematoma on his left temple that did not result in either an examination or exploration of  possible cause; and a visit to the GP with a cut to his tongue.    6.11  There is evidence that Bobbie’s voice (through his experiences and his perceived wishes and feelings) was not heard because there was insufficient attention paid to him through direct observation by the professionals who came into contact with him. There is evidence that disproportionate attention was paid to the needs of Jemima and this detracted from a focus on Bobbie. This accords with recent learning from an Ofsted analysis of SCRs undertaken between April and September 2010 where two major learning themes that emerged were “seeing and hearing the child” and “focusing on the child rather than the needs of the  Family S4 Serious Case Review  Overview Report   Page43 parents and carers”5.     Concealed Pregnancies  6.12  Concealed pregnancies are by no means a new phenomenon. In the past concealment may have had significant links to the stigma and shame attached to giving birth to an “illegitimate” baby and the culture of women and girls being sent away to a mother and baby home for their confinement and subsequently placing their baby for adoption.     6.13  Although societal attitudes and practice have changed greatly over the years, concealed pregnancies still occur. There is limited research into the phenomenon and the links between concealed pregnancy and child abuse. A pregnancy may be concealed for a variety of reasons, many based on fear or denial. In some cases the fear is because the pregnancy was a result of sexual abuse, either within or outside the family, and/or a woman is fearful of revealing a pregnancy for fear that it will provoke or increase incidents of domestic violence6.   6.14  Jemima’s pregnancy was confirmed at 33 weeks and was identified immediately as a concealed pregnancy, and she acknowledged to the midwife that part of the reason for the concealment was fear of her mother’s response. In the author’s view the lesson for learning was that this was accepted de facto, and did not trigger professional curiosity to gather further information in order to assess her vulnerabilities or explore the possibility of any issues of abuse.       6.15  The identity of the putative father was not explored with any rigour by some health professionals, and there is evidence that Jemima’s matter of fact responses were taken at face value: that she would tell him after the baby was born and later that he was in the services and had moved away and she had lost his phone number.  A more curious professional approach may have wanted to explore why she was being so guarded. The air of mystery surrounding Jemima and subsequently her relationship with her boyfriend seemed to be accepted as a fact, rather than prompting professional curiosity, which at the end of the day was a missed opportunity to gather information about these two adults to assess both protective parenting factors but also identify any interacting risk factors, that might threaten the baby’s health and safety.     6.16  The lesson for learning from this SCR is the need for a greater professional awareness of issues related to concealed pregnancies and the implications for professionals in gathering information, and the use of this in undertaking holistic assessments:                                                   5 The voice of the child: learning lessons from serious case reviews. Osfted, April 2011, reference no: 100224 6 Lewisham Safeguarding Children Board, Concealed Pregnancy and Birth Protocol  Family S4 Serious Case Review  Overview Report   Page44 “The reason for the concealment will be a key factor in determining the risk to the baby and that reason will not be known until there has been active professional exploration and assessment”. 7   Arrangements for Sickness Cover in The Health Visiting Service 6.17  The lack of formal arrangements for cover for the health visitor function when she was off sick for a month did have an impact on the outcome of this case in that the Accident and Emergency notification was not responded to (it was date stamped and filed by the health visitor assistant). If a health visitor had read the notification it is likely and in line with their role that she would have visited Bobbie and Jemima to find out more about the visit to Accident and Emergency and would have been able to assess and respond to any safeguarding concerns and offer Jemima any necessary support or safety advice. In addition the baby clinic was run by a nursery nurse, which is not ideal without a health visitor present.   The Need to Ensure that Childminders Receive the Support and Training they Need. 6.18  The isolation of the childminder in this case had an impact on her ability to fulfil her professional duties. This lesson for learning needs to be used to inform a review of the current support and training for childminders to promote a culture change and ensure that this situation does not arise again.  The Need for Effective Communication  6.19 There were some examples where more communication needs to take place between professionals, such as between GPs and health visitors, and between GP Practices. There has been some specific learning from this SCR for improving practice within GP Practice 2. They have now conducted a “significant event” meeting and changed their policy immediately so that if a baby/child attends with an injury as a new patient, information will be sought straightaway from the previous GP. The new policy has been included in their updated Locum pack.     6.20 There are also lessons for learning about the need for explicit communication that emerged from the interaction between the Police, OoHS and Hospital 3 over the five day period following the serious injury to the baby, where much communication did take place, but matters became muddled because the quality of the communication was such that on occasions those involved had differing perceptions of what had been communicated and what was going on. In analysing the information available, it is the Overview Author’s view that adequate procedures and protocols are in place, although their concurrent use needs clarifying for practitioners, but that the main issue here was the implicit nature of the communication that took place, when it needed to be explicit. The detail of this is outlined in paragraphs 5.41-5.59. It is important to stress that in this case the confusion between professionals and the procedures/protocols                                                                                                                                                         7 Lewisham Safeguarding Children Board, Concealed Pregnancy and Birth Protocol, page 5.  Family S4 Serious Case Review  Overview Report   Page45 being used did not have a negative impact on outcomes for the baby, as he was being safely cared for in hospital, but it is a matter that needs exploring as it could be a pivotal issue in future cases.           6.21 The learning from this SCR, as expressed by the Police, is that “It is important that all agencies understand the views of other agencies and that they are properly communicated” (Police IMR paragraph 8.4). This matter will be taken forward through a recommendation that addresses the quality of communication between professionals, and also communication and ownership on a wider level within the inter-agency community (see recommendation 7).  The Need to Clarify Where Enquiries Regarding Child Protection Checks Should be Made 6.22 It has emerged from this case that there is confusion in CSSC and in other agencies about who should be contacted to make an enquiry about whether a child or siblings are or have been subject to a child protection plan. The CSSC IMR highlights this confusion (paragraphs 9.1-9.3), this is despite the fact that the inter-agency safeguarding procedures state that such enquiries should be made to the Designated Manager.    6.23 The CSSC IMR helpfully draws out the distinction between an enquiry to the Designated Manager that implicitly suggests that there are child protection concerns even though they may be, as was the case in the telephone call from the Child Protection Nurse, low level or as yet unsubstantiated. Such an enquiry can be conducted without parental consent and does not in itself constitute a referral. A request to the local office for a check “should be conducted when there are no apparent child protection concerns and there is parental agreement to seek information from other agencies” (Children’s Social Care IMR paragraph 9.3).       6.24 What has become apparent in this case is that the child protection nurse, in telephoning the local Children’s Social Care office, was seeking to make an enquiry about whether there was a child protection plan in place for this child or any siblings. Good practice would have suggested that the caller was re-directed to the Designated Manager in the Safeguarding Unit.      Ensuring that Lessons Learned from Previous Serious Case Reviews become Embedded Into Practice. Why is this still a problem? 6.25 There is evidence that previous SCRs have been conducted to a high standard and every effort has been made to provide the tools to ensure that the lessons learnt are used to improve practice, such as through the synopsis of learning which is produced in addition to the executive summary. However, despite this, there is evidence in this SCR that several of the issues that have emerged have been issues that have been identified in previous ones. This may be a systemic issue that needs further examination. It will be important for the LSCB, through its SCRP and the appropriate sub-groups, to look into what more can be done to ensure that  Family S4 Serious Case Review  Overview Report   Page46 lessons learnt from SCRs are disseminated effectively and impact on practice in a sustainable and demonstrable way. If there are obstacles to learning, these need to be identified and addressed. Munro views learning as an on-going and iterative process: “Considering how the system can become better at monitoring how it is performing, learning about merging difficulties, responding creatively and adapting to tackle them. The aim is a legacy where the system is better equipped to continuously learn and improve.”8     7.0 CONCLUSIONS  What Might Have Been Done to Ensure Better Outcomes for Bobbie?  7.1  There are several pivotal points in this case where, if different action had been taken by professionals, there may well have been a different and better outcome for Bobbie:  • If the childminder had sought advice from her safeguarding adviser in relation to the facial bruises and the signs and symptoms of neglect (the persistent smell of cigarette smoke, the fact that when he was brought to her in the morning he had not usually been fed and changed since the evening before, the incident with the curdled milk, mother’s distress at the lack of support from her boyfriend) this may well have enabled her to recognise the safeguarding risks to Bobbie and take appropriate action. There is evidence that her own stereotypical perceptions, over optimistic view of the situation and focus on Jemima rather than the baby limited her ability to take appropriate action.   • When Bobbie was taken to Accident and Emergency with a large haematoma on his left temple there is evidence that he was not appropriately examined. Jemima’s explanation for the injury was taken at face value and there is no evidence that a differential diagnosis of non-accidental injury was considered. Had Bobbie been properly examined and non-accidental injury considered it is likely that this would have resulted in a referral to CSSC and the Police and resulted in a strategy meeting and could have resulted in better outcomes for him.     • If GP 1 at GP Practice 1 had discussed the letter of notification in relation to the baby being taken to Accident and Emergency with the health visitor there is little doubt, given the other examples of her professionalism that she would have followed this up with Jemima and her family. As it was, no such discussion took place and the second notification was processed (by the health visitor assistant) but not followed up until the health visitor returned to work a few weeks later.  • When Bobbie was seen by the Locum GP at GP Practice 2 he did examine him “thoroughly”, but took Jemima’s explanation for the                                                  8 Munro Report, page 10  Family S4 Serious Case Review  Overview Report   Page47 injury at face value and did not consider a differential diagnosis of non-accidental injury, despite “his gut feeling telling him that something was not right” (GP IMR). If he had telephoned GP 1 at GP Practice 1 he would have discovered the incident with the nose bleed and the visit to Accident and Emergency with the haematoma on his temple, and it is likely that his actions on that day would have been different and resulted in better outcomes for Bobbie. However, as there is no specific guidance about bleeding from the mouth in non-mobile babies and children his actions can be considered as reasonable. If this guidance had been in place it would have helped him consider and act upon his “gut feeling” in a more structured way. • If the health visitor at GP Practice 2 had demonstrated professional curiosity and “respectful uncertainty” following Bobbie’s appointment with the Locum GP she could have telephoned GP Practice 1. Although the health visitor there was off sick, she could have spoken to GP 1 and would have discovered about the nosebleed incident and the visit to Accident and Emergency and it is likely, in view of this, that she would have acted differently and there may have been a better outcome for Bobbie.  • When the baby was seen at GP Practice 1 at Christmas GP 1 referred him to Hospital 1, but did not mention the nose bleed incident, the visit to Accident and Emergency, the fact that Jemima had said that Bobbie had fallen off the sofa a few days before or the fact that this had been a concealed pregnancy. Had these things been mentioned then it is likely that the hospital would have considered a differential diagnosis of non-accidental injury earlier. This may not have affected the outcome for Bobbie, but it is likely that CSSC and the Police would have been alerted sooner and been able to respond more speedily. • If enquiries had been made of the Designated Manager by medical professionals who saw Bobbie at various points there would have been an audit trail that would have triggered an earlier referral to CSSC. Examples of this are: medical professionals in Accident and Emergency when Bobbie was taken with a large haematoma on his left temple; GP 2 when Bobbie was taken with a cut to his tongue and GP 1 when he had a bloody discharge from his nose and when he was taken there “lifeless and unresponsive” just before Christmas.      Could the Injury Have Been Predicted? 7.2  There is no evidence to suggest that the injury could have been predicted but with hindsight there were signs and symptoms of neglect and possible non-accidental injury in the weeks prior to this significant injury that point to clear safeguarding concerns about this baby. With hindsight there was a pattern of escalating injuries that was not recognised by any of the professionals involved that culminated in the very serious injury to Bobbie just before Christmas.      Family S4 Serious Case Review  Overview Report   Page48 Could the Injury Have Been Prevented? 7.3  There is some evidence to suggest that this injury may have been prevented. If a thorough assessment of Bobbie had been undertaken when he was taken to Accident and Emergency at Hospital 1 with a head injury, the differential diagnosis of possible non-accidental injury may have been identified. This is likely to have resulted in a strategy meeting and the earlier involvement of CSSC and the Police with the family. It is possible that the section 47 interventions with the family at an earlier stage may have resulted in Bobbie becoming subject of a child protection plan and this may have resulted in better outcomes for him. There is also evidence that the injury could have been prevented if GP 2 had followed his “gut feeling” that something was not right. If he had contacted GP 1 he would have discovered information about the visit to Accident and Emergency that had been withheld by the parents and that may have prompted him to contact CSSC and make an enquiry of the Designated Manager.  8.0 OVERVIEW REPORT RECOMMENDATIONS:   8.1  Assessment of/response to indicators of risk There is evidence that there was insufficient focus on the voice of the child. This was a non-mobile and non-verbal baby and visible signs of neglect and non-accidental injury either went unnoticed or were noticed and not responded to by the professionals involved. There were concerns raised during the SCR about the assumptions made by professionals that all was well despite signs to the contrary. The view was taken that the baby was ‘laid back’ - meaning content - when in fact he had probably learnt early on that demanding food or nurture elicited no response i.e. he had “given up” trying to get his needs met by care givers.  Recommendation 1 It is recommended that the LSCB promotes the need for all professionals to listen to the voice of the child. This should specifically include a focus on the needs of the child where they are not able to communicate verbally, for example, pre-verbal children and children with impairment. It is additionally recommended that the DSCB disseminate the recent Ofsted evaluation paper entitled “The Voice of the Child”.  8.2 Assessment of Capacity to Parent: Concealed Pregnancy  The pregnancy was concealed, which is increasingly rare nowadays, but no professional apparently considered this as a potential indicator of increased vulnerability of Jemima or her ability to parent within any assessment undertaken.   Recommendation 2  That the LSCB develops and disseminates good practice guidance relating to Concealed Pregnancies and Births in order to promote a greater understanding of the possible vulnerabilities of Jemima and possible increased safeguarding risks to the child.  8.3 Information Sharing The childminder had identified concerns about the baby, for example, bruising to the baby’s face and some signs of neglect but did not report these.   Family S4 Serious Case Review  Overview Report   Page49 Recommendation 3  It is recommended that the LSCB ensures that a) childminders routinely record the health visitor contact details of children they enrol and b) that childminders are clear that they must contact their Early Years Safeguarding Adviser when there are safeguarding concerns about a child (such as bruising in a non-mobile baby) and that they can contact the child’s health visitor about more general parenting concerns that may then trigger the health visitor to provide the parent(s) with additional support or advice. (For example, in this case, the curdled milk and unclean presentation of the baby).    8.4 Assessment of/response to indicators of risk There were several instances of injury seen by professionals that were not reported or acted on appropriately.  Recommendation 4 That the “Bruising, bleeding, fractures and possible injuries in children who are not independently mobile” protocol produced by health professionals is taken to the LSCB for endorsement so that it can be disseminated for use by all professionals in the inter-agency community, with clear guidance on the point of contact for  professionals who have concerns.   8.5 Information Sharing The first contact by Hospital 3 to Local Office 1 was by way of a child protection enquiry made to the local office in addition to asking for information about out of hours contact arrangements.  The local office should have referred this enquiry to the Designated Manager at the Safeguarding Unit.   Recommendation 5 That a practice alert is sent to all agencies to remind of the distinction between the two types of enquiry and the appropriate person to contact in each instance.  The two types of enquiry are: a) enquiries made to the local area office (with parental consent) about whether a family is known to CSSC and  b) enquiries made in cases where there are concerns that child is suffering or is likely to suffer significant harm, which need to be made via the Designated Manager in the Safeguarding Unit and not to the local area office.  8.6 Assessment of/response to indicators of risk  During the SCR there was confusion about the understanding of the S47 process and the parallel criminal investigations. Whilst this confusion did not appear to have been an issue at the time of the incident and did not have any impact on the outcome for this child it highlighted the need for clarity in the SUDI protocol about when it is used in conjunction with S47 enquiries (e.g. when the child is still alive and there are safeguarding concerns).  Recommendation 6 That the SUDI protocol (which is in the process of being revised) is further reviewed in light of the learning from this SCR. Specifically in relation to how the protocol can be used effectively in cases where the baby is not expected to die, and how the interface with section 47 enquiries can be managed alongside this, particularly with regard to holding strategy  Family S4 Serious Case Review  Overview Report   Page50 meetings and to avoid confusion in the use of terminology.  8.7 Communication and Ownership Bobbie sustained several injuries and each of these was viewed and assessed in isolation and did not lead to a proper recognition of potential child protection concerns. In addition, when the baby was admitted to hospital with the final serious injury, the GP did not pass on all of the available and pertinent information.   This has been an issue in previous SCRs (see Baby C and Baby M) which suggests that learning from these SCRs has not become embedded in practice.  Recommendation 7 That the LSCB considers what the barriers are that prevent lessons from previous serious case reviews becoming embedded into practice.  8.8 Inter-agency Relationships There is evidence from the respective IMRs from agencies involved during the five-day period from Christmas Eve, that there was a differing understanding of how the procedures were being applied and at what stage the threshold for a s47 enquiry was reached. This became an issue for the Panel, particularly in relation to the purpose and focus of the meeting at the hospital on Christmas Day. It was apparent that the Police, Hospital and OOHS had a differing understanding of the process being followed and whether OOHS could or should have attended.  Recommendation 8 Communication should be explicit rather than implicit and accurately recorded at the time. Clarity and greater understanding about each other’s roles in child protection situations and in the purpose and recording of strategy discussions is required.                   Family S4 Serious Case Review  Overview Report   Page51 REPORT ADDENDUM: 6 December 2013 What actions have been taken in response to the findings?  This SCR in respect of Family S4 was initiated in February 2011 and was initially concluded and signed off by the Dorset Safeguarding Children Board (DSCB) in March 2012 but due to significant delays in the criminal process the report has not been able to be made public until now.    In this time, there has been significant changes made to practice as a result of this Review and these have been detailed below. Despite the publication delays, the DSCB has shared the learning with professionals working with children and support agencies to change practice to better safeguard children in the future.  The action plan developed as a result of this review sets out the actions required in order for each of the recommendations above to be fulfilled.  This action plan has been monitored quarterly at each meeting of the Dorset Safeguarding Children Board and the auditing of those actions has been undertaken by the DSCB Quality Assurance Group.  The action plan has now been completed in full.  The DSCB ensured that the SCR for this family was independently chaired and the overview report was independently authored.  This ensured that agencies in Dorset were sufficiently challenged about their practice in this case.    The independent overview author also spoke with family members following the trial in order to understand their perspective and significant consideration was given by the DSCB to what life was actually like for this baby.  A learning document called a Synopsis of Learning was disseminated to all agencies in April 2012 by the DSCB; this was shared by agencies with all staff in addition to being used as a training tool.    The action plan incorporated the following learning and changes in practice:  Hospital 1  Since the initial case review there have been clear changes in policy, information available to staff and messages in training. Assessment tools used by staff all include emphasis on the child. Compliance to policy is monitored through audit and reported to the Trust safeguarding children committee.  The Trust is compliant with all the recommendations from this review and continues to work with multi-agency partners to improve practice.   GP and Health Visiting Services  The healthcare community in Dorset takes the safety of everyone very seriously especially those who are vulnerable or unable to protect themselves.   We are continuing to work closely with our partners around issues concerning child safety. This includes the appointment of a dedicated safeguarding lead and named responsible GP, along with the introduction of a training package for GPs and an updating of the Bruising protocol for all local health providers.  Family S4 Serious Case Review  Overview Report   Page52   Early Years and Childcare Service   Although there was no direct criticism of the Local Authority Early Years services and their support to the childminder in question, action has been taken to address the concerns raised.  Following recommendations from the individual management review we reviewed the support provided to childminders in Dorset and recognised the complexity and potential for confusion in roles. As a result a service specification was produced and tendered with the new Childminder Support and Development Service being in operation since September 2012. The service ensures all childminders have a named advisor providing on-going support from the pre-registration stage. During this time childminders have reported improved satisfaction with the service and there has been a rise in the quality as judged by Ofsted. The requirements for safeguarding training have been strengthened with childminders now expected to attend the DSCB level 3 multi agency safeguarding training.    Children’s Social Care Services   Response to concerns about actions over Christmas All social work teams have had the opportunity to meet a member of the Safeguarding Unit and talk through the value of child protection checking taking place through the Safeguarding Unit.  In addition, this issue is emphasised at all Multi Agency Safeguarding Training where issues around recognition of child abuse and referrals are discussed.  The Sudden Unexplained Death in Infancy Protocol has been re-written and cross agency training has taken place.  This recognises the difference between response and the SUDI Protocol and response under Section 47 Referral.  In addition, the importance of response over Public Holidays has been addressed by the Out of Hours Service.  Since the Action Plan has been put in place, there has been no repeat of the concerns raised through the Serious Case Review.  Update on the family circumstances Bobbie remained in hospital for approximately one month.  During this period, Social Care initiated Care Proceedings and were granted an Interim Care Order.  When Bobbie was well, he was discharged to the care of Foster Carers – Jemima and Stephen remained together during this period and after assessment, Bobbie was placed with his grandparents.  After some while, Stephen admitted to Jemima that he dropped Bobbie, therefore causing the injuries accidentally.  Jemima immediately separated from Stephen and asked for Bobbie to be returned to her; this was assessed and a return home monitored through Court processes.  Bobbie now lives at home successfully with Jemima, who has the ongoing support from maternal grandparents.  Stephen has no contact with Jemima or Bobbie.  Jemima takes Bobbie to all his medical appointments and he regularly attends the local Pre-School.  He is a happy little boy who relates well to Jemima and his grandparents.   