Death of a 12-week-old infant girl in October 2021 following co-sleeping with her mother and twin sibling. Delilahs mother had consumed alcohol and cocaine the previous night and had experienced multiple incidents of domestic abuse. Learning themes include: the effect of twin births on risks associated with co-sleeping; viewing substance use in the context of domestic abuse and depression; impact of alcohol use on parenting capacity; the presence of domestic abuse in current and past relationships; limitations in the child and family assessment; effectiveness of the child in need plan; understanding family composition and functioning, including older children living with family members in other local authority areas; and disguised compliance. Recommendations include: remind partner agencies of the importance of an early referral for an assessment of risk to an unborn child; obtain assurance from partner agencies that consistent, unambiguous safe sleep advice is given to parents in respect of multiple births; develop a policy outlining action to be taken when parental consent to observe sleeping arrangements for new born children is declined; empower professionals with knowledge of alcohol risk identification; ensure the local Domestic Abuse Partnership Board address the training needs of non-specialist domestic abuse professionals, reflecting on the many ways domestic abuse may affect victims; ensure child and family assessments explore relevant issues in sufficient depth; ensure child in need plans are specific about what needs to happen and by when, and that plans are not ended prematurely; and commission a case study highlighting the challenges of professional engagement and the importance of exercising professional curiosity.
      
 Title:  Local child safeguarding practice review – ‘Delilah’. LSCB: Sefton Safeguarding Children Partnership Author: David Mellor Date of publication: 2022  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.                           Strictly Confidential   1        Sefton Safeguarding Children Partnership  Local Child Safeguarding Practice Review – ‘Delilah’   Contents                                                                                      Page Number  Introduction                                                                                       2          Terms of Reference                                                                          3-4        Synopsis                                                                                           5-16       Family contribution                                                                        17-19                                 Analysis                                                                                           20-47                                  List of Recommendations                                                              48-49                                 References                                                                                                                                  Appendix A                  Strictly Confidential   2       1.0 Introduction  1.1 Delilah (a pseudonym) died in Hospital 1 during October 2021. She was twelve weeks old. She had been conveyed to hospital by ambulance after her mother found Delilah face down and unresponsive in the bed in which she (mother) had been sleeping with Delilah and her twin sibling during the afternoon of that day. Delilah’s twin sibling was unharmed. Delilah’s mother reported that she had consumed 4 bottles of beer the previous night and was later found to have also taken cocaine.   1.2 Sefton Safeguarding Children Partnership decided to conduct a local child safeguarding practice review (LCSPR) after initially conducting a Rapid Review in accordance with Chapter 4 of Working Together to Safeguard Children 2018. The Rapid Review reflected on mother’s lengthy history as a repeat victim of domestic abuse across several relationships and the substantial involvement of services with mother, her partners and their children. The Rapid Review highlighted many opportunities which could have made a difference if explored further by professionals and noted several factors of concern in partnership practice.   1.3 The Designated Nurse Safeguarding Children at NHS South Sefton Clinical Commissioning Group (CCG) and NHS Southport and Formby CCG was appointed as the chair of a Panel established to oversee the LCSPR. She has 32 years experience of working in the NHS and has spent the last 8 years in her current role. She has extensive experience of working as a Panel member on LCSPRs and other statutory reviews. She had no direct involvement in, or management responsibility for services involved in, this case. David Mellor was appointed as the independent reviewer. He is a retired police chief officer who has ten years’ experience as an independent reviewer/author of LCSPRs and other statutory reviews. He has no connection to services in Sefton. A description of the process by which the review was conducted is set out in Appendix A.  1.4 An inquest will be held in due course.  1.5 Sefton Safeguarding Children Partnership wishes to express their heartfelt condolences to Delilah’s family.      Strictly Confidential   3      2.0 Terms of Reference  Period on which the CSPR will focus:  2.1 The CSPR will focus primarily on the period from December 2020 (when mother’s partner was remanded in custody following a serious assault on her) and Delilah’s death in October 2021. It is recognised that some partner agencies had substantial prior contact with mother, her partners and their children which were summarised where relevant to the key lines of enquiry set out below.  Purpose of a CSPR:  2.2 The purpose of child safeguarding practice review is to identify improvements to be made to safeguard and promote the welfare of children.   Key lines of Enquiry:  a. The National Child Safeguarding Review Panel has urged Sefton Safeguarding Children Partnership to consider benchmarking local arrangements against the guidance in their Out of routine: A review of sudden unexpected death in infancy (SUDI) in families where the children are considered at risk of significant harm. The National Panel advise that the ‘prevent and protect’ practice model for reducing the risk of SUDI would provide a framework for reviewing the local strategy for safer sleeping arrangements.  b. What effect did the birth of twins have on the risks associated with co-sleeping and what advice was given to mother in this regard?   c. Was mother’s mental health sufficiently understood including depression, prior postnatal depression, self-harm and suicidal ideation?  d. How effectively did practitioners respond to concerns about mother’s alcohol use?  e. Were agencies aware of mother’s use of illicit drugs? If so, what action did they take?  Strictly Confidential   4 f. Was the impact of mother’s alcohol use on her parenting capacity fully considered and addressed?  g. What support was offered to mother to help her address her alcohol use?   h. Was mother’s alcohol use seen in the context of her experience of domestic abuse from partners and her anxiety and depression?  i. Was the history and dominating presence of domestic abuse in mother’s relationships with the father of the twins and with previous partners fully understood and the impact on mother fully considered?    j. Was there sufficient understanding of the impact of the father of the twins on the household, even though he was serving a term of imprisonment for assaulting mother?  k. How comprehensive was the child and family assessment undertaken prior to the birth of the twins? Was sufficient consideration given to the substantial history of agency involvement with the family?   l. Was the Pan-Merseyside Pre-Birth Protocol followed in this case?  m. How effective was the Child in Need Plan in respect of the unborn twins? How appropriate was the decision to close the Child in Need plan prior to the birth of the twins?  n. Was family composition and functioning fully understood, including mother’s older children who were living with family members in other local authority areas?  o. How effectively did agencies respond to indications of disguised compliance in mother’s contact with services?  p. How effective was communication and information sharing and multi-agency working generally in this case?  q. Did the restrictions imposed as a result of Covid-19 impact in any way on agency contact with mother and the children or affect mother and the children in any way?    r. The Rapid Review commented that some of the potential areas of learning from this case are longer term issues which have been highlighted by Strictly Confidential   5 previous reviews. The CSPR should therefore consider how learning from this, and earlier reviews can be embedded in professional practice.   s. What was understood by partners about the lived experience of the child?  3.0 Chronology of key events  3.1 Delilah’s maternal grandparent’s have contributed to this review. The maternal grandmother spent time staying with mother to support her following the birth of Delilah and her twin sibling. She described Delilah as a very placid baby, in contrast to her twin sibling who was much more active. She said that Delilah was ‘coming on brilliantly’ and that she had begun smiling as she got a little older. The only concern maternal grandmother said that she had was that Delilah would go ‘pure white’ whilst she was asleep although her colour would be restored when she woke up. She said that this had been mentioned to the community midwife, who had provided reassurance. The maternal grandmother felt that mother had coped well with parenting twin babies, although she said that it was very hard work.  She added that Delilah and her twin had always been dressed in ‘beautiful’ clothes. Professionals who provided mother and the twins with antenatal support observed that mother appeared to have a good emotional bond with the twins and was attentive to their needs. The home environment was described as ‘good’ and professionals felt that the twins appeared to be well cared for, loved and cherished. They were taken to all GP appointments. The maternal grandmother said that Delilah’s sudden death had been a terrible shock for the family but that they had recently marked what would have been her first birthday by releasing balloons off a local pier.  3.2 This LCSPR discloses a history of domestic abuse across mother’s four relationships which is significant in its frequency and nature. The police attended twenty two incidents of domestic abuse in which mother was always the victim, the first of which was reported in 2006 when mother was 19. The father of her first child (child 1) was sentenced to a lengthy period of imprisonment for assaulting her and there were several incidents of domestic abuse involving the father of her second and third children (child 2 and child 3).  Mother was frequently assessed as being at high risk of domestic abuse and during her relationship with the partner who was subsequently found to be the father of Delilah and her twin sibling (referred to as mother’s ‘partner’ throughout this report), she was referred to the Multi-Agency Risk Assessment Conference (MARAC)1 - a multi-agency meeting to which the highest risk domestic abuse victims are referred - five times between October 2019 and December 2020 and the injuries she sustained required hospital admission in respect  1 MARAC is a multi-agency meeting to which the highest risk domestic abuse victims are referred Strictly Confidential   6 of two of those referrals. Mother was also referred to the IDVA service2 on five occasions during this period but the support the service was able to provide to mother was very limited as most attempts at contact were unsuccessful despite repeated attempts.    3.3 There had been extensive children’s social care involvement with mother, her partners and their children from 2013 relating to ‘mother’s lifestyle and volatile relationships’, concerns about parental substance misuse – particularly mother’s long history of alcohol misuse, parental neglect of her elder three children (child1, child 2 and child 3) relating to poor school attendance, unsatisfactory home conditions, lack of access to health services and disclosures by the children that they had been left alone. There had also been concerns about mother’s mental health and her risk of self-harm and complaints of anti-social behaviour from neighbours. Mother’s level of engagement with children’s social care and early help was a cause for concern throughout these years.   3.4 Mother’s elder three children were subject to child in need plans from August 2019 until February 2020 (child 2 and child 3) and April 2020 (child 1). By this time mother’s relationship with her partner had begun which exposed her – and her children – to significant harm from domestic abuse. Mother spent some time in a refuge in Liverpool in the early months of 2020 but resumed the relationship with her partner when she left the refuge at the beginning of the first Covid lockdown in March 2020. By the time the above mentioned child in need plans had ended and none of the children remained in the physical care of mother. Child 1 was living with her maternal grandparents in Liverpool and child 2 and child 3 were living with their father in Lancashire. All of these living arrangements for the children appear to have been informal.   3.5 Following the resumption of mother’s relationship with her partner in late March 2020, the police were called to domestic abuse incidents in March, April and May 2020 (two incidents). On 17th August 2020 mother and another male were assaulted by her partner. Mother sustained a large laceration to her head and a fractured nasal bone and was admitted to hospital 1. Her relationship with the partner appears to have ended for some months. She reported a burglary at her home in late November 2020 in which jewellery was stolen and the house ‘ransacked’. Mother later told the  2 Independent Domestic Violence Advisor (IDVA) Their main purpose is to address the safety of victims at high risk of harm from intimate partners, ex-partners or family members in order to secure their safety and the safety of their children. Serving as a victim’s primary point of contact, IDVAs normally work with their clients from the point of crisis to assess the level of risk, discuss the range of suitable options and develop safety plans.   Strictly Confidential   7 police that she suspected her partner to be responsible although the offence remains undetected.     3.6 On 2nd December 2020 the police went to mother’s home address after she had failed to attend the College at which she was a student. The police located mother at her home address with her partner. She had sustained swelling and bruising to her left eye, a cut and swollen eye, bruising to her left ear and reported pain in her jaw and left wrist from a sustained attack from her partner and was transported to Hospital 1. The partner was arrested. Mother declined to provide a statement. However, the partner was charged with the two assaults committed on 17th August 2020 and was kept in custody. Mother was treated for her injuries and the hospital made a MARAC referral and referrals to the children’s social care departments for the geographic areas in which child 1 lived with her maternal grandparents and child 2 and child 3 lived with their father.   3.7 On 6th December 2020 mother was arrested for being drunk and disorderly following an incident at the maternal grandparent’s address. Child 1 was present. In his contribution to this review, maternal grandfather has given an account of the events which preceded mother’s arrest (Paragraph 4.7) including physically restraining her from running in front of traffic. Mother subsequently told police officers that she thought about self-harming ‘all the time’ and was seen by the Criminal Justice and Diversion Team whilst in police custody. The team attempted to conduct a full mental health screen although mother did not wish to complete the full assessment. It was concluded that there was no evidence of severe mental illness. She was deemed to have mental capacity to make her own decisions. Mother denied any thoughts of self-harm or suicide, adding that she had not had such thoughts ‘for years’. This response appears inconsistent with the account provided by maternal grandfather and with what mother had said to officers at the time of her arrest. The Criminal Justice and Diversion Team formed the view that the risk of self-harm earlier identified by the police related to when mother was intoxicated and that when sober, she denied these. The team helped mother with temporary overnight accommodation, attempted to contact the Venus project3 and a Refuge and provided contact numbers for crisis support and Women’s Aid. The police dealt with mother by way of community resolution, although she failed to comply with the conditions.  3.8 Following mother’s arrest child 1 was referred to Early Help to establish if the child felt safe with mother. Early Help was unable to contact mother until 9th February 2021 after a delay in allocating a worker and initially having an incorrect  3 The mission of the Venus Centre is to empower, promote and support women, young women and their children in developing their potential, recognising their choices, achieving their goals and challenging injustice Strictly Confidential   8 telephone number for mother. Mother declined support stating that she was now ‘in a much better place’ and was no longer drinking heavily. However, the Early Help worker supported mother to make an appointment with a solicitor to explore regaining contact with child 2 and 3 now that her partner was in prison. Early Help also spoke to the maternal grandparents by phone and established that child 1 had been living with them for two and a half years. They also declined support and Early Help closed the case on 11th March 2021. There is no indication that child 1 was spoken to during this period of Early Help involvement. Nor is there any indication that mother disclosed that she was pregnant.  3.9 On 16th December 2020 mother’s case was discussed at MARAC where it was noted that her partner was on remand awaiting trial for the 2nd December 2020 assault on mother although it was stated that it was likely that this would be an evidence-led prosecution as mother had not provided a statement to the police. As stated in paragraph 3.2 this was the fifth time mother had been referred to MARAC as a high risk victim of domestic abuse during her relationship with her partner. Mother’s pregnancy was not known to partner agencies at that time. IDVA had attempted to contact mother following the 2nd December 2020 incident but had received no reply and had closed her case on 8th December 2020 due to lack of contact. (The LCSPR has been advised that cases can be closed by IDVA when there has been a reduction in risk to the service user, no further actions are possible from the IDVA service, even if risk remains high or the service user has disengaged from support).  3.10 On 21st December 2020 the police referred mother to adult mental health services after maternal grandfather reported finding indecipherable writing on the wall of mother’s home which mother said was a ‘suicide pact’ which her partner had cajoled her into writing on the wall and that she had gone along with this to ‘appease’ him. A mental health worker phoned mother who confirmed that she had been coerced into writing on the wall and that she had no intention to act on the ‘suicide pact’ and that her partner was ‘off the scene’. Mother was offered a welfare check from the mental health triage care service but declined this. She said that she did not need any support at that time and the referral was closed on the grounds that there were no assessed risks.  3.11 On 25th January 2021 mother had a pregnancy booking-in appointment with Hospital 1 midwifery by telephone. The midwife documented that mother declined to provide the name of the father but disclosed that there had been domestic abuse in a previous relationship and previous involvement by children’s social care. The midwife documented that mother had provided only limited ‘social’ information. In early February 2021 it was established that mother was expecting twins.  Strictly Confidential   9 3.12 Also on 25th January 2021 mother’s partner was sentenced to 30 months imprisonment for assaulting mother and a male during the incident which took place on 17th August 2020. On the advice of the Crown Prosecution Service, the partner was not charged in respect of his assault on mother on 2nd December 2020 as mother had declined to make a statement and a further charge was thought unlikely to result in a lengthier sentence.  3.13 The safeguarding midwife subsequently reviewed the information shared by mother at the booking-in appointment and also accessed mother’s electronic records – which are separate to maternity records – and noted previous Emergency Department (ED) attendances relating to domestic abuse and decided to make a referral to children’s social care because of the potential impact of domestic abuse on the unborn child and the need for an assessment to consider ‘past harms and current concerns’. The referral was made on 26th February 2021, received by the MASH on 1st or 2nd March 2021 when requests for information were made to relevant partner agencies.  3.14 On 4th March 2021 the Sefton MASH decided that a child and family assessment should be completed as there had been two significant episodes of domestic abuse since the case had been closed to Sefton children’s social care in April 2020. It was noted that mother had refused to divulge the details of the father and concern was expressed that he may be the partner who was the perpetrator of the two most recent incidents of domestic violence. The assessment was to explore whether mother had made sustainable changes to her lifestyle to meet the developing needs of her children once born, or whether a ‘high risk’ pre-birth assessment was required given the history. It was noted that alcohol misuse has been an ongoing issue but that mother had stated that she had not drank since discovering she was pregnant. The assessment was to clarify what strategies/services mother had engaged with in order to achieve abstinence from alcohol. It was also decided that the assessment needed to explore child 1’s living arrangements as she spent the majority of her time with maternal grandparents, ‘due to it being easier for her to get to school’ but had regular contact with mother, described as being on a daily basis. MASH noted that there was no formal arrangement in place in respect of child 1 residing with maternal grandparents. The MASH expressed concern about child 1 being exposed to the issues affecting mother’s life, instability in child 1’s care arrangements and a lack of permanence.   3.15 It has been established that Sefton MASH was aware that child 1 remained open to Early Help at the time they decided a child and family assessment should be undertaken. At that time the MASH didn’t have access to the ‘Early Help Module’ and was therefore reliant on information derived from the enquiries they completed. The LCSPR has been advised that the MASH now has access to the ‘Early Help Module’.  Strictly Confidential   10  3.16 The child and family assessment was allocated to a social worker on 4th March 2021. The social worker received no answer to the first two unannounced visits (mother may have been attending College at this point) to mother before seeing her on 19th March 2021. This was the only time that mother was seen during the child and family assessment which was completed on 27th April 2021. The social worker accessed management oversight on two occasions – once when the child and family assessment was completed and on a second occasion shortly after the child in need plan was begun. Following the first management oversight, it was documented that the team manager would assist and support the social worker should mother continue to refuse to engage and that consideration would be given to whether there was a need for escalation. There is no indication that the case was escalated and it is unclear what form the ‘assistance and support’ took. Child 1 was visited on one occasion at maternal grandparent’s address, although this visit was made by a duty social worker as the social worker completing the child and family assessment was unavailable. The LCSPR has been advised that the social worker was undertaking the 12 month Assessed and Supported Year in Employment (ASYE) employment-based programme of support and assessment for newly qualified social workers at the time she was allocated the child and family assessment.  3.17 Mother reported no alcohol use since finding out she was pregnant and said that although the pregnancy was unplanned, she was excited about the arrival of twins. She added that her college course was having a positive impact on her life.   3.18 The child and family assessment template contains 44 separate headings which relate to potential concerns. The template invites the social worker completing the assessment to answer ‘yes’ or ‘no’ in respect of each of the headings. All headings were answered ‘no’ with the exception of ‘emotional abuse’ and ‘financial exclusion’. Amongst the headings which appeared to have been incorrectly answered ‘no’ were ‘concern about alcohol misuse by the parent/carer’ and headings in relation to domestic abuse and mental health. Under ‘What we are worried about’ the following was listed:  • Mother's lack of engagement with Children's Social Care. • Children's social care unable to evidence mother's preparation for the unborn babies. • Mother does not have her three children in her care and states this is on a voluntary basis. • Mother is not disclosing the identity of the father of the unborn twins. • History of domestic violence and a lack of work completed around this. • History of alcohol misuse and a lack of work completed around this. Strictly Confidential   11 • Not known if mother has support around her in Southport as maternal parents live in Liverpool.   3.19 Under ‘What needs to happen’ the following was listed:  • Mother to engage with Children's Social Care for support in preparation for the unborn babies. • Mother to be open and honest with professionals regarding the father of the unborn babies. • Mother to address Children Social Care's concerns and have discussions around this and what support can be offered. • Identify what level of support mother has around her for when the babies are born. • Child 1 – who was documented not to have said much about mother and said that she ‘sees her sometimes’ - to remain in the care of her grandparents in line with a positive risk assessment and her feelings/wishes.   3.20 The outcome of the assessment was the need for further intervention in the form of domestic abuse support, alcohol support and more was to be found out about the identity of the father which mother continued to be unwilling to divulge. Child in Need (CiN) support was to be provided to explore whether mother had made sustainable changes to her lifestyle or whether a ‘high risk’ pre-birth assessment was required given her history. If mother did not engage with child in need planning, the team manager would become involved and escalation would be considered. The team manager directed that a CiN meeting was to be arranged within 10 working days to which all core agencies were to be invited. The Panel questioned the rationale for Child in Need support as opposed to Child Protection Planning. The child and family assessment provides no specific rationale for deciding on Child in Need support although this appeared to be a course of action which was dependent on mother’s engagement. In the event of this not being forthcoming ‘escalation’ would be considered.  3.21The social worker completing the child and family assessment initially struggled to contact mother’s midwife as there had been a change in the midwife to whom mother had initially been allocated. However, the specialist safeguarding midwife shared information with the assessment in respect of mother’s engagement with maternity services from the point at which she booked-in for the pregnancy. This information disclosed initial concern about mother’s engagement with maternity services which had improved subsequently. The social worker also contacted mother’s health visitor but she had no information to contribute as the health visitor antenatal visit was not due to be completed before 28 weeks gestation i.e. late May 2021.  Strictly Confidential   12  3.22 Mother’s housing provider had applied for a court injunction due to ‘prolonged and regular noise nuisance’ in March 2021 but on 19th April 2021 the matter had been adjourned until August 2021 – until after mother had given birth.  3.23 On 17th May 2021 mother’s housing provider wrote to her after receiving a report of music being played in the evening (no further details) and to advise her to remove a number of household items and electrical goods from her rear garden.   3.24 On 8th June 2021 health visitor 2 visited mother and completed the antenatal contact. Mother’s case had been allocated to health visitor 1 but she was providing support to another team as a result of Covid 19 pressures. Mother said that, after being shocked at first, she was excited to be expecting twins. She confirmed that she was attending antenatal appointments. Lullaby Trust safe sleep guidelines were discussed, and mother said that she was aware of these guidelines and said that she intended to follow them. Mother went on to say that the child and family assessment was ongoing and that she had been informed that there would be a CiN plan in place for her and the twins. Mother reported feeling well emotionally, adding that she had been prescribed antidepressants in the past but ‘did not like them’. She said she experienced depression ‘on and off’ but found it best to talk about how she was feeling, adding that she had had counselling in the past. Mother did not disclose the identity of the unborn twin’s father.  3.25 The health visitor did not share the outcome of the antenatal visit with the social worker on the grounds that no concerning factors had been highlighted.  3.26 The child in need plan had commenced on 19th May 2021 and was concluded on 17th June 2021. One child in need meeting took place which was attended by mother and the social worker at mother’s home address. This meeting took place on 16th June 2021 – the day before the child in need plan was concluded. Two areas of need were addressed by the plan, which were ‘support for mother raising twins as a single parent’ in respect of which a referral to Home-Start was the key action and ‘mother’s historic alcohol misuse for which she had not accessed meaningful intervention’. In respect of this second area of need, the plan stated that there had been no evidence of mother struggling with her mental health or alcohol use, that mother was aware of the services available to her and that she was aware of the need to continue to engage with health professionals and be open and honest. An update had been obtained from midwifery to the effect that mother was engaging with them and attending all appointments. No update was obtained from the health visitor, but it was anticipated that the health visitor would continue to support mother following the birth of the twins. Children’s social care closed the case on 30th June 2021. Strictly Confidential   13  3.27 On 27th June 2021 Home-Start received the referral from children’s social care in which the social worker wrote that mother was expecting twins and may benefit from support, advice and guidance, that she had previously struggled with her mental health and coping with twins could impact upon this, that she was isolated with very limited support networks and that the unborn babies’ father was not involved. The referral also stated that mother had three children of which she was not the main carer but that child 2 and 3 had been staying with her at weekends recently and she hoped that this would continue following the birth of the twins. The referral went on to state that mother has experienced domestic abuse in relationships in the past with ‘her children’s father’s and her ex-partner’ who was currently in prison for assaulting her and with whom mother stated that she had no contact.  3.28 The Home-Start worker – who herself was the mother of twins – visited mother on three occasions prior to the birth of the twins. Mother engaged positively with the worker. She expressed some anxiety about the forthcoming birth as it had been decided that a C-section was necessary. Mother said that she had organised a crib for when the babies were born.  3.29 The twins were born in late July 2021 and discharged home after five days as Delilah’s twin had had jaundice.   3.30 On 2nd August 2021 health visitor 1 made the primary birth visit. Mother and the twins were to be supported at ‘Universal Plus’ on the grounds of prematurity and multiple births. The twins appeared clean, appropriately dressed and handled gently by mother. They were being fed with expressed breast milk and formula. The health visitor viewed the day time sleeping arrangements which consisted of a large crib and baby chairs. Mother was concerned that the large crib was easily rocked and could therefore tip over. She said that she was currently using the baby chairs for the twins to sleep in. The health visitor discussed these arrangements with mother and pointed out that the chairs were slightly elevated and not flat and therefore mother needed to observe the twins at all times when they were sleeping in the baby chairs. The health visitor emphasised that the safest place for the babies to sleep was on a firm, flat surface in the ‘feet to foot’ position. The health visitor offered to view the night time sleeping arrangements but mother declined this. She reported that the twins slept together in a crib – also documented to be a ‘next to me’ cot - next to her bed. Mother was signposted to the multiple births association (TAMBA) website. (TAMBA is now known as the Twins Trust) Mother commented that she was already a member of an online multiple birth forum although no details of this were shared with the health visitor.  Strictly Confidential   14 3.31 Mother was also visited by the community midwife which discharged her from their service following a final home visit on 10th August 2021.   3.32 Home-Start maintained contact following the birth of the twins and established that mother was receiving support from maternal grandmother. The Home-Start worker visited on 9th August 2021 and documented that mother appeared to be coping well, though very tired – as expected. Mother agreed to take the twins, together with child 2 and 3 on a forthcoming trip organised by Home-Start but she did not attend the pre-arranged collection point near her home when the trip took place on 19th August 2021. Thereafter mother largely appeared to disengage from Home-Start.  3.33 On 2nd September 2021 health visitor 1 completed the 6-8 week contact. Mother appeared to love and cherish the twins and there were no health concerns. The babies were now being fed exclusively by formula. Mother reported that the twins slept in the baby chairs and the health visitor re-iterated her advice that the safest place for the twins to sleep was in a cot or a crib with a firm, flat surface in the ‘feet to foot’ position. Mother again said that the twins slept together in a cot at night. Mother apologised for the lounge – where the visit took place – being messy. The health visitor documented that the area was a little messy but not overly concerning.  3.34 On 3rd September 2021 mother registered the twins with her GP practice and she took them for their first immunisations on 16th September 2021 and postnatal check for mother and development check for the twins on 29th September 2021. The GP had no concerns about the twins. Gaviscon was prescribed for Delilah’s twin after mother reported some feeding difficulties.   3.35 Home-Start continued to receive no reply to their phone calls to mother and on 10th September 2019 the Home-Start worker phoned the social worker who advised that children’s social care were no longer involved and that there were no concerns.   3.36 On 22nd September 2021 mother sent the Home-Start worker a series of texts in which she said that she had been in a ‘really dark place’ over fears that she and the twins would be evicted because of complaints from a neighbour. She said that she was supposed to attend court in early September 2021 but had been unable to find a babysitter ‘plus I was too depressed to even care’. Mother went on to apologise for not getting in touch with the Home-Start worker, explaining that her ‘ex had been in touch and I’m paranoid about social services’. She then requested the Home-Start worker to write a letter of support to say that the conflict with her neighbour was affecting her health and caused her to give birth early and that the babies were born ‘very small’ as a result. Mother attached an image of a letter Strictly Confidential   15 relating to legal proceedings relating to the complaint from her neighbour. In response, the Home-Start worker made several attempts to ring mother but received no reply and had no further contact prior to Delilah’s death. (Mother’s housing provider have confirmed that mother did not attend an interim injunction hearing on 1st September 2021 and that she was not legally represented at the hearing as her solicitors had previously removed themselves from the case due to mother’s non-engagement. Her housing provider had no further contact with mother prior to the death of Delilah despite multiple attempts by letter, telephone and visit).  3.37 On 4th October 2021 health visitor 1 made a home visit. The twins were clean, appropriately dressed and handled with care by mother. Mother reported that Delilah had been vomiting and so she had given her some Gaviscon which had been prescribed to Delilah’s twin. The health visitor advised against this and encouraged mother to feed little and often to try and prevent the vomiting.  3.38 Delilah was last seen by a professional on 11th October 2021 when mother took the twins to the GP practice. Delilah’s twin was reviewed for colic and Gaviscon continued. Mother reported similar symptoms in Delilah, and she said she had tried Gaviscon which she said had helped. The GP prescribed Gaviscon for Delilah. Mother declined an examination of Delilah as the child was asleep.  3.39 The following day (12th October 2021) mother called 999 at 4.48pm after finding Delilah in mother’s bed face down and unresponsive under the covers. A rapid response vehicle arrived at the home address at 4.57pm 12th October 2021. Advanced Paramedics were present in addition to two ambulances and air medics who assisted at the scene. Delilah was unconscious and had gone into cardiac arrest. She was transferred to Hospital 1 where medical interventions were undertaken but she was pronounced dead at 5.48pm the same day.   3.40 Mother stated that having fed both babies she went upstairs to bed with them around 12 noon. She went on to say that she positioned both babies on their backs in her king size bed. She added that she positioned herself against the bedroom wall and positioned Delilah next to her and Delilah’s twin on the other side of Delilah. She said that it was unusual for her to co-sleep but thought it would be alright given the size of her bed. When she woke she found Delilah further down the bed, under the covers and unresponsive.   3.41 Mother said that she had consumed 4 bottles of beer the previous night. A receipt relating to the purchase of the beer on 11th October 2021 was found in mother’s bedroom as well as empty beer containers under her bed and in the baby changing bag. A half empty bottle of prosecco was also found in bedroom. Toxicology tests found both alcohol and cocaine in mother’s body. Strictly Confidential   16  3.42 The only sleeping facilities found in mother’s bedroom was a single snuzpod, which is a popular bedside crib which does not appear to have been a suitable bed for twins to sleep together in. In their contribution to the LCSPR, Delilah’s maternal grandparents stated that the twins slept together in a ‘canvas type’ cot which was placed next to mother’s bed. They said that one side of the cot could be opened and that this was the side of the cot placed next to mother’s bed. This enabled mother to easily lift the twins out of the cot and onto her bed for feeding (Paragraph 4.10). It is assumed that the maternal grandparents were referring to the snuzpod.                                   Strictly Confidential   17      4.0 Family contribution  4.1 The ongoing police investigation into the death of Delilah precluded an invitation to mother to contribute to the LCSPR. Merseyside Police advise that a charging decision in respect of mother is not expected to be made until September 2022, which appears to rule out involving mother in the LCSPR.   4.2 Delilah’s maternal grandparents were invited to contribute to the LCSPR and decided to do so. The independent reviewer met the maternal grandparents at their home address where child 1 also resides. The maternal grandparents have also been caring for Delilah’s twin sibling since shortly after Delilah’s death. Decisions about the long term future of Delilah’s twin sibling have yet to be finalised.  4.3 The maternal grandparents were aware of mother’s history as a victim of domestic abuse to an extent. It was clear that maternal grandfather had become particularly involved in efforts to safeguard mother from her most recent partner and that following the partner’s serious assault on mother and another male on 17th August 2020 (Paragraph 3.5), mother had stayed with the maternal grandparents for a time. The maternal grandparents were unaware of the MARAC process nor were they aware of the number of times mother had been the subject of MARAC referrals. They went on to say that mother kept a lot of information about domestic abuse from them and perceived herself to be a ‘strong person’ who could ‘look after herself’ in intimate relationships.  4.4 The maternal grandparents described the circumstances under which child 1 came to live with them permanently. They said that when mother moved to her current address, child 1 was keen to continue attending the school near her previous home. This necessitated a very early start to catch a bus which the maternal grandparents felt was too heavy a burden for a child of that age. As they lived much closer to child 1’s school, they suggested that child 1 stay at their house during the week and return to her mother and two younger siblings at the weekend. They said that these informal arrangements were agreed with mother, and this gradually progressed into child 1 residing with the maternal grandparents permanently. They implied that a factor in child 1 residing with them permanently was because she had witnessed some of the domestic abuse suffered by her mother. They said that they began to regard child 1 as another child of their own, although this remained an informal arrangement. Strictly Confidential   18  4.5 The maternal grandfather recalled his involvement in the incident which took place on 2nd December 2020. He said that during the morning he received a phone call from one of his daughter’s friends in college to ask him if he had heard from her. He said he then tried ringing his daughter and received no reply, adding that she was often hard to get hold of and that her partner frequently took her phones off her. He said he contacted the police via 101 and was advised that they were unaware of any incidents at his daughter’s house. (The LCSPR has been provided with details of the substantial efforts the police made to trace mother after they also were contacted by her college the same morning). He was unable to travel to his daughter’s house – which was 25 miles away - until late in the afternoon. He found the patio door open at his daughter’s address and shouted her name. He said she came down the stairs and said “Dad, don’t start nothing”. He said that he went upstairs to his daughter’s bedroom – which was in darkness as the lights frequently did not work. He realised that there was a male in the bedroom but couldn’t see him properly and so called the police. He added that the police attended and subsequently found the partner in the garden and arrested him. His daughter was taken to hospital to be treated for her injuries.   4.6 The maternal grandfather said that the partner was later bailed a condition of which was that he was not to contact mother, (maternal grandfather is mistaken about the partner being bailed) but the maternal grandfather said that the partner continued to contact her using a false Facebook profile, and repeatedly asked her not to ‘press charges.’ (the police have advised that it is possible the partner may have created the false Facebook account whilst on remand using a ‘contraband’ mobile phone or that the false account could have been created by a third party) He said that mother stayed with them (the maternal grandparents) for a period following the 2nd December 2020 assault.  4.7 The maternal grandfather went on to recall the incident on 6th December 2020 following which mother was arrested by the police (Paragraph 3.7) and subsequently referred to adult mental health services (Paragraph 3.10). He said that he took his daughter out for a walk to get her some fresh air after she had been drinking at the maternal grandparent’s house. He said that she began trying to ‘throw herself under a bus’, saying that she ‘wanted to die’. He said he physically prevented her from doing so by wrapping his arms around her to restrain her. He went on to say that he asked passers-by to ring the police, but no-one did. He said that he managed to get his daughter back to his house and she went to bed. At round 2 or 3am she awoke and said that she wanted to leave. The maternal grandfather tried to prevent her leaving as he feared for her safety and he said that she then became aggressive towards him and she rang the police – who attended and arrested her.  Strictly Confidential   19 4.8 Neither maternal grandparent was aware of the involvement of Early Help in respect of child 1 following the 6th December 2020 incident. Nor could they recall the children and family assessment commenced by children’s social care in April 2021 or the visit by the duty social worker to speak to child 1 as part of that assessment. (It should be borne in mind that the maternal grandparents have had very significant involvement with children’s social care since the death of Delilah – including an in-depth assessment of their suitability to provide long term care for her surviving twin sibling and that this high level of contact may have made it difficult to distinguish between one social worker visit and another). They said that they were unaware that there had been a Child in Need plan and that they were completely unaware that there had been any professional involvement in mother’s antenatal or postnatal care other than that which would be provided in respect of any pregnancy, although they could recall meeting the Home-Start worker.   4.9 The maternal grandparents said that they helped mother prepare for the birth of Delilah and her twin sibling and provided support following the births. Maternal grandmother stayed with mother and the twins for two periods following the birth and felt that her daughter was ‘coping brilliantly’ and that though it was very hard work, she appeared very confident in her care of the twins. The maternal grandmother said that during the period she was staying with her daughter and the twins, it would be 10pm before all tasks related to the care of the twins were complete. The maternal grandparents added that they looked after the twins at their house one weekend approximately two weeks before Delilah’s death.    4.10 The maternal grandparents described the sleeping arrangements for the twins. They said that they slept together in a ‘canvas type’ cot which was placed next to mother’s bed. They said that one side of the cot could be opened and that this was the side of the cot placed next to mother’s bed. This enabled mother to easily lift the twins out of the cot and onto her bed for feeding. They added that mother also had a ‘massive’ cot which she kept downstairs which she felt was ‘too big’ for the twins and also appeared a little unsteady in that it rocked from side to side.   4.11 The maternal grandparents said that after he was imprisoned for assaulting mother, she rarely talked about the partner and when she did so, she talked of him as though he was ‘in the past’. However, they felt that they could not rule out mother having indirect contact with the partner whilst he was in prison, suggesting that this could have been facilitated by the partner’s relatives.       Strictly Confidential   20      5.0 Analysis and findings   5.1 Four Key Practice Episodes have been identified where professionals were directly involved in working with Delilah’s mother to address safeguarding concerns, assess the risks to the unborn Delilah and her twin sibling and consider their support needs. For each Key Practice Episode the key lines of enquiry addressed are listed.  Key Practice Episode 1: Referral from midwifery and MASH decision  Key Practice Episode 2: Child and Family Assessment  Key Practice Episode 3: Child in Need plan not fit for purpose, not sufficiently inclusive and closed prematurely.  Key Practice Episode 4: The general professional response to mother’s lack of consent for the twin’s sleeping arrangements to be viewed and her sporadic engagement with professionals generally.   Key Practice Episode (KPE) 1 Referral from midwifery and MASH decision Key line of enquiry (KLOE) l addressed by KPE 1.  5.2 Midwifery made an appropriate referral to children’s social care after the  safeguarding midwife reviewed the information shared by mother at the booking-in appointment and information she was able to access from mother’s electronic records (Paragraph 3.13).   5.3 However, the referral was not made until a month after mother’s booking-in appointment. The Pan Merseyside Pre-Birth Protocol emphasises the importance of making a referral at the earliest possible opportunity in order that any assessment is conducted in sufficient time to provide parents with the opportunity to show evidence of change or, if any assessment indicates that a baby may not be safe with the parents, to allow practitioners the time and opportunity to make clear and structured plans for the baby’s future and set up support for the parents where necessary.   Strictly Confidential   21 5.4 The reason for the delay in making the referral was that, prior to submitting it, it was intended to advise mother of the safeguarding referral at her next appointment with midwifery. However, she did not attend scheduled screening blood test appointments on 16th and 23rd February 2021 and so the referral was delayed until mother attended an antenatal appointment on 26th February 2021. However, it is recommended that Sefton Safeguarding Children Partnership reminds the NHS Foundation Trust for Hospital 1 and all partner agencies of the importance of making a referral for an assessment of the risk to an unborn child at the earliest possible opportunity.  Recommendation 1  That Sefton Safeguarding Children Partnership reminds the NHS Foundation Trust for Hospital 1 and all partner agencies of the importance of making a referral for an assessment of the risk to an unborn child at the earliest possible opportunity.  5.5 Sefton MASH made an appropriate decision that a child and family assessment should be completed. The Pan Merseyside Pre-Birth Protocol provides a non-exhaustive list of criteria for deciding to conduct a child and family assessment. The list is reproduced below, and all the criteria appear to have been met in Delilah and her twin’s case with the exception of ‘parent is a Looked After Child’ and ‘concealed or denied pregnancy’. A brief summary of the evidence of each criteria being met is shown in italics.  • There are concerns that parent/their partner/potential carer may pose a risk to children (examples may include previous neglect or physical abuse of children, or sexual offences) – mother had previously neglected her older children and the conduct of her partner had exposed the older children to risks associated with domestic abuse. • There are concerns regarding parent/their partner/potential carer in terms of their parenting capacity. Such concerns may include mental health problems, learning disability or inability to parent or protect children from harm – there were concerns about mother’s mental health and wellbeing including the risk of postnatal depression which she appeared to have experience following the birth of child 1 and the risk of self-harm • Parent/ their partner/potential carer has children that have been made subject to a Child Protection Plan, or Care or Supervision Order at any time in the past (or if proceedings are ongoing) – mother’s older children had been subject to child protection and child in need planning and this had ended only in April 2020. • If the parent is currently a Looked After Child – not applicable. Strictly Confidential   22 • There are concerns re domestic abuse. These could relate to any person who may be involved with the unborn baby – mother had been a high risk victim of domestic abuse in three intimate partner relationships including her most recent relationship with the partner who it was thought may be the father of the unborn twins. • There are concerns regarding problematic drug/alcohol misuse of parent/their  partner/potential carer – there had been concerns about parental drug misuse and mother’s long term alcohol misuse for which she had not accessed support. • There are significant concerns about the lifestyle of partner/their partner/potential carer which would impact on their ability to parent or protect children – whilst it would be completely inappropriate to regard the domestic abuse suffered as a ‘lifestyle’ issue, mother’s housing provider had shared her the substantial history of anti-social behaviour complaints from neighbours with the police and via the MARAC process. • See Concealed or Denied Pregnancy Protocol if a pregnancy is concealed or denied – not applicable.  5.6 Sefton MASH directed that the assessment was to explore whether mother had made sustainable changes to her lifestyle to meet the developing needs of her children once born, including clarifying what strategies/services mother had engaged with in order to achieve her stated abstinence from alcohol. The MASH decision strongly implied that if sustainable changes were found not to have been made by mother, a ‘high risk’ pre-birth assessment was required given the history. (The term ‘high risk’ pre-birth assessment is not used in the Pan Merseyside Pre-Birth Protocol).  5.7 The MASH also expressed concern over child 1’s exposure to the issues affecting mother’s life, instability in child 1’s care arrangements and a lack of permanence and directed that child 1 should also be included in the assessment. Sefton MASH was aware that child 1 remained open to Early Help for a similar purpose at that time. (Paragraph 3.15)  Key Practice Episode 2 Child and Family Assessment KLOEs k, l, p, c, d, f, g, & n addressed by KPE 2. 5.8 The Pan Merseyside Pre-Birth Protocol states that the children and family assessment will gather information from all involved agencies using the Pre-Birth RAG Screening Tool which enables the professional completing the tool to apply ‘red’ or ‘amber’ to a number of factors such as ‘parental drug/alcohol misuse’ to clarify the level of need. There is no indication that the RAG Screening Tool was used in this case but the most crucial departure from the Protocol was the absence of an Strictly Confidential   23 assessment meeting of all professionals involved at which the support required is identified. The outcome from the professionals assessment meeting will be either Proceed to Pre-Birth Assessment, (it is presumed that this is equivalent to the ‘high risk’ pre-birth assessment referred to by MASH) Child-in-Need Plan, Early Help or No Further Action.  5.9 Awareness of the Pan Merseyside Pre-Birth Protocol appeared to be low amongst the practitioners who attended the learning event arranged to inform this LCSPR and several agencies who contributed reports to this review stated that they were unaware of the Protocol. The failure to follow the Protocol had a significant impact on the multi-agency response to the risks to the unborn Delilah and her twin sibling. The LCSPR has been advised that the Protocol was appropriately promoted when initially launched in June 2019. However, the passage of time and turnover of staff may necessitate regular reminders of key policies.  5.10 It is therefore recommended that Sefton Safeguarding Children Partnership promotes awareness and compliance with the Pan Merseyside Pre-Birth Protocol.   Recommendation 2  That Sefton Safeguarding Children Partnership promotes awareness and compliance with the Pan Merseyside Pre-Birth Protocol, in particular the requirement to hold a professional assessment meeting to collectively identify the level of support the family need.  5.11 Multi-agency involvement in the child and family assessment appeared quite limited in Delilah’s case, although at the practitioner learning event arranged to inform this LCSPR the social worker who completed the assessment said that the midwife initially allocated to mother had changed which hampered contact with midwifery. However, the booking-in midwife would not usually be the midwife to which mother would be allocated and midwifery provided children’s social care with the details of mother’s contact with midwifery from the booking-in appointment onwards. The health visitor had not completed the antenatal visit which is expected to take place between 28-32 weeks gestation and therefore had no current information to share at that stage. The antenatal visit took place on 8th June 2021 (30 weeks gestation) whilst the child and family assessment had been completed by 27th April 2021). However, children’s social care had had extensive prior involvement with mother, her children and their fathers which was included in the child and family assessment. There was no documented contact with agencies who mother said that she had been involved with in the past such as the local drug and alcohol service and the local women’s and children’s aid service in order to verify the information she provided. Mother’s housing provider also held a substantial amount Strictly Confidential   24 of information in respect of her tenancy including a noise nuisance complaint received during mother’s pregnancy with the twins which may have undermined her assertion that she had abstained from alcohol since discovering she was pregnant. 5.12 As no there was no multi-agency professionals meeting, the social worker’s team manager was the sole decision maker in respect of the action to be taken in response to the child and family assessment. Additionally, there appears to be no mechanism for advising the MASH of the outcome of the child and family assessment. When Sefton MASH decided that this assessment should take place, the MASH had strongly implied that if sustainable changes were found not to have been made by mother, a ‘high risk’ pre-birth assessment was required given the history. The LCSPR Panel discussed whether it would be beneficial to introduce a ‘feedback loop’ back to the MASH, so that the MASH could have the opportunity to challenge an outcome of MASH decision making which appeared unsatisfactory – such as the child in need plan outcome from the child and family assessment in this case. After careful consideration the Panel felt that introducing an additional process in the form of a feedback loop back to the MASH would not be justified as the emphasis should be on following existing procedures such as the multi-agency professionals meeting required by the Pan-Merseyside Pre-Birth Protocol, which was a key step omitted in this case.   5.13 Overall, the Panel concluded that a key element which needed to be strengthened in this case was assessment planning to ensure that the child and family assessment was purposeful. Draft Practice Standards for managers and assistant managers in children’s social care have been shared with this LCSPR. The Practice Standards emphasise the importance of managers ensuring that thorough enquiries are undertaken which produce good quality assessments, the importance of assessment planning could receive stronger emphasis, given the learning from this case. It is therefore recommended that Sefton Safeguarding Children Partnership seeks assurance that the finalised Practice Standards for children’s social care managers gives appropriate emphasis to ensuring assessment planning takes place to support purposeful assessments.  Recommendation 3 That Sefton Safeguarding Children Partnership seeks assurance that the finalised Practice Standards for children’s social care managers gives appropriate emphasis to ensuring assessment planning takes place to support purposeful assessments.  5.14 The social worker who conducted the child and family assessment experienced considerable difficulty in evidencing mother’s parenting capacity as she engaged only in the initial session. This was undoubtedly a major contributing factor to the Strictly Confidential   25 limitations of the child and family assessment. The LCSPR Panel questioned whether children’s social care practice standards for child and family assessments should specific a minimum number of contacts with the parent/carer(s). Whilst accepting that the single contact with mother during the child and family assessment in this case was too low, children’s social care did not support specifying a minimum number of contacts with the parent/carer(s) on the grounds that the focus should, as stated above, be on the pre-planning and purposefulness of the contacts rather than the number. 5.15 The children’s social care individual management report (IMR) highlighted a number of areas in which the child and family assessment could have been strengthened, particularly  • the exploration of mother’s mental health – apart from referencing a concern about mother’s mental health raised by the children’s school in 2018 and observing that her past relationships had been ‘mentally abusive’, there was no further reference to mother’s mental health. Mother’s GP records disclose long term low mood since her teenage years when she had trichillotomania (mental disorder that involves recurrent, irresistible urges to pull out hair from one’s scalp, eyebrows or other areas of the body, despite trying to stop), cutting herm arms around 2012 and an overdose around 2013. She may have experienced postnatal depression following the birth of child 1 and had been referred to mental health services as recently as December 2020 following attempts to harm herself.  • the exploration of her alcohol misuse, the triggers for misusing alcohol and the development of strategies for ensuring the safety of the new born children should mother resume alcohol consumption following the births – the assessment stated that mother said that she believed the reason she drank alcohol was because of what the assessment described as her ‘physically and mentally abusive’ relationships (the LCSPR Panel commented that the term ‘mentally abusive relationship’ was unhelpful and could have been more appropriately phrased). The Panel observed that mother’s alcohol misuse was almost certainly secondary to the trauma she had experienced in her life. The Assessment could have explored what strategies mother had used to abstain from alcohol after finding out that she was pregnant and what strategies she could use to prevent alcohol misuse when she began parenting the new born twins as a single parent.  • the absence of evidence that the lived experiences, previous assessments and interventions relating to children 1, 2 and 3 were considered or the circumstances that led to them not living with mother were explored in any Strictly Confidential   26 meaningful way – the assessment documented that child 1 was ‘aware’ of the violence that mother had experienced from previous partners and had been ‘exposed to her alcohol use’. Child 2 and 3’s expose to the impact of domestic abuse and mother’s alcohol misuse was referred to in the summary of children social care’s prior involvement with the family but was not further explored or analysed in the assessment.  5.16 The question arises as to whether professionals from the key disciplines involved in this case had sufficient knowledge of approaches to take to identify and advise people at risk from their consumption of alcohol. For example mother reported drinking 18 units of alcohol per week prior to her pregnancy at her maternity booking-in appointment in respect of Delilah and her twin sibling. Mother went on to report that she had not drunk alcohol since becoming aware of her pregnancy. This presented an opportunity for the midwife to explore mother’s alcohol use prior to pregnancy, why she drank alcohol to that level and how she had managed to become abstinent. Government guidance for professionals who are not specialists in preventing alcohol misuse, recommends that health and social care, criminal justice and community and voluntary sector professionals should routinely carry out alcohol risk identification and deliver brief advice as an integral part of practice (1). The Panel also felt that professionals who are not specialists in preventing alcohol misuse should recognise the importance of ‘supported referral’, i.e. positively encouraging the person to make a referral and following up on this. 5.17 It is therefore recommended that Sefton Safeguarding Children Partnership writes to partner agencies to remind them of the above mentioned Government guidance to enable agencies to benchmark their current practice against the guidance and take any steps necessary to empower relevant professionals with knowledge of alcohol risk identification and the ability to deliver brief advice as an integral part of their practice. Recommendation 4 That Sefton Safeguarding Children Partnership writes to partner agencies to remind them of the above mentioned Government guidance to enable agencies to benchmark their current practice against the guidance and take any steps necessary to empower relevant professionals with knowledge of alcohol risk identification and the ability to deliver brief advice as an integral part of their practice including supported referral. 5.18 As stated, the children’s social care individual management report (IMR) highlighted a number of areas in which the child and family assessment could have been strengthened. The recent Ofsted inspection of Sefton local authority children’s Strictly Confidential   27 services found that most assessments of children who need help and protection were poor and overly focussed on the presenting issue without considering the history or information from partners to understand children’s needs (2). The Ofsted inspection report also highlighted a lack of management oversight and challenge – which is also an aspect of this case. 5.19 The LCSPR has been advised that an improvement plan to address the challenges outlined in the Ofsted inspection is due to be signed off imminently by the Sefton Improvement Board. Given that the improvement plan seems likely to address key issues emerging from this LCSPR including the extent to which child and family assessments explore relevant issues in sufficient depth and the extent to which there is sufficient management oversight and challenge of assessments, the LCSPR Panel debated whether the progress reports certain to be required to monitor the Ofsted improvement plan would be a satisfactory means by which the Safeguarding Children Partnership could obtain the necessary assurance that relevant learning from this case was being addressed. When the Ofsted improvement plan is available, the Safeguarding Children Partnership will be in a position to decide whether the improvement plan progress reports will be a suitable vehicle for obtaining assurance in respect of Recommendation 5 – and also Recommendation 7. 5.20 It is therefore recommended that Sefton Safeguarding Children Partnership obtain assurance over the extent to which child and family assessments explore relevant issues in sufficient depth and there is sufficient management oversight and challenge of assessments. Recommendation 5 That Sefton Safeguarding Children Partnership obtains assurance from the Sefton Improvement Board over the extent to which child and family assessments explore relevant issues in sufficient depth and that there is sufficient management oversight and challenge of assessments. 5.21 A key discussion at the practitioner learning event arranged to inform this LCSPR highlighted the centrality of domestic abuse in mother’s adult life, the severe violence she had suffered, the controlling relationships she had been in, the impact of domestic abuse on her access to her older children, the fact that she had been consistently reluctant to support prosecutions of her abusive partners, the impact of domestic abuse on her mental health and her self-esteem, the relationship between domestic abuse and her misuse of alcohol (and drugs), the impact on her relationships with professionals arising from her contact with those agencies which responded to domestic abuse incidents or offered her support.  Strictly Confidential   28 5.22 A recent Home Office commissioned study analysed information from Domestic Homicide Reviews (3) and found that 61% percent of victims had a vulnerability.  Of the vulnerabilities, 34% were mental ill-health, 28% were problem alcohol use and 22% were illicit drug use.    5.23 Several studies have confirmed that being subjected to domestic abuse can have devastating and long-term consequences for mental wellbeing and the perpetration of domestic abuse is a key driver of women’s mental ill health. Additionally, survivors can face a range of barriers in accessing appropriate mental health support (4) including:   • The impact of domestic abuse often includes lowered self-esteem and feelings of shame, meaning that survivors may not feel able to seek out support.  • Survivors may face ‘diagnostic overshadowing’ where healthcare professionals may not recognise mental health concerns as being the result of abuse (Paragraph 3.10 may be an example of this)  • Survivors may also fear that mental health diagnoses will be used against them in any child contact or child protection legal proceedings (Although child 1, 2 and 3 had not been removed from her care by legal process, the fact that they were no longer in her care may have conditioned mother’s responses to professionals)  5.24 The literature also emphasises the importance of a trusting relationship between healthcare professionals and survivors for women to feel safe enough to be able to talk about domestic abuse and mental ill health (5). A notable feature of this case was the inability of professionals from a range of disciplines to establish a sufficiently trusting relationship with mother.   5.25 The LCSPR Panel discussed the extent to which the learning from this case suggests that there should there be an enhanced offer of support for victims of domestic abuse who have been repeatedly assessed as at high risk and referred to MARAC several times. Where standard approaches repeatedly do not succeed the Panel asked whether a different approach be considered? The Panel was advised that it was hoped that funding would be made available to recruit a complex case IDVA who would be able to review the support offered to survivors of domestic abuse who were not engaging with support or engaging only intermittently. If funding is approved, this would be a very welcome development which could have made a positive difference in mother’s case.  Strictly Confidential   29 5.26 Concern about mother’s self-harming behaviour also arose at times, most recently in December 2020. The strategy for preventing suicide in England recognises that ‘there is evidence of a strong association between domestic violence and self-harm (5). Additionally, Refuge (the national domestic violence charity) and the University of Warwick published research which found that depression, post-traumatic stress, anxiety and their behavioural consequences, such as social isolation, substance misuse and self-harm are common outcomes of domestic abuse, noting that these negative consequences are recognised risks for suicide (6). 5.27 The ‘dominating presence’ of domestic abuse in mother’s life went largely unexplored in the child and family assessment and during her pregnancy with the twins generally. A key factor in this appeared to be that mother’s partner was serving a lengthy prison sentence for assaulting her. Although mother declined to divulge the identity of the twin’s father, it was suspected that her partner was the father (which has been confirmed by DNA testing carried out as part of the care proceedings following Delilah’s death). Given that the partner had been a controlling presence in mother’s life and given that he may have had an interest in her pregnancy, the possibility that direct or indirect contact may have continued following his imprisonment should have been considered. In their contribution to this LCSPR Delilah’s maternal grandparents stated that mother rarely talked about the partner following his imprisonment and when she did so, she talked of him as though he was ‘in the past’. However, they felt that they could not rule out mother having indirect contact with the partner whilst he was in prison, suggesting that this could have been facilitated by the partner’s relatives. (Paragraph 4.11).  5.28 No enquiry was made about the partner’s likely release date and he effectively became what is often referred to as a ‘hidden male’, although in this case the Panel felt that he was an ‘ignored male’. Learning from previous case reviews has highlighted the issue of professionals not identifying and/or assessing key men, such as fathers and mothers’ partners, involved in the care of children who died or suffered harm. ‘Hidden male’ learning from previous reviews which may be applicable to the particular circumstances of this case includes the need to avoid placing complete reliance on mother to tell them about the role of her imprisoned partner in her life and the lives of the twins. Learning from previous reviews recommends that professionals talk to other people involved in the child’s life such as extended family and friends. In this case, contact with the prison via the Probation Service could have been considered. The learning also emphasises the importance of engaging with mothers and building trust and highlights the role which supervisors should play in supporting practitioners to do this. The learning also found that professionals were sometimes reluctant to ask questions because they were reluctant to appear to judge the decisions parents make about their personal and sexual relationships. The LCSPR Panel observed that another factor in Strictly Confidential   30 the lack of enquiry about mother’s partner and her history of domestic abuse may have been a lack of confidence by professionals and a reluctance to discuss domestic abuse history with victims for fear of causing them undue harm by ‘re-traumatising’ them. 5.29 Unfortunately, when mother disclosed to the Home-Start worker on 22nd September 2021 that she had been contacted by her ‘ex’ – who may, or may not have been her most recent partner – the Home-Start worker assumed she was referring to the father of child 2 and 3, with whom the worker believed mother to be on reasonably amicable terms. Information about the most recent partner had been included in the referral the social worker made to Home-Start, but mother’s history was complex and so this was a case when a conversation between the social worker and the Home-Start worker could have been beneficial. Delilah’s maternal grandparents have advised this LCSPR that mother may indeed have been referring to the father on child 2 and 3 as they felt that he ‘called the tune’ over access to child 2 and 3, sometimes denying mother access to them and on other occasions expecting her to look after the children at very short notice. They said that mother found herself looking after child 2 and 3 for ‘about a week’ during the period following the birth of Delilah and her twin sibling.  5.30 It is therefore recommended that non-specialist domestic abuse professionals involved in assessing, providing support or otherwise working with victims of domestic abuse should receive training which encourages professionals to reflect on the many ways in which domestic abuse may affect victims. Additionally, members of the LCSPR Panel felt that non-specialist domestic abuse professionals should be encouraged to make greater use of advice and support from colleagues who are specialists in domestic abuse. Recommendation 6 That Sefton Safeguarding Children Partnership share the learning from this LCSPR with the Sefton Domestic Abuse Partnership Board so that the latter Partnership Board may take account of the learning from this and other cases to address the training needs of non-specialist domestic abuse professionals involved in assessing, providing support or otherwise working with victims of domestic abuse. Such training should encourage professionals to reflect on the many ways in which domestic abuse may affect victims. 5.31 Despite the limitations in the child and family assessment, the list of issues ‘we are worried about’, namely ‘mother's lack of engagement with children's social care’, ‘lack of evidence of mother's preparation for the birth of the babies’, the fact that ‘mother did not have her three children in her care’, her ‘reluctance to disclose the Strictly Confidential   31 identity of the father of the unborn twins’, the ‘history of domestic violence and a lack of work completed around this’, the ‘history of alcohol misuse and a lack of work completed around this’, ‘concern about the level of local support for mother given the physical distance from maternal grandparent’s home’ (Paragraph 3.18) arguably could have merited a specialist Pre-Birth Assessment or ‘high risk’ pre-birth assessment in the language used by Sefton MASH. In the event, it was decided that mother should be supported by child in need planning. 5.32 Before assessing the effectiveness of the child in need planning, it may be helpful to consider the potential difference a specialist pre-birth assessment could have made in this case. Applying the assessment framework for conducting pre-birth assessments developed by Martin Calder (7), relevant questions from Calder’s framework which may have facilitated a more thorough exploration of relevant issues include: • Mother’s experience of being parented  • Mother’s feelings towards the current pregnancy – wanted or not? Planned or unplanned? Result of sexual assault? Domestic Abuse present?  • Abnormal perception i.e. are they trying to replace previous children?  • Do they have a realistic plan in relation to the birth and their care of the baby?  • History of being responsible for children – What happened? Why did it happen? Is responsibility appropriately accepted?  • What do previous risk assessments say?  • What is the parent’s understanding of the impact of their behaviour on the child? What is different about now?  • Attitude to previous children no longer being in her care? (this seems to be a particularly important question in this case. A key factor in closing child in need plans in respect of child 1 and child 2 and 3 in early 2020 was that the children were no longer residing with mother) • Any reluctance to work with professionals? • Attitude to professional involvement – including this assessment?  5.33 Children’s social care have advised the independent reviewer that they are in the process of developing a fresh approach to pre-birth assessment as part of the Sefton Building Attachment and Bonds Service (BABS) which is piloting a Parent Infant Mental Health Service (PIMHS) for 12 months to work with 70 families funded by the Local Authority and Early Help and located in Family Hubs. The PIMHS service will support vulnerable families during the pregnancy and in the early weeks after the baby is born with specialist, therapeutic support to help families build good bonds and attachment with their baby. The pre-birth assessment element of this programme is not sufficiently developed to share with the LCSPR, but it is described Strictly Confidential   32 as a collaborative multi-disciplinary team (MDT) model for pre-birth assessment’s for vulnerable/at risk parents and infants. It is unclear at this stage whether this fresh approach will have implications for the Pan Merseyside Pre-Birth Protocol.  5.34 Neither the health visitor service nor Hospital 1 midwifery received a copy of the child and family assessment. Children’s social care have advised the independent reviewer that the child and family assessment should be shared with partner agencies if child protection or child in need support is provided. In this case a copy of the child and family assessment should have been shared with midwifery and health visiting as part of the child in need plan. It is not known why the assessment was not shared although the child in need plan was brief, largely ineffective and apparently not inclusive of partners. However, neither midwifery nor health visiting requested a copy of the child and family assessment from children’s social care. It is also worth pointing out that had the Pan Merseyside Pre-Birth Protocol been followed, then both services would have been invited to participate in the multi-agency assessment meeting and would – presumably – have received a copy of the child and family assessment at that time.  5.35 The provider of health visitor services appeared to be unaware of the Pan Merseyside Pre-Birth Protocol. It therefore follows that if an agency is unaware of the protocol, they are not in an informed position to challenge lack of compliance with the Protocol by any other agency.   5.36 As stated the social worker who completed the child and family assessment was undertaking the 12 month Assessed and Supported Year in Employment (ASYE) employment-based programme of support and assessment for newly qualified social workers at the time she was allocated the child and family assessment. Children’s social care have advised the LCSPR that from September 2022 an Academy will be created for all ASYE social workers. These social workers will be supernumerary and will work separately from the social work teams and will be allocated no more than five families to work with for the first six months of their ASYE year. They will also benefit from weekly reflective practice sessions and clinical and therapeutic support. This is a very welcome development. The social worker who carried out the child and family assessment and managed the child in need plan did not benefit from the arrangements described above and therefore any challenges to the assessment and the child in need plan arising from this LCSPR should be informed by the lack of expected support she received. It should also be acknowledged that the social worker played a full part in the practitioner learning event arranged to inform this LCSPR.  5.37 Whilst welcoming the creation of the social work Academy, Panel members expressed concern about the effectiveness of management oversight of the social Strictly Confidential   33 worker in this case and also in previous LCSPR or equivalent reviews. Children’s social care acknowledged that improving first line management oversight is a key issue in Sefton which is being addressed through a range of measures including additional training for first line managers and the use of a performance management dashboard which will allow the interrogation of data relating to management oversight and staff supervision. The need for the Safeguarding Children Partnership to obtain assurance in respect of management oversight is reflected in the earlier Recommendation 5.   Key Practice Episode 3  Child in Need plan not fit for purpose, not sufficiently inclusive and closed prematurely. KLOE’s d, f, h & m addressed by KPE 3.  5.38 The child in need plan was in place for barely a month and only one meeting was held and this was attended by only the social worker and mother. This meeting had the appearance of a child in need home visit as opposed to a child in need meeting. The children’s social care IMR states that midwifery and the health visitor attended the single child in need meeting but, having viewed the child in need plan, this does not appear to be the case. Neither the health visitor or the community midwife are listed as attending the single child in need plan meeting although the plan lists them under the heading ‘other’ which is confusing. Further enquiry by children’s social care has now concluded that there is no compelling evidence that the health visitor or the community midwife were invited to the child in need meeting.  5.39 It is difficult to see how the child in need plan addressed any of the unresolved concerns highlighted in the child and family assessment. With the exception of the valuable referral to Home-Start, the child in need plan does not appear to have advanced matters at all and represents an unjustified de-escalation in professional concern. The opportunity to contact agencies which had attempted to engage with mother in the past such as local domestic abuse support organisations, the drug and alcohol service, adult mental health services and the IDVA service appears to have been overlooked.  5.40 The child in need plan ended less than a month prior to the birth of Delilah and her twin. The children’s social care IMR concluded that a period of postnatal involvement would have been beneficial given that mother would be caring for the twins as a sole carer, she had disclosed previous postnatal depression and there was quite a substantial risk that she would resume alcohol consumption when faced with the pressures of caring for the twins. It is difficult to disagree with this view, which is most definitely not a hindsight judgement.  Strictly Confidential   34  5.41 The children’s social care IMR states that there is no indication of any dissent to children’s social care’s decision to close the case on 30th June 2021. It appears correct to observe that there were no challenges by partners to decisions taken by children’s social care. There were a number of factors which contributed to this situation. As stated virtually all professionals involved in the case seemed to be unaware of the provisions of the Pan Merseyside Pre-Birth Protocol, the child in need plan was not sufficiently inclusive, there didn’t seem to be a culture supportive of proactive information sharing (the health visitor did not share the outcome of the antenatal visit with the social worker for example) and there was an absence of feedback loops (feedback to midwifery on the outcome of their 26th February 2021 safeguarding referral for example). The absence of feedback loops creates an environment where the challenging of partner agency decisions is much less likely.  5.42 The recent Ofsted inspection found that plans for children in need lacked specificity on what needs to happen and by when, multi-agency child in need meetings are not always taking place and plans are not always updated (8). Given that conduct and effectiveness of the child in need plan for Delilah and her twin appears to be consistent with the recent Ofsted finding, the Sefton Safeguarding Children Partnership may wish to obtain assurance about the effectiveness of child in need planning from the Sefton Improvement Board. Recommendation 7 That Sefton Safeguarding Children Partnership obtains assurance from the Sefton Improvement Board that child in need plans are sufficiently specific about what needs to happen and by when, that progress against the actions in the plan are robustly monitored, that child in need planning is inclusive of all relevant partners, that all relevant partners proactively engage in the process and that plans are not ended prematurely and that decisions to end plans are multi-agency decisions. Key Practice Episode 4  The general professional response to mother’s lack of consent for the twin’s sleeping arrangements to be viewed and her sporadic engagement with professionals generally. KLOE’s a, b & p, addressed by KPE 4.  5.43 During the health visitor antenatal visit (health visitor 2), Lullaby Trust* safe sleep guidelines were discussed with mother who said that she was aware of these guidelines and that she intended to follow them (Paragraph 3.24).  Strictly Confidential   35 *Concern has been expressed locally about the Lullaby Trust’s advice on co-sleeping which accepts that some parents may still choose to bed-share with their baby and offers advice on how to minimise the risk to their baby if the parents choose to share a bed with the baby.  5.44 ‘Multiple births’ was one of the two grounds which determined that mother and the twins would be supported at the ‘Universal Plus’ level, which is defined as follows:  ‘To identify vulnerable families, provide, deliver and co-ordinate evidence based packages of additional care, including maternal mental health & wellbeing, parenting issues, families at risk of poor outcomes and children with additional health needs’ (9).   The highest level of health visitor support is ‘Universal Partnership Plus’ which is defined as follows:  ‘To work in partnership with parents and agencies in the provision of intensive multi-agency targeted packages where there are identified complex health needs or safeguarding needs’ (10).  5.45 Arguably mother merited support at Universal Partnership Plus level given the safeguarding concerns which had led to the midwifery referral to children’s social care on 26th February 2021 and the child and family assessment which followed. However, as we have seen the concerns were effectively de-escalated by children’s social care and the child in need plan ended prior to the birth of the twins.   5.46 During the primary birth visit by health visitor 1 (Paragraph 3.30) the daytime sleeping arrangements were observed and appropriate advice was given in respect of mother’s use of the baby chairs for the twins to sleep in during the day time. Because the chairs were slightly elevated and not flat, mother was advised to observe the twins at all times when they were sleeping in the baby chairs. Mother also had a large crib in the lounge but she appeared to be worried about how safe the crib was as she said it was easily rocked and she feared it might tip over. The maternal grandparents confirmed this view of the large crib (Paragraph 4.10). It is not known what the health visitor’s view of the suitability of this large crib was, but there is no indication that this large crib was used for night time sleeping.   5.47 Mother declined the health visitor’s offer to view the night time sleeping arrangements. Mother reported that the twins slept together in a ‘next to me’ cot or crib next to mother’s bed in her bedroom. There is no indication that the health visitor or any other professional was allowed to view the night time sleeping Strictly Confidential   36 arrangements for the twins. Health visitors do not have any powers to require a parent to allow them to view sleeping arrangements and so mother’s lack of consent was accepted. However, greater professional curiosity about the night time sleeping arrangements was merited. It is not known when mother resumed alcohol consumption but, from the investigation into Delilah’s death, mother’s bedroom appears to have been a place in which she consumed alcohol whilst watching TV and discarded empty alcohol receptacles. The Mersey Care IMR states that had the night time sleeping arrangements – as described by mother – been observed, this ‘would not have been a significant concern’ as a ‘next to me cot’ would have been deemed more suitable than a moses basket. However, the Rapid Review report found that not all models of ‘next to me’ cots are suitable for twins, but this was not explored or verified as to its suitability.  5.48 The health visitor went on to emphasise that the safest place for the babies to sleep was on a firm, flat surface in the ‘feet to foot’ position. She also signposted mother to the multiple births association (TAMBA) website. (TAMBA is now known as the Twins Trust) Mother commented that she was already a member of an online multiple birth forum although no details of this were shared with the health visitor. Again, there was an opportunity for greater professional curiosity to establish the details of the online multiple birth forum and enquire what benefit mother had gained from membership.   5.49 The Merseyside Child Death Overview Panel produced Multi-Agency Safe Sleeping Advice in November 2019 – which is currently being updated to reflect the learning from the aforementioned Out of Routine report - which contains advice on safe sleeping in respect of multiple births. The document observes that many parents choose to co-bed their twins due to issues of space and goes on to note that there are risks associated both with the babies sleeping too close together and overheating and also when the babies are old enough to roll and potentially obstruct the other baby. The document goes on to advise parents to ‘start sleeping the babies at opposite ends of the cot from the beginning, this means that they will both be in the feet to foot position with their own bedding firmly tucked in. Only place babies side by side in the cot in the early weeks, when they cannot roll over or on to each other. Make sure that they are not close enough to touch and potentially obstruct each other’s breathing’. It is unclear whether this advice is routinely given by professionals in respect of multiple births.  5.50 The Hospital 1 IMR states that midwifery discussed safer sleep with mother on several occasions both ante and postnatally. It was first discussed at the booking-in appointment when both verbal and written advice was given. Safer sleep advice was also given postnatally on 24th July 2021 which was verbal with a ‘teddy cot’ card also given – which sets out the six steps of safe sleeping. Safer sleeping was also Strictly Confidential   37 discussed the following day and a leaflet provided along with a room thermometer on which the six steps of safe sleeping are shown. Safe sleep was discussed again on 10th August 2021 at the final discharge appointment with the community midwife. Additionally, the Red Book (child’s health and development log) also has a safe sleep section which is completed by community midwives. A copy of this is left with the parent.  5.51 The Hospital 1 IMR also states that the advice in terms of twins and safer sleep would be the same as for any baby (although sleeping positions can be different). However, the IMR acknowledges that the birth of twins could have an impact upon the risks associated with co-sleeping in that the cot needs to be large enough to accommodate two babies safely (if not using two separate cots/moses baskets) and the challenge of settling two babies rather than one may increase the risk of unsafe sleep behaviours due to possible increased stress and lack of sleep.  5.52 However, the Hospital 1 IMR notes that there does not appear to be any specific advice or information provided from maternity services in respect of safer sleep for twins. In response to this, the Trust intend to start providing parents of twins with a Safer Sleeping leaflet from Twins Trust on discharge from hospital.    5.53 The GP Surgery IMR noted that when the GP conducts the postnatal check, they use a template which references discussion of sleeping habits, although this was not documented during the consultation with mother. The GP practice has moved to a different template with much better access to online leaflets for all relevant aspects of the postnatal check. This ARDENS template is a resource which prompts to ask and record all relevant aspects of the postnatal and baby check. The LCSPR has been advised that the Named GP and Clinical lead for Children and Maternity will incorporate the change in practice implemented by Delilah’s GP practice into the Sefton GP Safeguarding Leads forum to support dissemination of impact of wider learning with respect to general practice.  5.54 The question arises of how the absence of consent to view the night time sleeping arrangements should affect any safe sleeping assessment. The safe sleep assessment completed by the community midwife has not been found (a copy should have been uploaded to the hospital system and mother would keep the original copy in the Red Book) but would not necessarily have stated whether the night time sleeping arrangements had been viewed by the community midwife or not. The health visitor completed also completed a safe sleep assessment at the antenatal contact and a new safe sleep assessment was completed at the birth visit and reviewed and updated at the follow up birth visit. The LCSPR Panel felt that a safe sleep assessment should not be viewed as complete if the night time sleeping arrangements have not been viewed. Strictly Confidential   38  5.55 Mother’s lack of consent to view the night time sleeping arrangements could also have been seen as consistent with a pattern of engagement with professionals which was invariably on mother’s terms. One of the actions in the child in need plan was for mother to be open and honest with professionals. By this time the child in need plan had ended and, as we have seen, the plan had not been inclusive. As a result professionals working with mother and the twins in the postnatal period appeared less focussed on the potential engagement problems with mother.   5.56 The LCSPR Panel felt that a lack of consent to view the night time sleeping arrangements for Delilah and her twin should have prompted further action. In this case, the absence of consent appeared to be accepted without question. It is not known how frequently consent to view night time sleeping arrangements is declined. The Panel felt that the reason why consent is declined should be documented and further attempts to obtain consent to view the night time sleeping arrangements should be made. This was felt to be particularly relevant to parent’s with mental health issues as there may be occasions when the parent may be more receptive to a request to view night time sleeping arrangements.   5.57 The Panel felt that declining consent to view night time sleeping arrangements should always trigger a multi-agency conversation with professionals who were also involved with the family. Other professionals visiting the address may be able to opportunistically view the night time sleeping arrangements. For example the health visitors were aware that Home-Start were providing support. The Home-Start worker was initially able to develop a good rapport with mother as she was also the mother of twins and therefore she might have been better placed to obtain mother’s consent to view the night time sleeping arrangements. The Panel acknowledged that voluntary sector organisations such as Home Start are sometimes better placed to overcome issues relating to parental mistrust because they are non-statutory and are therefore not seen as a threat by families.  5.58 Overall the LCSPR Panel felt that where consent to view night time sleeping arrangements, the matter should be escalated as a matter of course, particularly when there are safeguarding concerns.   5.59 The investigation into Delilah’s death found a ‘next to me cot’ commercially marketed as a ‘snuzpod’ in mother’s bedroom which was not suitable for twins as it was not large enough to safely accommodate both twins, and that the risks associated with the babies sleeping too close together outlined in Paragraph 5.49 may therefore have been present. As previously stated, in their contribution to the LCSPR, Delilah’s maternal grandparents stated that the twins slept together in a ‘canvas type’ cot which was placed next to mother’s bed. They said that one side of Strictly Confidential   39 the cot could be opened and that this was the side of the cot which was placed next to mother’s bed. They said that this enabled mother to easily lift the twins out of the cot and onto her bed for feeding (Paragraphs 3.42 and 4.10). It is assumed that the maternal grandparents were referring to the ‘snuzpod’ found in mother’s bedroom following Delilah’s death. As the ‘snuzpod’ was not large enough to safely accommodate both babies, it seems possible that mother may have been co-sleeping with one or both of the twins throughout the postnatal period.  5.60 Had mother consented to the health visitor viewing the night time sleeping arrangements, the health visitor would have been able to point out the risks involved in both twins sleeping in the ‘next to me’ cot or ‘snuzpod’. This demonstrates the importance of explaining to parents/carers the importance of viewing night time sleeping arrangements. The LCSPR Panel felt that the expectation that professionals will ask to observe night time sleeping arrangements should be highlighted to parents from the beginning of the maternity journey through to postnatal care.   5.61 The LCSPR Panel is aware that the Merseyside Child Death Overview Panel’s (CDOP) Safer Sleep Group is currently reviewing the Pan-Merseyside Safe Sleep Protocol. The Chair of the ‘Delilah’ LCSPR Panel has ensured that learning about safe sleep which has been drawn out of this case has been promptly shared with Merseyside CDOP so that it informs their deliberations. It is understood that the revised Pan-Merseyside Safe Sleep Protocol will be completed in the near future. Given the considerable learning arising from this LCSPR in respect of safe sleep issues generally, and safe sleeping for multiple births, it is recommended that Sefton Safeguarding Children Partnership share this LCSPR report with the Merseyside CDOP Safer Sleep Group and the latter group obtains assurance from all relevant partner agencies that consistent, unambiguous safe sleep advice is given to parents in respect of multiple births.  Recommendation 8  That Sefton Safeguarding Children Partnership shares this LCSPR report with the Merseyside CDOP Safer Sleep Group and that the latter group obtains assurance from all relevant partner agencies that consistent, unambiguous safe sleep advice is given to parents in respect of multiple births.  5.62 It is also recommended that Sefton Safeguarding Children Partnership works with partner agencies to develop a policy which sets out action the action to be taken when parental consent to observe night time sleeping arrangements for new born children is declined including risk assessment, multi-agency collaboration and escalation. Additionally, the LCSPR Panel felt that it would be of value to collect data Strictly Confidential   40 on how frequently parental consent to observe night time sleeping arrangements is declined.   Recommendation 9  That Sefton Safeguarding Children Partnership works with partner agencies to develop a policy which sets out action the action to be taken when parental consent to observe sleeping arrangements for new born children is declined including risk assessment, multi-agency collaboration and escalation.  Mother’s engagement with professionals  5.63 During the period on which this LCSPR focusses, mother’s engagement with professionals appeared to be entirely on her terms. She appeared to be extremely guarded about sharing information with or accepting help from agencies and at times appeared to adopt an avoidant approach which was particularly noticeable in her limited engagement with the child and family assessment.   5.64 It is particularly concerning that professionals frequently accepted what mother shared with them at face value. The exceptions to this were when midwifery made the safeguarding referral and when Sefton MASH gathered information in order to inform their response to the safeguarding referral. Although substantial information was retrieved from past contact with mother as part of the child and family assessment, the concerns raised by this past contact were largely unexplored with mother.  5.65 The overall lack of professional curiosity in respect of mother is very disappointing and meant that many professional interactions with mother were superficial. The Panel noted that the Rapid Review which preceded and informed this LCSPR was able to speedily highlight a range of factors of concern in respect of mother which are set out below:  • Alcohol (mis)use  • History of mental health struggles (depression)  • Past episode of self-harm (2018, butter knife) and periods of suicidal thoughts  • Potential increased risk for Mother to suffer from post-natal depression having previously experienced it  • History of suffering from depression.  • Victim of significant domestic abuse spanning 15 years.  • Maternal grandfather had noted that Mother’s mental health had deteriorated prior to the date of the baby’s death  Strictly Confidential   41 • Evidence from the partnership of many instances where there was disguised compliance  • She was selective with information she shared with professionals   Taken together, these concerns indicated that mother was a vulnerable person who was in need of support.   5.66 It is suggested that had professionals gathered and analysed this readily available information they would have been much better placed to work constructively and assertively with mother.   5.67 There was insufficient challenge to mother by professionals. For example, mother advised children’s social care that the reason she did not engage with the child and family assessment was that she was wanting to conclude her university work. There doesn’t appear to be any challenge to this, nor any links made to the fact that she had also not been attending her midwifery appointments at that time.   5.68 Additionally information mother shared was often not fact checked by professionals. For example contact with drug and alcohol services would have undermined her account that she had been unable to engage with the service because of a house move.  5.69 Mother appeared to be optimistic about her future as her partner was serving a lengthy term of imprisonment, she had enrolled in a college course and she appeared to be excited about the prospect of giving birth to twins. Mother’s optimism appeared to ‘rub off’ on professionals.  5.70 There was some evidence of mother encouraging professionals to collude with her to keep information from children’s social care. For example when the North West Ambulance Service (NWAS) attended the 17th August 2020 incident (Paragraph 3.5) the crew sought mother’s consent to make a safeguarding referral in respect of her which she declined, stating that ‘this may impact on her children visiting the house’ (although NWAS made an appropriate referral in respect of mother’s children) and in the series of texts mother sent the Home-Start worker (Paragraph 3.36) she explained that her ‘ex had been in touch and I’m paranoid about social services. I don’t think you are like that but I can’t be sure! Xxx’. When this type of behaviour is observed it should be escalated but there is no evidence that it was.  5.71 ‘Working with families where their engagement is reluctant or sporadic’ has been identified by the National Child Safeguarding Practice Panel as one of the six key practice themes to make a difference in reducing serious harm and preventing Strictly Confidential   42 child deaths caused by abuse or neglect (11). The National Panel highlights the following key learning from other LCSPRs in respect of this theme:   • ‘Relationship-based practice recognises the importance of effective relationships and connections between practitioners and families in creating the motivation and opportunity for change’.  • ‘An understanding of adults’ own experiences is essential to addressing concerns about their lack of engagement.’   • ‘Motivational interviewing provides a strong framework to initiate difficult conversations. The model of question, affirmation, reflection and summary enables practitioners to maintain a balance between being directive, supportive and non-judgmental’.   • ‘Non-engagement may be better understood as ‘closure’ – a response in circumstances of unresolved adverse childhood experiences or socio-economic pressures, where individuals believe that what is happening to them is largely outside their locus of control and this may mitigate against their capacity for behavioural change. Effective relationship-based work with families is essential to enable a better understanding of the way that closure interacts with other risk factors’.   • ‘Some parents find difficulty in engaging with a large number of professionals and may have limited capacity to understand the different roles and their contribution. This indicates the importance of a single lead practitioner with a key relationship with the family’.   • ‘Missed appointments, blocking of communications and cancelled visits are all indications of avoidant behaviour and require proactive follow-up’.  5.72 Reflecting on this learning, the key issue appears to be the lack of professional understanding – and appreciation - of mother’s own life experiences, which was essential for professionals to address concerns about her lack of engagement. The LCSPR Panel felt that professionals did not understand mother’s needs and did not appear to appreciate that mother’s unmet needs could place her children at increased risk. The Panel discussed how professionals could be better supported to work more effectively with parents/carers whose engagement was avoidant, reluctant or sporadic. Panel members emphasised that every agency was working with mother on a consent basis from the point at which it was decided to support at child in need level. The Panel felt that weaknesses in practice provided opportunities for parents or carers to avoid engagement. Therefore implementing this report’s Strictly Confidential   43 earlier recommendations - which are intended to strengthen the ‘whole system’ for proving support to the parents of unborn children where safeguarding concerns exist – would reduce opportunities for avoidant behaviour by parents/carers. The Panel also felt that adopting a trauma informed approach to engaging with mother could have been particularly helpful in this case.   5.73 After careful reflection, it is recommended that the challenges experienced in professional engagement with mother in this case is developed in to a case study by the IDVA service and Sefton Women’s and Children’s Aid (SWACA ) to be used where appropriate in learning and development. Specifically the case study could be used to highlight the importance of gathering information about any prior concerns in respect of a parent or carer (Paragraph 5.64) and to allow professionals to reflect on how they could overcome barriers to parental engagement in similar circumstances in the future.   Recommendation 10  It is recommended that Sefton Safeguarding Children Partnership commissions the development of case study by the IDVA service and SWACA based on the challenges experienced in professional engagement with mother in this case which would be used where appropriate in learning and development. Specifically the case study could be used to highlight the importance of exercising professional curiosity to gather information about any prior concerns in respect of a parent or carer (Paragraph 5.64) and to allow professionals to reflect on how they could overcome barriers to parental engagement in similar circumstances in the future.   ‘Out of Routine’   5.74 The National Child Safeguarding Practice Review Panel published a review entitled ‘Out of routine: A review of sudden unexpected death in infancy (SUDI) in families where the children are considered at risk of significant harm’ (12), hereinafter referred to as ‘Out of routine’. These cases represented one of the largest groups of cases notified to the National Panel and involve parents co-sleeping in unsafe sleep environments with infants, often when the parent had consumed alcohol or drugs. Additionally, there were wider safeguarding concerns – often involving cumulative neglect, domestic violence, parental mental health concerns and substance misuse. The National Panel concluded that whilst there was no evidence to suggest that advice on reducing the risk of SUDI had not been routinely given, this advice was not clearly received or acted upon by some of those families most at risk.    Strictly Confidential   44 5.75 The case of Delilah has many of the features of those considered by ‘Out of Routine’, particularly concerns about domestic abuse, parental mental health and substance misuse (drugs and alcohol). Mother was given safe sleeping advice although questions have been raised over whether she received consistent safe sleep advice in respect of multiple births. As stated mother did not consent to the night time sleeping arrangements for the twins being viewed by the health visitor which limited the opportunity to check that mother had understood and followed the advice.   5.76 ‘Out of Routine’ arrived at the following three conclusions:  • Professionals needed to obtain a better understanding of parental perspectives in order to develop a supportive yet challenging relationship which facilitates more effective safer sleep conversations.  • Work to reduce SUDI needs to be embedded in multi-agency working and not just seen as the responsibility of health professionals.   • The use of behavioural insights and models of behaviour change to support interventions to promote safe sleeping need to be explored.    5.77 This LCSPR suggests that there is further work to be done to embed work to reduce SUDI in multi-agency working. For example ‘Out of routine’ highlighted the following issues which are of direct relevance to this LCSPR: • the importance of risk assessment in relation to safe sleeping and that risk assessment should be an ongoing process, • the need for work to promote safe sleep environment to be more closely integrated with wider assessments and planning to address safeguarding concerns – such as the child and family assessment and subsequent child in need plan in this case and  • the risk accompanying any disturbance of routine infant sleeping arrangements by changing circumstances – in this case mother’s fear of eviction which may have contributed to a resumption of alcohol consumption.  5.78 Additionally, professional appreciation of the risk of SUDI appeared to gradually reduce from the point at which midwifery made the referral and the MASH decided that a child and family assessment was required. By the time the twins were born professional concern about the risk of SUDI appeared to be low despite the presence of a number of risk factors, exacerbated by multiple births.   5.79 This LCSPR has been advised that Sefton Safeguarding Children Partnership Executive Board received a report relating to ‘Out of Routine’ which noted that “out Strictly Confidential   45 of Routine’ proposed that each Safeguarding Partnership should make consideration of the following areas. • How well do we understand the views of parents about safe sleep information: format, accessibility, timing, key messages and ‘conversations’ with practitioners? How is this integrated with messages around normal infant care and safety? • How far do practitioners in our workforce have the knowledge and understanding appropriate to their role to promote safer sleeping? How is this role integrated with a multi-agency response if required?  • How is the recognition of unsafe sleep arrangements and risk of SUDI incorporated into multi-agency safeguarding procedures and practice tools for responding to neglect, domestic violence and abuse, children of alcohol and substance misusing parents, and children at risk where a parent has a mental health problem? • Is there sufficient workforce capacity to develop and maintain support for parenting (including safer sleep advice) with families with additional needs and for highly vulnerable families?  If not what initiatives have been taken to address this or work within the constraints. • How is the partnership assured of its work to promote safer sleeping and reduce the risk of SUDI?  5.80 The LCSPR has been advised that the above ‘Out of Routine’ proposals were submitted to the Early Years sub group and roll out to nursery providers/settings. This appears to have been a narrower approach than envisaged by ‘Out of Routine’ although this LCSPR has also been advised that ‘Out of Routine’ was to be considered by the Cheshire and Mersey Public Health Forum and Merseyside CDOP’s Safer Sleep Group.  Working in partnership with housing providers  5.81 Mother’s housing provider had substantial contact with mother and her partner over a number of years. The only point at which the housing provider appears to interact with other agencies in contact with mother appeared to be via the MARAC process. During mother’s pregnancy with Delilah and her twin sibling, the housing provider were taking eviction proceedings against her which were paused to allow her to give birth. The eviction proceedings appeared to be a source of stress to mother which she shared with the Home-Start worker. Given that stressors could trigger a resumption in her alcohol misuse, it would have been beneficial for information to have been shared between the housing provider and other agencies when mother’s tenancy appeared to be at risk. Key opportunities for information sharing appeared to be the child and family assessment, the point at which the housing provider paused the eviction proceedings when they became aware of Strictly Confidential   46 mother’s pregnancy and the text messages sent by mother to the Home-Start worker.   Impact of Covid-19   5.82 Covid 19 restrictions appears to have increased the reliance on telephone consultations with mother although many services continued to be provided on an in-person basis such as home visits by the community midwife, health visitor and Home-Start. Mother was not infrequently difficult to reach by phone and whilst still in a relationship with her partner, the maternal grandparents have advised the review that he sometimes took her phone off her as part of his controlling behaviour. It is generally regarded as more challenging to build relationships with people via telephone as opposed to in-person contact.  5.83 Mother may have cut short her stay in the Refuge in Liverpool during the first phase of the pandemic because she was confined to her room and prevented from associating with other women – who could have been a valuable source of peer support – because of Covid-19 restrictions. Leaving the Refuge earlier than planned could have increased the risk that she would return to the abusive relationship with her partner.  5.84 The IDVA service has advised the LCSPR that they moved to a virtual offer as a result of the Covid-19 restrictions, which prevented consideration of the IDVA making a joint visit to mother alongside a partner agency which was already in contact with her.   Good Practice   5.85 The Rapid Review report identified the following good practice:  • Lancashire Police blue lighted medics from Hospital 2 to Hospital 1 which meant they were in attendance before the child arrived at the hospital (Police)  • Paediatric Consultant made herself available to discuss circumstances of case with partner currently incarcerated. Partner was included in considerations for this as well as bereavement support. (Paediatric Consultant)   5.86 In addition, the LCSPR has highlighted the following:  • Merseyside Police’s investigation of the incidents of domestic violence in August and December 2020 enabled the successful prosecution of the partner for assaults in the absence of any statement from mother. Strictly Confidential   47  • Home-Start allocated the children’s social care referral in respect of mother to a worker who was herself a mother of twins. This initially appeared to be very successful in promoting engagement with mother who was motivated to ask the Home-Start worker about her experiences of parenting twins.  • When this report was presented to Sefton Safeguarding Partners, they felt that the MASH decision to conduct a child and family assessment following the referral from maternity (Paragraph 3.14) should be recorded as good practice.                                     Strictly Confidential   48    List of Recommendations   Recommendation 1  That Sefton Safeguarding Children Partnership reminds the NHS Foundation Trust for Hospital 1 and all partner agencies of the importance of making a referral for an assessment of the risk to an unborn child at the earliest possible opportunity.  Recommendation 2  That Sefton Safeguarding Children Partnership promotes awareness and compliance with the Pan Merseyside Pre-Birth Protocol, in particular the requirement to hold a professional assessment meeting to collectively identify the level of support the family need.  Recommendation 3 That Sefton Safeguarding Children Partnership seeks assurance that the finalised Practice Standards for children’s social care managers gives appropriate emphasis to ensuring assessment planning takes place to support purposeful assessments.  Recommendation 4 That Sefton Safeguarding Children Partnership writes to partner agencies to remind them of the above mentioned Government guidance to enable agencies to benchmark their current practice against the guidance and take any steps necessary to empower relevant professionals with knowledge of alcohol risk identification and the ability to deliver brief advice as an integral part of their practice including supported referral. Recommendation 5 That Sefton Safeguarding Children Partnership obtains assurance from the Sefton Improvement Board over the extent to which child and family assessments explore relevant issues in sufficient depth and that there is sufficient management oversight and challenge of assessments. Recommendation 6 Strictly Confidential   49 That Sefton Safeguarding Children Partnership share the learning from this LCSPR with the Sefton Domestic Abuse Partnership Board so that the latter Partnership Board may take account of the learning from this and other cases to address the training needs of non-specialist domestic abuse professionals involved in assessing, providing support or otherwise working with victims of domestic abuse. Such training should encourage professionals to reflect on the many ways in which domestic abuse may affect victims. Recommendation 7 That Sefton Safeguarding Children Partnership obtains assurance from the Sefton Improvement Board that child in need plans are sufficiently specific about what needs to happen and by when, that progress against the actions in the plan are robustly monitored, that child in need planning is inclusive of all relevant partners, that all relevant partners proactively engage in the process and that plans are not ended prematurely and that decisions to end plans are multi-agency decisions. Recommendation 8  That Sefton Safeguarding Children Partnership shares this LCSPR report with the Merseyside CDOP Safer Sleep Group and that the latter group obtains assurance from all relevant partner agencies that consistent, unambiguous safe sleep advice is given to parents in respect of multiple births.  Recommendation 9  That Sefton Safeguarding Children Partnership works with partner agencies to develop a policy which sets out action the action to be taken when parental consent to observe sleeping arrangements for new born children is declined including risk assessment, multi-agency collaboration and escalation.  Recommendation 10  It is recommended that Sefton Safeguarding Children Partnership commissions the development of case study by the IDVA service and SWACA based on the challenges experienced in professional engagement with mother in this case which would be used where appropriate in learning and development. Specifically the case study could be used to highlight the importance of exercising professional curiosity to gather information about any prior concerns in respect of a parent or carer (Paragraph 5.64) and to allow professionals to reflect on how they could overcome barriers to parental engagement in similar circumstances in the future.   Strictly Confidential   50     References (1) Retrieved from https://www.gov.uk/government/publications/alcohol-applying-all-our-health/alcohol-applying-all-our-health (2) Retrieved from https://files.ofsted.gov.uk/v1/file/50182670 (3) Retrieved from https://www.gov.uk/government/publications/key-findings-from-analysis-of-domestic-homicide-reviews/key-findings-from-analysis-of-domestic-homicide-reviews  (4) Retrieved from  https://www.womensaid.org.uk/wp-content/uploads/2021/12/FINAL-WA-literature-review.pdf  (5) ibid  (6) Retrieved from https://www.nspa.org.uk/wp-content/uploads/2018/08/New-Suicide-Report2c-Refuge-and-University-of-Warwick.pdf  (7) Calder MC (2019) How to carry out effective pre-birth assessments. Seminar at Community Care Live London 2019, Business Design Centre, 16th October 2019  (8) Retrieved from https://files.ofsted.gov.uk/v1/file/50182670  (9) Retrieved from https://www.england.nhs.uk/wp-content/uploads/2014/03/hv-serv-spec.pdf  (10) ibid  (11) Retrieved from https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/984767/The_Child_Safeguarding_Annual_Report_2020.pdf  (12) Retrieved from https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/901091/DfE_Death_in_infancy_review.pdf     Strictly Confidential   51    Appendix A  Process by which the CSPR was conducted  This LCSPR was informed by the Rapid Review which preceded it and the information provided to the Rapid Review by involved partner agencies.  Chronologies of contact with Delilah and her family from involved agencies were submitted as were individual management reports in which involved agencies reflected on the key lines of enquiry agreed for the LCSPR. Chronologies and individual management reports were submitted by:   • GP Surgery • Jigsaw Housing • Mersey Care NHS Foundation Trust • Merseyside Police • Sefton Children’s Social Care • Sefton Council Independent Domestic Violence Advisor’s Team • Sefton Early Help Team • Sefton Home-Start • Sefton Multi Agency Risk Assessment Conference (MARAC) • Sefton Women’s and Children’s Aid • Southport and Ormskirk Hospital NHS Foundation Trust  A short report was submitted by the North West Ambulance Service  A Panel of managers from the agencies involved in this case was established to oversee this review. Membership of the Panel was as follows:   Designated Nurse Safeguarding Children – Sefton (Chair) NHS Cheshire and Merseyside Partnership Manager  Sefton Safeguarding Children Partnership Assistant Director  Sefton Children’s Social Care Chief Executive Officer Sefton Women’s and Children’s Aid Assistant Director – Safeguarding  Mersey Care NHS Foundation Trust Named GP and Clinical Lead for Children & Maternity   NHS Cheshire and Merseyside Names Midwife – Safeguarding  Southport and Ormskirk Hospital NHS Foundation Trust Detective Chief Inspector  Merseyside Police Strictly Confidential   52 Legal Advisor Sefton Council Advanced Practitioner Sefton Council Public Health Administration & Communications Officer Sefton Safeguarding Children Partnership Independent Reviewer Independent  The independent reviewer analysed the chronologies and identified issues to explore with practitioners at a learning event facilitated by the lead reviewer.   Delilah’s maternal grandparents shared their views with the independent reviewer.  The independent reviewer developed a draft report to reflect the agency reports and the contributions of practitioners who attended the learning event. The report was further developed with the assistance of the LCSPR Panel into a final version and presented to Sefton Safeguarding Children Partnership.                     