Fractured skull to a 13-month-old boy in March 2017. Parents sought medical advice because of a swelling to John's head but were not able to explain how the injury had occurred; they advised the paediatrician that he was a very active child with a habit of head banging. Some weeks later, following a change of manager at Children's Social Care (CSC), a child protection conference was arranged, John was placed on a child protection plan and care proceedings commenced. In August 2016, John bruised his face whilst trying to crawl, but the GP did not refer the episode to CSC; a couple of months later mother took him to GP with a torn frenulum after which the GP did send a referral to CSC who decided no further action was required. Lessons learned: the role of the father was largely absent in practitioner records; professional curiosity is especially important for unexplained injuries; the case mapping exercise undertaken by the social worker and team manager used the Signs of Safety model but focused too much on the present and did not take into account historical concerns. Recommendations include: ensure that practitioners are reminded about the effect of their intervention on families and importance of involving them in the formulation and delivery of plans; ensure that multi-agency safeguarding hub (MASH) workers are clear about whether parental consent has been given and for what purpose; advise MASH workers that formal feedback should be given to GPs who make a referral regarding a possible non-accidental injury.
      
 Title:  Serious case review on John: born February 2016, date of serious incident March 2017. LSCB: Bexley Safeguarding Children Board Author: Felicity Schofield Date of publication: 2018  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.                           Page 1 of 22   Bexley Safeguarding Children Board    Serious Case Review on John  Born February 2016, date of serious incident March 2017                Independent reviewer: Felicity Schofield   Date of publication – September 2018    Page 2 of 22    Contents  1. Introduction         pg. 3  2. The process         pg. 3  3. The involvement of the parents       pg. 4  4. Background to the period covered by the Review (prior February 2016)  pg. 4  5. Practice during the period covered by the Review (January 2016 to June 2017) pg. 5  6. John’s lived experience        pg. 12  7. Organisational context        pg. 12  8. Lessons learned/findings       pg. 13  9. Action taken already        pg. 16  10. Recommendations        pg. 17  Appendix – Terms of Reference       pg. 18    Page 3 of 22 1. Introduction  1.1 The subject of this Serious Case Review (SCR) is a young boy, John. John is a pseudonym, chosen in consultation with his family.  1.2 John suffered a fractured skull in March 2017 when he was 13 months old. His parents had sought medical advice because he had a swelling to his head but were not able to explain how the injury had occurred. John has an older half-brother, born in 2010, about whom there have been no concerns and who is not the subject of this SCR.   1.3 This SCR was commissioned because some weeks after John’s injury a new manager within Children’s Social Care Services (CSC) reviewed the way the case had been managed and expressed serious misgivings about the safeguarding actions that had taken place following John’s injury. As a result of these concerns, a child protection conference was arranged, John was placed on a child protection plan and care proceedings were commenced.  1.4 This Review covers the time period from John’s birth in February 2016 through to a child protection case conference in June 2017. Three key practice episodes within this 17 month period are described and analysed in detail. The Review has sought to understand what can be learned from the safeguarding activity that took place during this period and in particular to identify ways in which professionals might respond more effectively to unwitnessed or unexplained serious injuries in the future.  1.5 If these circumstances were repeated it is quite possible that, without change, the outcome for any child would be potentially life-threatening and a number of areas have been identified where practice could be improved. The recommendations from this Review are listed in the final section of the report.   1.6 John has subsequently made a full recovery. He has continued to live with his birth parents and the care proceedings were discontinued. Following a further period of social work support, the case was closed to CSC in January 2018.  2. The process  2.1 In July 2017, The Chair of the LSCB decided that this case met the criteria for a SCR as described in Working Together to Safeguard Children 2015. The reasons for this decision were that John had been seriously harmed and that there were concerns about how organisations had worked together to safeguard him following the serious injury and before he had been made safe.  2.2 The detailed terms of reference are attached as an Appendix. The purpose, framework, agency reports to be commissioned and the particular areas for consideration are all described there. Six agencies contributed reports to this Review.  2.3 Not all of the areas for consideration included in the Terms of Reference feature in this report because as the SCR progressed it became evident that some were not, in fact, relevant to the key practice episodes that are central to this Review.   2.4 Working Together to Safeguard Children 2015 states that SCRs should:  Page 4 of 22 • understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did;  • understand practice from the viewpoint of the individuals and organisations involved at the time, rather than using hindsight;  • provide a sound analysis of what happened in the case, and why, and what needs to happen in order to reduce the risk of recurrence; • be written in plain English and in a way that can be easily understood by professionals and the public alike  HM Government (2015:74)  2.5 A practitioner event was held in December 2017 and was attended by practitioners from the key agencies who were working with John and his family, together with the authors of the single agency reports.   2.6 The lead reviewer, Felicity Schofield, is independent of all professional agencies in the London Borough of Bexley, has had no previous direct involvement with or knowledge of the family who were subject to the review and has had no previous involvement in a professional capacity with safeguarding practice in Bexley. She is a social worker by profession.  3. The involvement of the parents   3.1 The lead reviewer and an officer from the LSCB met with the parents in November 2017 and again in March 2018. The parents already understood the reason for the SCR and were happy to contribute. By the time of the first meeting, John was no longer the subject of either a child protection plan or care proceedings.  3.2 The parents understood that unexplained injuries, especially in very young children, are a cause for concern and that non-accidental injury would normally be considered as a possibility in such circumstances. They also knew that a torn frenulum could be regarded as an indicator of abuse but said that they had only learnt this since the care proceedings had commenced.  3.3 The parents’ views are included as relevant throughout this review. It must be acknowledged, however, that their greatest concerns arose from finding themselves the subject of care proceedings weeks after John had been discharged from hospital, when they believed that they were working well with CSC and that no new concerns had been identified, which was in fact the case. The decision to commence proceedings falls outside of the scope of this SCR and is therefore not commented on in this report.   3.4 John’s mother has some difficulties with literacy, both reading and writing, and on occasion finds it difficult to understand complex information and to express herself clearly. Both parents came from supportive families who live nearby.  4. Background to the period covered by the Review (prior February 2016)   4.1 The mother’s first child was born in 2010. Between March 2011 and April 2015 there were three anonymous referrals to CSC alleging that the mother was neglecting her son, was intoxicated and smoking cannabis and that her son was ‘always bruised’. These reports were investigated by CSC and not substantiated and, therefore, the service did not remain involved with the family. Page 5 of 22  4.2 In the period leading up to her pregnancy with John, the mother received some help from Thriving Families, which was the local early help service. She was given advice about managing her older son’s behaviour which she found helpful. This service had ended before John was born.  4.3 John’s mother was identified as vulnerable during her pregnancy with him. The mother told her midwife that she had a history of depression and that her partner had a son who suffered with an inherited syndrome which had resulted in a physical impairment. This child did not live with them but visited regularly. The mother agreed to a referral for additional support from the Best Beginning team of midwives and thereafter she met with them every two weeks.   4.4 The mother’s depression was categorised by her GP as mild in that whilst on occasion being prescribed anti-depressant medication, she was never referred to psychiatric services. The mother was able to recognise when her mental health was beginning to deteriorate and would seek help accordingly from her GP.  5. Practice during the period covered by the Review (January 2016 to June 2017)  5.1 John’s birth was straightforward and no safeguarding concerns were identified by hospital staff or by the community midwife around the time of his birth.  5.2 The mother had significant contact with both the health visitor and the GP during the first few months of John’s life first because he had vomiting and feeding difficulties and then because of an erratic sleep pattern. On two occasions his parents took him to the local Emergency Department (ED) with feeding related problems and in July 2016, John was referred to a dietician for a possible milk allergy.  5.3 Neither of these difficulties affected John’s development, which was within normal limits, with his weight gain being described as ‘steady’. He was also very active and by the age of 6 months was beginning to crawl.  5.4 In August John bruised his face when lying on the carpet trying to crawl. The mother took him to the GP who accepted the mechanism of injury. With hindsight, the GP thinks that a referral to CSC should have been considered at that time because facial bruising to babies under the age of 12 months can be an indicator of physical abuse.  5.5 Throughout this period the mother sought advice on a very regular basis from both her health visitor and her GP, neither of whom were concerned about her care of John.  Key Practice Episode 1 (October 2016)  5.6 Towards the end of October 2016, the mother took John to the GP because a few days earlier he had injured his mouth whilst pushing himself up on a washing basket. In fact he had torn his frenulum, which is the fold of tissue inside the mouth that joins the upper lip to the gums.   5.7 A torn frenulum is a rare injury which can be a sign of abuse and the GP, following a discussion with the practice safeguarding lead, decided that given the nature of the Page 6 of 22 injury, together with the mother’s other vulnerabilities, she should make a referral to CSC. The GP discussed this proposal with the mother, who gave her consent.   5.8 The GP’s written referral to CSC described the mother’s anxiety and depression which had been made worse by John’s sleep problems. The GP advised CSC that the mother had sought her advice on a number of occasions. She also stated that, in her opinion, the mother’s explanation could explain the torn frenulum. The GP did not refer to the incident of facial bruising in August in her referral letter.  5.9 The family were also discussed at the practice safeguarding meeting, where it was noted that the health visitor knew them well and that she had referred them to Family Lives, a befriending service for families with preschool children.   5.10 The team manager and assessing social worker in CSC decided that no further action was required because ‘safeguarding concerns had not been identified’. This decision was reached without making any contact with the GP, the mother or the health visitor. The GP was informed of and accepted CSC’s decision.  5.11 Family Lives responded promptly to the health visitor’s referral, arranging for a volunteer to visit the mother some three weeks later.  Analysis  5.12 A torn frenulum can be indicative of physical abuse because it is an unusual injury to occur accidentally. Typically it can be caused by rough feeding where a bottle is pushed too hard into a baby’s mouth. Whilst there is not enough evidence in the literature to support the view that a torn frenulum in isolation is diagnostic of child abuse, any injury of this type must be assessed in the context of the explanation given, the child’s developmental stage and a full examination (NSPCC, 2012).  5.13 In this case, it was known that John had a history of feeding problems and that the mother had a history of anxiety and depression. There had also been anonymous referrals in 2013 and 2015 of neglect and physical abuse/rough handling in respect of the older half-sibling, albeit unsubstantiated when investigated by CSC. There had been an earlier incident of facial bruising to John, although this information was not included in the referral from the GP.   5.14 It would have been helpful to consult the health visitor before deciding whether or not an assessment was needed. The reason the health visitor was not contacted by CSC was because the social worker had concerns about whether or not the mother had given her consent to contact partner agencies. There was, of course, no reason why the social worker could not have sought the mother’s agreement to contact her health visitor.  5.15 In these circumstances, an assessment, in consultation with partner agencies, would have been the most appropriate course of action to take. It would have provided CSC with a fuller picture of the family and enabled them to determine whether or not the family would benefit from some extra support. CSC could also have considered consulting a paediatrician about the injury. GPs do not undertake child protection medicals and are, necessarily therefore, less experienced in diagnosing possible non-accidental injuries. As part of this SCR CSC have concluded that their response to this referral did not give sufficient weight to the mother’s history and the previous referrals. Page 7 of 22  Key Practice Episode 2 (March 2017)  5.16 On an evening in March 2017, John’s parents took him to an Urgent Care Centre on the advice of NHS Direct because he had a lump on his head. They did not know how he had got the injury. In view of the fact that this was an unwitnessed injury, the doctor who saw John referred him to the Paediatric Emergency Department, in line with the agency’s safeguarding policy. The parents were equally keen for John to be seen by a specialist.  5.17 In the early hours of the following day, further tests showed that John had a skull fracture and he was admitted to hospital. The hospital staff were concerned because this was a serious injury for which the parents could offer no explanation despite the fact that John would have been expected to be distressed following the injury. The parents advised the paediatrician that John was very active and had a habit of head-banging. They also thought that he might have hurt himself whilst being bathed by a relative, but the relative denied this when questioned by the mother. A full skeletal survey was arranged and a body map was completed. There were no other external signs of injury.   5.18 The paediatrician, a registrar in the ED, contacted the CSC out-of-hours team and faxed them an inter-agency referral form, with the parents’ consent. He recorded that CSC had implied that there was other information about this family but did not share it with him. On interview the paediatrician stated that he questioned the social worker’s refusal to provide background information but again, the social worker refused to do so.  5.19 It was hospital policy to check that the referral had been received by CSC but this was not done on this occasion, possibly because the ED was very busy that night.   5.20 There is no record within CSC of either the telephone conversation to the Out-of-hours team or that the faxed referral was received. Consequently it has not been possible to establish why the social worker did not share any background information about the family.  5.21 The hospital safeguarding adviser was notified of John’s admission later the same day. He contacted John’s health visitor and CSC who provided him with relevant background information. He also updated the inter-agency referral form to include details of the other children in the home and faxed it to the multi-agency safeguarding hub (MASH).   5.22 On the same day, in response to the referral, a MASH worker contacted the ward for further information but none was available at that time. Later that day the outcome of the full skeletal survey was that not only were there no other injuries but there was also no evidence of the skull fracture which had been found by the earlier CT scan. All the test results were sent to Birmingham Children’s Hospital for expert opinion from a paediatric radiologist. It was not unusual for there to be a discrepancy between test results which is why it was standard practice to seek the expert opinion of a paediatric radiologist (there was no such an expert in the local hospital).  5.23 The hospital safeguarding adviser advised the Consultant and recorded on the electronic case file that John should remain on the ward until the results of the skeletal Page 8 of 22 survey had come back from Birmingham and then that CSC should be contacted to discuss a plan of care. However, the ward staff did not read the electronic case file where the safeguarding adviser had recorded the background information and his advice about not letting John go home, reading only the paper records which were in operation alongside the electronic records.  5.24 Neither the MASH health professional nor the health visitor advised either their line manager or the provider trust safeguarding team when John was admitted to hospital, which would have been expected practice. Therefore, there was a missed opportunity for the safeguarding team to have oversight of and challenge decisions made in respect of the risk analysis and management plan put in place prior to John’s discharge from hospital.  5.25 Despite the fact that non-accidental injury was being seriously considered at this time, CSC made no enquiries about John’s sibling’s welfare and no plan was discussed with the hospital staff regarding the parents’ contact with and care of John in hospital pending the outcome of the opinion from the paediatric radiologist. A strategy meeting at this point does not appear to have been considered by any agency.  5.26 Over the weekend the parents received ‘mixed messages’ from hospital staff regarding their care of John. On the one hand they were required to keep the door open of the room where John was being cared for in hospital, yet they were allowed to take John home and bring him back to the hospital on two consecutive days over the weekend. They were then not allowed to take him home on a third occasion.  5.27 The decision to allow John to go home over the weekend was made by the consultant in discussion with the nurse in charge of the ward. They noted that the parents’ care of John on the ward was appropriate and decided that the injury was accidental and that there were no safeguarding concerns. This decision was taken against the advice of the hospital safeguarding adviser and without consulting CSC, the GP or the health visitor, which was contrary to the hospital’s safeguarding guidelines.  5.28 After the weekend, John’s care transferred to a second consultant whose approach was more cautious. In his opinion John should not be allowed to return home again until more information was available. CSC advised the ward that they had taken no further action since the original referral but the case had been allocated for an assessment that day. It was agreed that John should remain in hospital until the expert opinion from Birmingham had been received. The parents struggled to settle John and wanted to take him home as they had over the weekend but this time their request was refused.  5.29 The following day, the hospital confirmed that John had a skull fracture which remained unexplained but no other injuries had been identified. The paediatrician confirmed that in the absence of an explanation, it was not possible to know whether or not the injury was accidental. CSC made a referral to the police.  5.30 A number of meetings took place on March 22. First a professionals meeting, also referred to as a discharge planning meeting, took place at the hospital. The police were not invited. The consultant was not able to attend. A junior doctor advised attendees that John’s head banging was unlikely to be the cause of the injury which was more likely to have been caused by a fall. The social worker is recorded as saying that this Page 9 of 22 information made her ‘more worried’. Ward staff noted that John was very active. It was agreed that: • John would remain in hospital until CSC had completed their assessment • The social worker would assess the safety of the sibling • The health visitor would visit every 2 weeks • The volunteer from Family Lives would visit weekly Whilst the meeting was formally minuted, the minutes were not circulated to the attendees.  5.31 Later that same day the Police and CSC held a telephone strategy discussion where it was agreed that there should be a joint child protection investigation. The police promptly began their enquiries. They consulted a junior doctor who provided them with an update and interviewed both the parents and John’s older brother. None could offer any explanation for John’s injury. However, John was reported to be very active and particularly to like climbing. The parents also advised the police about John’s head banging.  5.32 There was also a case mapping meeting that day involving the CSC team manager and the allocated social worker, where a safety plan was developed to enable John to return home. An initial child protection case conference and a legal planning meeting were highlighted as needing consideration.  5.33 On 23 March in the absence of any medical evidence suggesting non-accidental injury, the police closed their criminal investigation. The police informed CSC of their decision, suggesting that the injury was likely to have been an accident, possibly as a result of lack of supervision.   5.34 The social worker discussed the case with her team manager and the decision was made that John should return home with a safety plan (a safety plan is an interim plan pending a longer term child-in-need or child protection plan). The plan included the grandmother staying with the family for a period of two weeks to provide additional support, although the specifics of the grandmother’s supervisory role were not detailed.  5.35 On 24 March, John was discharged from hospital following a meeting with a number of members of his extended family who together drew up a support plan which a relative sent to the social worker. The support plan included details of children’s centre activities and was subsequently updated by the relative over the course of the next few weeks. Whilst this meeting was minuted, the minutes were not distributed to the attendees. The social worker rang the health visitor to inform her of John’s discharge.  5.36 The CSC team manager left the department on 24 March, with the Assistant Team Manager being given responsibility for overseeing her work pending the arrival of a new Team Manager. On interview the Team Manager said that she was expecting there to be an initial child protection conference (ICPC). However, that was not the social worker’s understanding and she recorded that ‘the case will not be progressing to ICPC as the police have not been able to substantiate that the injury to John was non-accidental it is their view that the injury was caused due to neglectful parenting and they will be taking no further action.’ This course of action was signed off by the Assistant Team Manager who accepted the social worker’s analysis, based she believed on an earlier discussion with the team manager.  Page 10 of 22 Analysis  5.37 The use of faxes within the hospital has ceased since this SCR was commenced and has been replaced by secure email. It is of concern that there is no record of either the phone call made by the ED registrar or of the first faxed referral, which appears not to have been received.   5.38 There is no reason why a social worker should not have shared relevant information with the hospital registrar given the circumstances of the referral which were clearly related to a child protection matter. It is fortunate that the safeguarding adviser sent an updated version of the referral the following day.   5.39 On receipt of the referral, CSC took no further action waiting instead for updated information from health colleagues. No interim safeguarding action was identified as being necessary and as a result, for a period of five days, no agreements were reached about the parents’ continued care of John whilst in hospital and no enquiries were made about his sibling’s safety.  5.40 John’s unexplained head injury was identified as potentially non-accidental on a Thursday evening and yet a strategy discussion between police and CSC did not take place until the following Wednesday. Despite the fact that John was in hospital, that discussion did not include a health professional. In the intervening period, whilst CSC regarded John as being safe in hospital, he had in fact been allowed to return home on two separate occasions for lengthy periods of time.   5.41 Working Together 2015 states that ‘Whenever there is reasonable cause to suspect that a child is suffering, or is likely to suffer, significant harm there should be a strategy discussion involving children’s social care, the police, health and other bodies such as the referring agency. This might take the form of a multi-agency meeting or phone calls and more than one discussion may be necessary.’ (p.36)  5.42 If a strategy discussion had taken place before the weekend, an interim plan could have been agreed between the relevant agencies which could have been explained to both hospital staff and the parents. Instead individual professionals drew their own conclusions which differed over time despite the available evidence having remained unchanged.  5.43 When the strategy discussion did take place, it should have included the hospital consultant, not only because it was the hospital who had referred John in the first place but also because the degree of potential risk was particularly difficult to assess and therefore a medical opinion was especially important.  5.44 The social worker did not visit John, the family home or interview the parents before deciding, with her team manager, that it was safe to discharge him, relying instead on her police colleagues’ assessment. Whilst the decision to discharge John was taken by the social worker and team manager together, given the degree of uncertainty, a multi-agency forum would have been more appropriate.  5.45 Whilst the decision to discharge John may well have been the right one to take given the information available at the time, it was vital that the hypothesis (that the injury was accidental) was tested out through the ongoing social work assessment and review of Page 11 of 22 the safety plan. For this reason, the discharge planning meeting should have agreed a review date and all the relevant parties should have been provided with copies of the safety plan.  Key Practice Episode 3 (After John’s discharge from Hospital, March to June 2017)  5.46 At the beginning of May, a new team manager discussed John in supervision with the social worker for the first time and was concerned about the safeguarding action that had taken place following his head injury in March. The social worker had still to complete her assessment. As a result of the team manager’s concerns, a more senior manager was consulted and she stated that there needed to be an Initial Child Protection Conference (ICPC), which took place at the beginning of June. There was also a legal planning meeting in May.  5.47 In the 6 weeks since he had been discharged from hospital there had been no multi-agency review of the safety plan, although both the social worker and the health visitor had visited the family home and had not identified any significant concerns. The social worker does not appear to have discussed either with her manager or with the health visitor whether or not it was appropriate for the grandmother to leave the family home following her 2 week stay or to have recorded whether in fact the grandmother did stay for the full 2 weeks. There was no liaison between the social worker and the health visitor, the GP or the Family Lives volunteer, who had been identified in the safety plan as being required to visit weekly.   5.48 In April the health visitor recorded a bruise to John’s cheek and a graze on his forehead. The mother explained that the graze had occurred whilst John had been at a children’s centre and an accident report had been completed and sent to the social worker. She could not explain the bruise. The health visitor did not share this information with the social worker.  5.49 In May the mother showed the health visitor a bruise to John’s forehead which she said he had sustained falling against the settee. The health visitor did not share this information with the social worker or refer to it in her report to the ICPC, held at the beginning of June.   5.50 Overall, despite the fact that the cause of John’s head injury remained unknown, once he had returned home there seemed to be an acceptance that it had been accidental and the general level of concern decreased. There was a lack of professional curiosity from the health visitor regarding other facial bruises which was concerning in the context of the unexplained head injury. There is no reference in the CSC records to the safety plan or to the actions that had been identified in it, for example, assessing the sibling’s safety. There had been no review of the safety plan in the weeks since John had been discharged from hospital.   Analysis   5.51 The first few weeks after John’s discharge from hospital were an opportunity to assess the family situation and to test out the hypothesis that his serious head injury had been accidental.   Page 12 of 22 5.52 The Government guidance on timescales for assessments is that they should take no longer than 45 working days from the point of referral, but in this case there was a strong argument for the assessment to be completed more quickly. Similarly, the pan-London Child-in-Need procedures, which Bexley follows, state that Child-in-Need cases should be reviewed every 3 months as a minimum. Again, an earlier review was called for in this case given the level of concern following John’s head injury.  5.53 Immediately prior to John’s discharge from hospital a number of additional measures of support had been identified and put into place. These measures needed to be monitored and reviewed, but such actions were not evident in the weeks between his discharge and a reconvened strategy meeting which took place on 4 June.  5.54 Relevant practitioners, together with the parents, should have been provided with copies of the meeting minutes and of the safety plan. Additional efforts should have been made to ensure that the mother, given her literacy and comprehension difficulties, understood what had been agreed and what was expected of her.  5.55 Given the length of time that had passed since John’s discharge from hospital, a robust assessment and review of the family situation could have informed the strategy meeting in June and potentially avoided the need for either a case conference or care proceedings.   5.56 Whilst the initial response to John’s injury may have been flawed, he had been at home for a further 11 weeks, the parents had met the requirements of both the safety plan and the support plan, and the social worker had been undertaking an assessment. There had been no further injuries or new concerns identified.   6. John’s lived experience  6.1 John was 13 months old when he suffered a fractured skull. He is a white child, with normal levels of development, born in the Borough with a large extended family, many of whom live nearby.  6.2 The most commonly mentioned feature of John is his level of activity. He learnt to crawl and walk at an early age and was seen to be ‘into everything’ whilst staying in hospital. In fact he was so determined to try and climb everything within his sight that his father had to dismantle the bunk beds in the family flat to prevent him from climbing on them.  6.3 John’s parents reported that he had a high pain threshold, rarely crying out when he fell over or hurt himself.                           7. Organisational context  7.1 In September 2016, the Paediatric Liaison service in the hospital ceased and was subsequently incorporated into the Lewisham and Greenwich Trust (LGT) safeguarding children team, with the loss of two dedicated posts. From that date health visitors were only notified of ED attendances which were RAG rated Red and Amber and not those which were rag rated Green. John was brought to the ED on six separate occasions with minor ailments prior to the serious incident in March 2017. As a result of this change in policy, John’s Health Visitor did not receive notification of his last three ED attendances, Page 13 of 22 although the mother advised her after each visit and the GP would still have been notified.   7.2 Between January and June 2017 the health visiting service had to hold all vacancies and could neither recruit nor remodel the service while in a period of transfer to a new provider.  7.3 At the time John’s case was allocated to the CSC referral and assessment service, the receiving team was holding two social work vacancies and the manager and assistant team manager were concerned about the impact on caseloads of the remaining team members.   8. Lessons learned/findings  Referrals and Parental Consent  8.1 When the GP referred John to CSC in October 2016, she did so with the mother’s consent. However, enquiries were not made of other agencies following that referral, for example the health visitor, before making a decision to take no further action. One of the reasons for this decision was because the social worker did not think they had the mother’s consent to approach other agencies.  8.2 It is vital that workers within the MASH are clear about consent, whether it has been given and for what purpose. The social worker could have asked the parents for their consent to approach other agencies.  8.3 The role of the father was largely absent in practitioner records despite the fact that he attended and stayed in the hospital with the mother and was present at all subsequent meetings.  8.4 The MASH worker left a message for the GP regarding her referral. A conversation might have helped both parties gain a clearer picture of the situation.  Recommendations: MASH workers should be advised to give formal feedback to GPs who make a referral regarding a possible non-accidental injury.  The Safeguarding Partnership ensures that MASH workers are clear about whether or not parental consent has been given and for what purpose.  The Safeguarding Partnership should seek assurance that practitioners are routinely considering the role of and including fathers in their work with families  Unexplained/Unwitnessed Injuries  8.5 Unexplained injuries are the most difficult for practitioners to investigate and respond to appropriately. Contributions from all the key agencies are necessary in order to agree a way forward. For these reasons, it is vital that health, police and social work perspectives are taken into account. In the absence of a crime and with an injury that may or may not have been accidental, the social work perspective can be the deciding factor in those early decisions. In this case CSC were guided by their colleagues from Page 14 of 22 health and the police without contributing their own early social work assessment of the family situation.  8.6 Professional curiosity is especially important for unexplained injuries and must be maintained not just at the beginning of an investigation but throughout any subsequent monitoring period.   8.7 In the absence of an explanation any initial conclusion regarding an injury can only be made ‘on balance’ and in the weeks that follow practitioners must continue to be alert to the possibility that their initial conclusion was incorrect.  Recommendation: The Safeguarding Partnership should consider whether practice guidance is required in relation to unwitnessed/unexplained injuries, including the importance of practitioners maintaining a professional curiosity throughout the duration of their involvement with a family.  Involving parents & sharing plans  8.8 John’s parents had a history of seeking advice appropriately when they were anxious or concerned about their children’s health. However, the unclear and inconsistent messages they were given following John’s head injury potentially jeopardised their relationship with practitioners.   8.9 An unexplained injury is a difficult scenario for practitioners to deal with, having to balance the possibility that the parents may be being entirely truthful with the possibility that they may be deliberately misleading professionals. In such situations it is essential that plans and decisions are shared with relevant parties, not just verbally but in writing.   8.10 The failure to agree a plan across agencies whilst John was in hospital potentially put both John and his sibling at further risk and resulted in the parents questioning the hospital’s refusal to take him home when it had been agreed on the previous two days. Later on, the failure to share the safety plan with either family members or other relevant professionals potentially compromised practitioners’ abilities to monitor the plan and also led to the family not being clear about the parameters of the grandmother’s supervisory role.  8.11 The minutes of meetings and any plans which stem from them must be shared with those who have an ongoing role to implement and monitor those plans.  Recommendations: The Safeguarding Partnership should seek assurance that the minutes of meetings and plans are routinely shared with families and practitioners.  The Safeguarding Partnership should ensure that practitioners are reminded about the effect of their intervention on families and of the importance of involving families, as appropriate, in the formulation and delivery of plans.    Strategy meetings  Page 15 of 22 8.12 Working Together 2015 is clear that health colleagues should participate in strategy discussions and meetings. An audit by CSC of 30 cases held within the Referral & Assessment Team between the period 17/3/17 to 25/4/17 found that 86% of the strategy discussions had no health representative present. This practice must change.  8.13 In this case an early strategy meeting was needed to ensure the child’s safety whilst further enquiries were made. Simply being admitted to hospital is not a sufficiently robust plan for a child who may have suffered a serious non-accidental injury. Action needed to be agreed with regard to the parents’ contact with him whilst in hospital and with regard to his siblings. Without such guidance, hospital staff were left in a very difficult position and neither child was adequately safeguarded.  8.14 On 22 March there were three separate meetings about John. A single strategy meeting including both the police and the hospital consultant would have been a more appropriate way forward.  Recommendation:  The Safeguarding Partnership is assured that the ‘Multi Agency Strategy Meetings Joint Health, Police and Children’s Social Care Practice Guidance’ has changed practice and that health colleagues are now routinely included in strategy meetings and discussions.  Use of the Signs of Safety (SOS) Model  8.15 Bexley uses the SOS framework as a practice model across agencies as a means of helping practitioners to develop a common language to assess risk of harm in families. Signs of Safety has become one of the most widely adopted research-based programmes in child protection services in England, having been developed in Western Australia in the 1990s. It is a strengths-based approach which stresses the importance of working alongside families. It is, however, just a model and it cannot be assumed that its introduction will necessarily improve the quality of decision-making.  8.16 The authors of a comprehensive evaluation of SOS, published in July 2017, concluded that ‘while Signs of Safety is not a ‘magic bullet’ for the challenges that face CSC, it has the potential to help improve services for children and young people’, and that ‘the Signs of Safety framework was workable where authorities made the necessary commitment of trust in their staff at all levels, backed up by resources and time.’  8.17 In John’s case, the case mapping exercise undertaken by the social worker and team manager using the model focused too much on the ‘here and now’ and did not take into account historical concerns. The case mapping was also not informed by any social work assessment. Initial danger statements and safety goals were not created in line with expected practice standards. The safety plan was essentially a timetable of activities that mother was expected to participate and engage in.  Recommendation: The Safeguarding Partnership should ensure that the Signs of Safety approach is consistent with the requirements of Working Together and the Child Protection Procedures and complements the Statutory Guidance.  Discharge planning & continued monitoring  Page 16 of 22 8.18 The practitioners involved in the child protection investigation decided that ‘on balance’ John’s injury was accidental. Given the uncertainty regarding this conclusion, the early weeks following John’s discharge required a robust multi-agency plan which could test out this hypothesis and contribute to a fuller assessment of the family. The parents, the members of the wider family who had been asked to support them and practitioners needed to understand their respective roles, why there was an ongoing concern and what needed to happen in order to offer assurance (or otherwise) that John and his sibling were safe. These processes were insufficiently robust. At the very least there should have been a review of the safety plan at the point that the grandmother was no longer staying with the family.  The use of the Child Protection procedures & Case Conferences  8.19 There is no doubt that a fracture in a young baby is a potentially serious incident. The forum for sharing information to determine what risks are posed to children is well set out in Working Together 2015 as a child protection conference. If John had been discharged pending a child protection conference it is likely that the assessment of risk would have been more robust.  8.20 A child-in-need plan could have served the same function but only if it was given a similar priority to a ‘child protection case’ which did not happen with John.  9. Action taken already  Partners have reported that the following action has been taken:  9.1 Regarding the faxed referral since this SCR an email address has been supplied to the hospital to use and in addition the hospital safeguarding team have requested that no referrals are to be faxed.  9.2 With regard to the failure of hospital staff to read the electronic case records, a stamp has been obtained so that the safeguarding team can put an alert into the hospital notes indicating that there is information in the electronic records of relevance.  9.3 To improve and promote collaborative working relationships between agencies Children’s Social Care, Health and Police have created a ‘Multi Agency Strategy Meetings Joint Health, Police and Children’s Social Care Practice Guidance’ which details expectations of all agencies in relation to Strategy Discussions.  9.4 Since June 2017 all contacts within CSC that relate to an injured child under the age of five years are shared with the service manager and head of service.  9.5 The Multi Agency Safeguarding Hub has been re-designed to increase management oversight and capacity.  9.6 A review of caseloads within CSC was commenced in August 2017. Caseloads have now significantly reduced and are for the most part at expected caseload standards for frontline social workers. The issues attributed to not closing work down are being closely monitored by service managers and heads of service.  Page 17 of 22 9.7 The team for referral and assessment now has a permanently appointed team manager who can offer stability and continuity to the team.  10. Recommendations  The Safeguarding Partnership should:  (1) Ensure that the recommendations identified to improve practice within the single agencies’ reports are implemented  (2) Share the findings from this SCR with practitioners across the partnership, ensuring that the findings regarding the following areas are highlighted; • The timeliness of strategy discussions and meetings, assessments and the review of child-in-need plans • The importance of sharing plans and minutes of meetings with families and practitioners • The importance of ensuring that parents are given clear, consistent and timely messages regarding safeguarding concerns  (3) Seek assurance that practitioners are routinely considering the role of and including fathers in their work with families  (4) Ensure that practitioners are reminded about the effect of their intervention on families and of the importance of involving families, as appropriate, in the formulation and delivery of plans.   (5) Ensure that MASH workers are clear about whether or not parental consent has been given and for what purpose.  (6) Advise MASH workers that formal feedback should be given to GPs who make a referral regarding a possible non-accidental injury   (7) Consider whether practice guidance is required in relation to unwitnessed/unexplained injuries, including the importance of practitioners maintaining a professional curiosity throughout the duration of their involvement with a family.  (8) Seek assurance that the ‘Multi Agency Strategy Meetings Joint Health, Police and Children’s Social Care Practice Guidance’ has changed practice and that health colleagues are now routinely included in strategy meetings and discussions.  (9) Ensure that the Signs of Safety approach is consistent with the requirements of Working Together and the Child Protection Procedures and complements the Statutory Guidance.   Page 18 of 22 Terms of Reference November 2017  a. Purpose of the review  The Serious Case Review of John is seeking to learn more about the following: • Use of family history and sharing information between agencies • Early intervention • Ensuring compliance with child protection procedures • Use of the Signs of Safety approach • Management oversight, decision making and escalation • The culture within and between agencies  b. Time period being considered  John’s date of birth to date Interim Supervision Order obtained.  NB: Any relevant information from outside this time period to be included in ‘2. Context’ section of single agency reports.  c. Key questions  The Serious Case Review will focus on the following key questions which will be considered in single agency reports.  Use of family history and sharing information between agencies  • What did each agency know about John’s previous injuries? • Was information shared between agencies?  Early intervention  • What involvement did agencies have with the family prior to the significant event? • Were there any opportunities for early intervention and support?  Ensuring compliance with child protection procedure  • Was Working Together guidance followed in this case and if not what were the barriers? • Are the London Child Protection Procedures understood and do these inform multi-agency working? • How are child protection procedures used and referred to in day to day practice? • Do staff know where to go to get professional support including how to access good practice guidance and research? • Are there any specific procedures on working with young babies who are non-verbal and non- mobile and/or identifying abuse in babies and young children? • What training had staff involved with John had on basic child protection procedures, on child development and on signs and symptoms of abuse in Page 19 of 22 babies and young children? Did the training give them the skills and confidence to put their learning into practice?  Use of the Signs of Safety approach  • Is the Bexley practice model – Signs of Safety - well understood and applied in cases of non - accidental injury? • How does the Bexley practice model - Signs of Safety - impact on practitioner’s understanding of and management of risk?  Management oversight, decision making and escalation  • Who was responsible for decision making on this case and how were decisions made? • What do policies and procedures say about management oversight and decisions. Were these followed in this case? • How does the Bexley practice model - Signs of Safety- impact on decision making? • What is the policy for escalation within agencies? Were staff and managers aware of their agency’s escalation policy and the BSCB escalation policy? and does training cover what to do if there are disagreements within and between agencies and how to escalate concerns? • Is there specific training for managers/supervisors in overseeing cases of non-accidental or unexplained injuries in babies and young children? • Was legal advice sought at the time of the referral?  The culture within and between agencies  • Does the culture within and between agencies promote collaborative working and encourage debate, challenge and professional curiosity? • What is the professional culture around unexplained injuries?  d. Principles underpinning the Serious Case Review  • To always remember that the main purpose for undertaking a Serious Case Review is to learn and improve. • A recognition that safeguarding children is complex. • It is important to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did. • The review will seek to understand practice from the viewpoint of the individuals and organisation involved at the time rather than using hindsight. • Relevant research and case evidence will inform findings and recommendations.  e. Timescale and key milestones for the SCR  Date Milestone 15.09.17 Single-agency report template, chronolator template and meeting note to be sent to members. Letter notifying of review to be sent to the Chief Executive of each agency. To be confirmed BSCB Chair and allocated social worker to meet with the family to discuss the SCR process. Page 20 of 22 27.10.17 Members to return completed single-agency reports and chronologies. All reports and chronologies to then be circulated to members to review. 07.11.17 SCR Team Meeting, 11.30am-1.30pm, G21, Civic Offices.  REVISED SCHEDULE   17.11.17  SCR Team Members to share their own agency’s report with the practitioners and line managers involved in the case. SCR Team Members to also share the Practitioner’s Event invitation.  SCR Team Members to email bscb@bexley.gov.uk the name, role and email address of the practitioners and line managers to be invited to the Practitioner’s event. 24.11.17 Factual corrections in single-agency reports to be highlighted and file saved as ‘…v2’. Addendum reports to be sent to bscb@bexley.gov.uk  04.12.17 Practitioner’s Event – led by Independent Reviewer. *multi-agency chronology to be available on the day. Independent Reviewer to meet with family after Practitioner’s Event. 22.12.17 First draft SCR overview report circulated to members. 08.01.18 SCR Team Meeting, 1-4pm, G05, Civic Offices. Review report | Feedback on Practitioner’s Event | Feedback on meeting with family 22.01.18? Final draft report circulated to members. ? SCR Team Meeting (if required) 12.03.18 SCR Report to Quality and Effectiveness Board. To be confirmed Feedback to family. To be confirmed Feedback to staff. To be confirmed Copy of SCR overview report to be sent to Ofsted, DfE and the National Panel. To be confirmed SCR overview report published. To be confirmed Learning event.  f. Involvement of family  • BSCB Chair will meet with the family. • A meeting with the reviewer will be offered. • A meeting with the family once the review is completed and before publication.  g. Roles and responsibilities  A single agency report template and a chronology template have been sent to the SCR Team Members. SCR Team Members to identify a report writer within their agency. A letter to the agency Chief Officer has been sent notifying of the review (cc SCR Team Members).  Agency SCR Team Member Report Author Chief Officer Bromley Healthcare Lorraine Thomas, Named Nurse Safeguarding Children Lorraine Thomas, Named Nurse Safeguarding Children Jacqueline Scott Page 21 of 22 Lakeside Medical Centre Karen Upton, Named GP for Safeguarding Children Dr Laura Hindley Dr Prem Anand London Borough of Bexley Allison Parkinson, Head of Service, Family Support & Child Protection Nicki Shaw, Head of Professional Standards & Quality Assurance Gill Steward Metropolitan Police Service Caroline Jackson, Detective Inspector Russell Pearson , Specialist Crime Review Group Stuart Bell & Fiona Martin NHS Bexley CCG Jill May, Designated Nurse Safeguarding Children Sarah Ismail, Lead Consultant Community Paediatrician and Designated Doctor for Safeguarding Bexley N/A Dr Nikita Kanani Oxleas NHS Foundation Trust Jane Downing, Head of Safeguarding Children, Lead Named Nurse Rachel Lanlokun, Named Nurse Safeguarding Children Bexley Ben Travis Queen Elizabeth Hospital, Lewisham & Greenwich NHS Trust Clare Hunter, Named Nurse Safeguarding Children Dr Ildiko Schuller Tim Higginson  h. Publishing the report  The final report will be published on the BSCBs website for a minimum of 12 months and will include information on actions which have already been taken in response to the review findings, the impact these actions have had on improving services, and what more will be done.  i. Governance arrangements for the review  • There is an SCR Team (see 7. above) chaired by the BSCB Independent Chair. • The team will oversee and contribute to the review by adding their professional and local knowledge and support the reviewer through debate and discussion. • The team is responsible for quality assuring the review and ensuring that lessons are learned. • The team will meet periodically throughout the review process (see 5. above). • The BSCB Quality & Effectiveness Board will sign off the SCR report.  j. Communication plan  • As areas of learning are identified throughout the review process, anonymised information will be shared. • One of the key themes already identified by the SCR Team was professional’s understanding of, and safeguarding response to physical injuries in pre-mobile babies. A Learning Hub event is being organised to review single-agency and multi-agency policies and procedures used in Bexley around physical injuries in pre-mobile babies, consider relevant research, and identify best practice. Plans Page 22 of 22 will then be made for sharing learning and improvement actions will be recommended to the Q&E Board in January 2018. • In addition to learning being shared and action being taken through the review process, the BSCB will also host a Learning Event upon completion of the review to share all the findings, recommendations and wider programme of action.  k. Media plan  Lead responsibility for external communications rests with the BSCB Independent Chair in consultation with relevant service providers. Publication of any external messages will be facilitated by the London Borough of Bexley’s Head of Communications and its communications team supported by the BSCB Business Team. 