Death of an 11-month-old boy in March 2011, as the result of a serious head injury. Post mortem revealed older fractures and bruising. Mother was arrested under suspicion of causing EY's death. EY was looked after by the local authority until 7 months-old and parents had indicated that they wished him to be adopted; his older brother had not been looked after but parents had considered adoption. Mother concealed both pregnancies, initially concealed the existence of EY from members of her family and later concealed his existence to GP and children centre staff. Injuries to EY were observed by social workers, children centre staff, GP and Health Visitor in the weeks prior to his death. Issues identified include: insufficient recognition of the risks associated with concealed pregnancy; inadequate assessment; superficial engagement with family; underestimation of the risks associated with re-unification following a considerable period of separation; insufficient understanding of role of father and extended family; and non-compliance with child protection procedures in relation to reporting suspicious injuries. Identifies key lessons for practice, including: better coordination of health care for children who are discharged from being looked after; investigation in cases of concealed pregnancy, including the psychological and psychiatric status of parents; and recording in health records that takes account of the needs of other health professionals. Makes various interagency and single agency recommendations, covering: social care, health services and family support services.
      
 Title:  Serious case review: redacted overview report: services provided for EY and OY and members of their families during the period 1 July 2008 – 18 March 2011. LSCB: Windsor and Maidenhead Local Safeguarding Children Board Author: Keith Ibbetson Date of publication: 2014  This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC.  This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above.                         Final version 21 November 2011Redacted - March 2014Serious Case ReviewRedacted Overview ReportServices provided for EY and OY and membersof their families during the period1 July 2008 – 18 March 2011V10Windsor and Maidenhead LSCBIndependent Chair and Serious CaseReview Panel Independent ChairDonald McPhailSerious Case ReviewOverview Report AuthorKeith Ibbetson1Services provided for EY and OY and membersof their families during the period1 July 2008 – 18 March 2011CONTENTSSectionSerious Case Review FindingsPage1.Arrangements for the Serious Case Review (SCR)22.Details of family members and Genogram143.Narrative of agency involvement with the children andtheir family164.Evaluation of the services provided635.Conclusions1616.Recommendations164AppendicesITerms of reference of SCR173IIMembership of the SCR panel174IIIFull list of agency reports and background informationprovided175IVThe contribution provided by the Individual ManagementReviews (IMR)176VBackground documents and references180VIEdinburgh Postnatal Depression screening questionnaire181VIIHeight and weight chart for EY184VIIIBerkshire combined procedures on ‘bruising’185Full recommendations and action plan (recommendationsand actions of the SCR and the IMRs)SeparatedocumentThis report has been anonymised and redacted to ensure that personalinformation about family members that is not already in the public domain is notincluded. The report was written before it was known that the father of OY wasnot the father of EY. He remains referred to as the father in the report as thiswas what professionals believed at the time.21ARRANGEMENTSFORCONDUCTINGTHESERIOUSCASEREVIEWIntroduction1.1This report was prepared for Windsor and Maidenhead LocalSafeguardingChildrenBoard(LSCB)inordertofulfiltherequirements of Chapter 8 of the Working Together guidance.1 Theguidance sets out the arrangements for the local interagencyreview of cases which have given rise to serious concerns aboutthe safeguarding of children and where there may be importantlessons for the local network of agencies with child protectionresponsibilities.Thepurposeofthisreportistohighlightsignificant findings of the review with the objective of improvinglocal child protection practice.1.2The detailed current arrangements for review of such seriouscasesbyLSCBsinBerkshireareintheBerkshireLocalSafeguarding Board Procedures. 2 These reflect national guidanceand the SCR has sought to comply fully with the latest statutoryguidance. The terms of reference of this Serious Case Review(SCR)wereagreedinApril2011inlinewiththestatutoryguidance published on 1 April 2010. The Terms of Reference wereupdated on 23 May 2011 to take account of additional informationabout the case and to ensure that the SCR covered all of the areasin which there was potential learning.1.3ThisdocumentistheLSCBoverviewreportonthe SCR. Itsummarisesandcomplementsthefindingsoftheindividualmanagement reviews conducted by the agencies that were directlyinvolved. The guidance under which the SCR conducted its workprovides for the SCR overview report to be published in full.1.4The review concerns two children: EY was aged 11 months whenhe died on 20 March 2011 and his older brother OY was aged 23months. The children lived with their mother in Windsor andMaidenhead. Their father lived at a separate address in the1 HM Government, Working Together to Safeguard Children – 2010..2 http://berks.proceduresonline.com/chapters/p_ser_case_rev.html3borough as did the mother’s parents who had had some contactwith local services. On the morning of 18 March 2011 EY wastaken to hospital by ambulance. He had suffered a very serioushead injury. This caused his death two days later.1.5At the initial post-mortem examination EY was also found to havesuffered fractures of different ages to his leg and lower arm. Hehadsustainednumerousribfactures,someofthefracturesoccurring at the site of previous fractures. He had large and visiblebruising on his face and forehead and bruises on the trunk. At thispoint little is known about the circumstances of the death, whichare the subject of a continuing police investigation. The post-mortem report indicates that the cause of death was the result ofa ‘significant head injury’, which is ‘virtually impossible to explainother than as the result of non-accidental injury’. The healedfractures are said to have occurred at least two weeks before thedeath of EY. No opinion has been given as to the impact that theseinjuries might have had on EY’s health in the period prior to hisdeath or as to whether the injuries (other than the bruising to theface and head) might have been noticeable. However during thisperiod professionals and members of the public noticed visiblebruising to EY’s head. Section 4.3 of this report evaluates in detailthe reports of these injuries and the response of professionals. Itevaluates the action taken in response to these injuries and thepotential for professionals to have taken steps which might haveled to action to protect EY.1.6The putative father and the maternal grandparents were offeredthe opportunity to contribute to this report but did not take up thisoffer.4The scope, focus and terms of reference of the Serious CaseReview bearing in mind the circumstances of the death ofthe EY and the involvement of agencies1.7Working Together states that the LSCB in the area where the childlived should conduct a SCR when a child has died and ‘abuse orneglect is known or suspected to be a factor in the death’. Thecircumstances fit this criterion. Windsor and Maidenhead LSCBtherefore decided to conduct a SCR. No other LSCB is involved inthe SCR. All of the agencies involved are either located in theborough or health trusts which normally provide a service tochildren and families in the borough and are members of Windsorand Maidenhead LSCB.1.9In reaching the decision the LSCB noted the following backgroundinformation which may have affected professional practice anddecision making in the case and which would require attention inthe review:a number of agencies and professionals with child protectionresponsibilities had been involvedEY had been looked after by the local authority until the age ofseven months although the case was closed by the localauthority three months before he diedEY’s parents had initially indicated that they wished him to beadopteda number of professionals had noticed bruising and scratchesto EY in the weeks before his deathEY’s older sibling OY had not been looked after. Neither of thechildren had been the subject of a child protection plan at anypoint.1.10The recommendation to hold the SCR was made at the SCR groupmeeting on 31 March 2011. The independent chair of the LSCBDonald McPhail made the decision to undertake the SCR on thesame day. Work began at that point to agree the scope and termsofreferenceofthe review.Followingearlymeetings,formalnotifications of the review and the methodology for its conductwere sent to all Windsor and Maidenhead LSCB member agencies.Through a review of agency records the LSCB determined who5should contribute individual management reviews IMRs. A full listof the agencies involved in the review is set out in section 1.15below.1.11The Working Together guidance makes the LSCB responsible fordetermining the scope and terms of reference for the SCR takingintoaccountthecircumstancesoftheparticularcase.Consideration was given to this within the SCR panel and therewas also consultation with participating agencies. The generalterms of reference for the SCR adhere to the objectives for SCRsset out in the Working Together to Safeguard Children 2010:to draw together a full picture of the services providedto establish whether there are lessons to be learned from acase about the way in which local professionals and agencieswork together to safeguard childrento identify clearly what those lessons are, how they will beacted upon and what is expected to change as a result, andhenceimproveinteragencyworkingandbettersafeguardchildren1.12The terms of reference agreed for this review are set out in full ina separate document. Key sections highlighting the focus of thereview are reproduced as Appendix 1 to this document. The Termsof Reference address issues identified in Working Together toSafeguard Children 2010 as being of general relevance and alsoissues specific to the case history. The terms of reference werefollowed by the authors of individual management reviews and theindependent author of this overview report which provides achronological account of agency involvement with the family andthen focuses on the following questions and themes which areevaluated in detail in Section 4:historical information (prior to 1 July 2008) on the familymembers about factors that may have impacted on theparenting capacity of the mother or the fatherthe quality of assessment of circumstance relating to thechildren and their familyfactors that helped or hindered the engagement with the family6how well agencies identified and responded to children’sinjuries and other indicators of harmthe extent of, and professional understanding of, the supportfrom the extended familythe advice that was given and the services offered to theparents concerning adoption issuesrisk factors in the family known to agencies during the periodunder reviewwhether staff and managers dealing with the family had therequisite skills, knowledge and experience to respond to thecircumstances presented by the familywhether sufficient attention was given to issues relating thereunification 3 of EY and his mother following the period whenhe was in foster careThe findingsin relationtothetermsof reference areaddressed throughout section 4 of this report.1.13The overview report also makes recommendations on changesthat need to be made to implement the lessons of the SCR. Thesetake account of the recommendations containedinindividualmanagement reviews and developments in services that haveoccurred since the events in question took place. The SCR eithermakes recommendations on matters that are not already part ofthe work programme of individual agencies and the LSCB, or insome matters it makes recommendations to strengthen work thatis already taking place.Critical periods of agency involvement covered by the SCR1.14The scope of the SCR covered a period of two and a half years,beginning in July 2008. However as the mother had no antenatalcareinrelationtoherfirstpregnancyandnocontactwithagencies with child protection responsibilities prior to the birth ofOY the period covered by the SCR effectively begins with the birth3 Strictly speaking EY was not reunited with his mother. He was placed in foster careimmediately after his birth. This term will be used as shorthand because much of the researchon this issue is relevant to the circumstances of the case. However it is very important torecognise that EY’s mother had never looked after him until she assumed responsibility for hiscare at the age of seven months.7of OY in April 2009. Agencies were asked to scrutinise any earlierinformation in their records. If significant information had beenidentified the SCR panel agreed that it would modify the Terms ofReference accordingly. No significant background information hasbeen identified.Agencies involved by LSCB area1.15Thefollowingagenciesandcontractedprofessionalsprovidedservices to the children and to other family members within theperiodcoveredbythereviewandhaveprovidedindividualmanagement reviews.Berkshire East Community Health Services (which provided thehealth visiting service4)General practice (covering the services provided by four GPpractices)Heatherwood and Wexham Park Hospitals NHS FoundationTrustRoyal Borough of Windsor and Maidenhead CounciloSafeguarding Services 5 (which provides local authoritychildren’s social care services)oServices for Families (which provides and commissionschildren’s centre services and other family services)1.16A number of other agencies had very limited involvement in thecasehistoryandwerethereforeeitheraskedtoprovidechronologies, background information and reports or to contributevia additional discussions with SCR panel members:South Central Ambulance ServiceCombined Legal Services (hosted by Reading Borough Council)limited information was also obtained from the mother’s schoolrecords. This is referred to in section 3 of the report.no faith, voluntary or community groups were identified ashaving been involved.4 Berkshire East Community Health Services (BECHS) merged with Berkshire HealthcareTrust (BHFT) during the course of this review. References to BECHS and BHFT should betreated as synonymous in all documents related to this review.5 This service is referred to as ‘children’s social care’ in the body of the report81.17The Working Together guidance stipulates that a health overviewreport should be prepared on behalf of the commissioning PrimaryCare Trust (now NHS clusters). Their purpose is to provide anoverview of health provision and to identify the key findings fromthe SCR which have implications for NHS commissioning. TheDesignated Nurse for Safeguarding for NHS Berkshire preparedthis report. The findings of the health overview have contributedto the findings of this SCR overview report.Availability of records1.18With the exception of two sets of records all of the relevant healthand medical records were accessed for the SCR. The records notlocated were 1) the father’s paper GP records (the father’s currentelectronic record and summary were available) and 2) somepostnatal midwifery notes on the children’s mother. Although theinability to locate records is always a concern, neither are likely tocontain information which would significantly alter the findings ofthe SCR. OY did not have health visiting records during the periodunder review and EY did not have health visiting records from July2010onwards.Thisisbecausetheywereassignedtocore(universal) health visiting services which meant that the onlyrecords created were the Personal Child Health Record (PCHR)which is often referred to as the parent held record). As a result anumber of contacts with health visitors over the children (usuallyphone calls) were identified as having been recorded in the healthvisitor’s work diary. This is discussed in section 4.11 of the review.1.19All of the other relevant agency records were available for thereview. There are some significant gaps in the records. These andsome discrepancies between records are highlighted either in thenarrative or in the evaluation in this report.9Appointment of the SCR panel, the SCR panel chair and theappointment and role of the independent overview report author1.20A full list of the roles and job titles of SCR panel members iscontained in Appendix 2 of this report. SCR panel members aresenior managers in member agencies or designated professionalswith substantial experience of safeguarding children.1.21The SCR panel was chaired by Donald McPhail, who is also theIndependentChairofWindsorandMaidenheadLSCB.Thisarrangement is consistent with the statutory guidance. He is notemployed by any of the agencies involved in the review. He hassubstantial experience and expertise in child protection services.1.22The SCR overview report was prepared by Keith Ibbetson. He hasno relationship of any kind with any of the agencies involved inthe review or to anyone involved in the case or the SCR. He hasnot previously worked for Windsor and Maidenhead LSCB. He is anexperiencedauthorofSCRsandchairofSCRpanels.Theindependent author has not been a decision making member ofthe panel but has taken the following roles:to attend meetings of the SCR panel and provide professionaladvice as requiredto review the agency management reviews and to seek out andevaluate along with the SCR panel additional relevant materialto corroborate or develop the findings made by agenciesto assist the panel in improving the quality of the agencymanagement reviewsto prepare the overview report on behalf of the panel andfinalise it following panel discussionto prepare the executive summary on behalf of the LSCB1.23Since the decision to hold the review the SCR panel has met onseven occasions in order to:make decisions on the conduct of the reviewmanage the review so as to ensure that it complied with thestatutory guidanceconsider progress in the production of agency managementreviews and chronologies10receive and consider an initial draft of this overview report andof the health overview reportto decide when and how it would be best to engage membersof the family in the reviewto consider and agree recommendationsto consider a draft action planto agree the overview report, the recommendations and actionplan and to agree the executive summary for recommendationto the LSCBQuality of individual management reviews and steps taken toimprove their quality1.24The SCR panel and the overview report writer have scrutinised thequality of the IMRs to ensure that they provide a full and objectiveevaluationoftheworkofeachagency.Thequalityoftheindividual reviews has largely been good and some are consideredto be of a very high quality. They have all made an importantcontribution to the findings of the SCR. All of the review writerswere asked to clarify points of detail in their reports. The SCRasked for a small number of the reviews to be amended andresubmitted because they did not adequately cover areas thatwereconsideredessential.Therehasbeenahighlevelofcooperationinthatprocessandsupportfromalloftheparticipating agencies.1.25A full list of the individual reviews provided, dates of submissionand dates of resubmission of versions is included as appendices tothis report which also contain further comment on their qualityand contribution to the review.Parallel processes that have impacted on the conduct of the SCR1.26Thames Valley Police is conducting the criminal investigation intoEY’s death. The SCR panel and the overview author have receivedupdates on the progress of police enquiries. The enquiries havebeen protracted because of the need to obtain the report of acomplexpost-mortemexaminationwhichinturnreliesoninformation from a number of medical specialists. At the time of11writing the future direction of the criminal investigation is thesubject of discussions with the Crown Prosecution Service, whichis to be expected given the circumstances of the death.1.27Theseniorinvestigatingpoliceofficerhasprovidedtheindependent overview report author with more detailed progressreports on the range of information that has become availableduring the criminal investigation. Whilst the focus of the SCR isthe provision of services to EY and his family, this has allowed theSCR panel and the independent overview report author to feelconfident that the review can take account of any additionalsignificant information that may not have been known to agenciesbefore the death of EY. It also allows the SCR to anticipate anyfurther issues of potential public concern that might emergeduring the criminal trial.Agreed extensions to the normal timescale for completion of theSCR1.28Chapter 8 of Working Together (April 2010) makes the Chair ofthe LSCB responsible for determining what action to take whenthe SCR panel considers that it is necessary to exceed the sixmonth timescale laid down in the statutory guidance for thecompletion of SCRs. 6 At its meeting in August 2011 the SCR paneldiscussed the timescale that would be required for the completionof the SCR. In particular it had become apparent that the post-mortem enquiry had identified that in addition to the injury thatcaused EY’s death there had been injuries of different ages. Thepanel agreed that it would be essential to know as much aspossible about the nature of these injuries and the time bandwithin which they were believed to have occurred in order for theSCR to evaluate the professional practice in the case history fully.1.29The SCR panel has been mindful of the need for member agenciesto take action in the meanwhile in order to learn lessons and toimplementrecommendationswhilethereviewcontinued. The6 Section 8.23 – 8.2412progress made in the implementationof recommendations isreflected in the agency action plans linked to the SCR.Involvement of family members1.30The mother and father of OY and EY were informed in writing thatthe SCR had been initiated. The SCR panel has discussed in detailwhether it would be possible to involve family members in thereview in order to include their perspective on the services thatwere provided. Following discussion with Thames Valley Police theconsensus view of panel members and the overview report authoris that given the specific circumstances of the case it would not bepossible to do this without the risk of prejudicing the criminalinvestigations and any potential criminal trial. This is because inthis case there is a significant overlap between the evidence thatmay be relevant to criminal proceedings and the areas which areof interest to the SCR (such as the observation of injuries to EY byprofessionals and discussions with their mother about them).1.31This position will be kept under active review and it is hoped thataftercriminalproceedingsarecompletedtherewillbeanopportunity to discuss the case with involved family members. TheLSCB has been asked to adopt this report on the basis that it is afull report of the lessons from the SCR at this point and in therecognitionthatadditionalinformationmaysupplementthefindings at a later date.The papers constituting the SCR and arrangements for publication1.32The SCR consists of the following reports and documents:the overview reportthe combined chronology of agency contactsthe individual management reviews (and background reportsfrom agencies with very limited involvement)the integrated multi-agency action planthe draft executive summary1.33A draft executive summary has been prepared for submission withthe SCR papers to Ofsted. The content of the final version of theexecutive summary and LSCB action plan will be finalised for13publication after evaluation by Ofsted. The LSCB wishes to be astransparent as possible about the findings of the SCR in order thatthepublicandotherprofessionalsmayhaveasfullanunderstanding as possible about the case history and about thedecisionsandactionsofpublicbodiesandthecourts.Afterevaluation by Ofsted and the completion of all parallel processes 7the LSCB will therefore give further detailed consideration to thepublication of additional material taking into account the currentcircumstancesofthefamily,theamountandnatureoftheinformation that is already in the public domain, any advice fromcentral government, the views of the father of OY and other familymemberswhoknowthesurvivingchildandanyfurtherinformation that emerges from criminal proceedings.7 In addition to the criminal investigation there are also care proceedings in relation to thesurviving sibling142DETAILS OF FAMILY MEMBERS2.1This information is presented in the following way:details of members of the family who had contact with servicesduring the period under reviewa Genogram of the children’s extended family. This includes allfamily members listed in agency records, though not all hadcontact with agenciesaseparateGenogramshowsthefamilycompositionaspresented by the mother to the Children’s Centre8Details of family membersNameFamily role, relationship andliving arrangement in March2011M/FEthnicity andreligionAge atMarch 2011Child OYSubject of SCR – living with themother in Windsor and MaidenheadMWhite UK23 monthsChild EYSubject of SCR – living with themother in Windsor and MaidenheadDied 20 March 2011MWhite UK11 monthsMotherMother of children – living in familyhome in Windsor and MaidenheadFWhite UKFamilymembersstated that theywere non-practisingChristians(Redacted)FatherFather of children – living elsewherein Windsor and MaidenheadM(Redacted)MaternalgrandmotherLiving elsewhere in Windsor andMaidenhead. Extent of contact andinvolvement with the children at thetime of the deaths was not known indetailF(Redacted)MaternalgrandfatherLiving elsewhere in Windsor andMaidenhead. Extent of contact andinvolvement with the children at thetime of the deaths was not known indetailM(Redacted)15Full Genogram of family members based on local authorityrecords.(Redacted)The mother told the Children’s Centre that EY was called CK and that hewas the child of her cousin and that she was his unpaid childminder. Shenever named the cousin.(Redacted)In July 2010 the mother told her GP that she only had one child, thoughher precise meaning is open to interpretation.163NARRATIVE OF EVENTSA note on terminology – denied and concealed pregnancy3.1Agency records, chronologies and management reviews have usedthe terms ‘concealed’ pregnancy and ‘denial of pregnancy’. Thereis relatively little research dealing with this issue. However onepaper which has been seen by SCR panel members distinguishesbetween the concepts of 1) ‘denial of pregnancy’ in which thewoman has no apparent awareness of the pregnancy for most orall of the pregnancy and 2) concealed pregnancy in which womenknow that they are pregnant and actively conceal the pregnancy. 9There are a number of different explanations proposed as to whyboth phenomena occur.3.2The accounts given by the mother in this case are set out in thefollowing paragraphs as they occurred in the case history. Sheclaimed that she was not aware at all of her first pregnancy (withOY) until she went into labour. Using the terminology proposed byFriedman et al this pregnancy would be categorised as an exampleof ‘pervasive denial’ which occurs ‘when not only the emotionalsignificance but the very existence of the pregnancy is kept fromawareness’. In some cases, weight gain, lack of periods and otherbodily changes may not be present or may be misconstrued and‘even labour pains may be misinterpreted’. 10 However the accountgiven by the father to a midwife shortly after the birth of OYindicates that he thought that the mother might be pregnant atthree months and suggested that she should have a pregnancytest. She in turn admitted that she had a feeling ‘and hoped that itwould go away’. This suggests a concealed pregnancy. The secondepisode would be categorised as a ‘concealed’ pregnancy (thoughthe mother claims that she did not know about it until a weekbefore the birth).9 Friedman, Henegan and Rosenthal, (2007) ‘Characteristics of women who deny or concealpregnancy’ Psychosomatics, 48.2 March – April 200710 Ibid (page 117)173.3In relation to this case history it is not clear whether this is auseful distinction. This is not because it may not be valid butbecauseanycategorisationreliesonthewomanconcernedremembering and giving an honest account of her knowledge andfeelings. The mother in this case misled professionals and friendson many occasions and so her accounts cannot be relied on. Therehas not yet been any opportunity to test the mother’s accountgiven, either in court or in a thorough psychiatric evaluation. Thefathergaveaccountsofhisknowledgeofthepregnanciesimmediately after the birth of EY but then, with the exception ofdiscussions with his GP, he was never subsequently asked aboutthe details of what exactly had happened.3.4In the following narrative the SCR refers to the pregnancies asbeing ‘concealed’. This is because this is the term most widelyused by professionals and the one that was used most widely inthe case records, not because it is accepted that the pregnanciesfit the categorisation used by Friedman et al. At this point it is notpossible to say how much knowledge the mother had of her twopregnancies and if there was a difference between the two. Thereport will also emphasise the practical consequences of both‘denial’ or ‘concealment’ and the risks that this gave rise to for theinfants concerned such as the lack of any antenatal care anddelivery without nursing or medical attention.3.5It is also important that attention is not focused exclusively ondenialandconcealmentsolelyintheantenatalperiod.Thenarrative which follows also shows that the mother continued toconceal the existence of EY from other members of her family foralmost seven months; she denied his existence to herself for longperiods when she did not visit him and by her own admission didnot think about him. On one occasion she denied his existence toher GP and she went to great lengths to conceal his existencefrom the staff and other service users at the children’s centre.3.6Section 4.3 will however refer to the Friedman paper further,particularlytherecommendationsthatitmakesaboutthe18management of the pregnancy and psychiatric and child welfareconcerns when such a pregnancy is discovered or disclosed.Background history relevant to the review:3.7Agency records contain very little information about the lives ofmother and the father prior to the period under review. This is fortwo reasons: Firstly, neither parent had any significant contactwith agencies. Secondly, during the period under review very littlebackgroundinformationabouttheparentsortheirfamilycircumstances was obtained because no detailed assessment offamily circumstances was undertaken. The reasons for this aredescribed in more detail in section 4.3 below.3.8Basic details of family members’ ages and backgrounds are set outin section 2 above. Prior to 2008 the mother attended her GPinfrequently and had no significant health problems. At the age ofeight she had difficulty reading and there were concerns that shemight have dyslexia. There is no evidence of any further actioninvolving health professionals over this. The mother attendedmainstream primary and secondary school and at one point herschool identified her as being listed as having special educationalneeds. These were at stage 1, the lowest level, indicating that theschool would take action to meet her needs within its localresources. No further information is available about this. Whenshe was eight years old the mother was noted by her GP to be‘slow to follow instructions’. The mother left school in 2004 afterher GCSEs. She had been entered for 13 exams but obtained nopasses at grade A-C. There is no indication at all that she had alearningdifficulty.Shewasreportedtobeworkingasareceptionist when OY was born. No previous work history wasobtained. She gave this job up but the records do not stateexactly when.3.9Given the father’s age there are no school records available. Hehas no criminal convictions or record of other contact with thepolice. He was never asked about his background and the only19background information about him is from his GP records. Heattended his GP infrequently for treatment of minor ailments.(Redacted) His handwritten records have not been obtained andmay contain further information but there is no indication that it isof any relevance. (Redacted)The mother and father workedtogether prior to the birth of OY. Some months later the fathertold his GP that he had changed jobs.Agency contact during the period of review covered by thechronologyEvents prior to the birth of EY3.10OY was born at the home of his father. His mother had receivedno antenatal care and (according to the account his father gave tohis GP) the mother gave birth to OY in bed while the father wasasleep. OY was born at 40 weeks gestation and weighed 3.63 kg.The mother had a low iron level there were no other medicalcomplications. The father and maternal grandparents visited thehospital after having been contacted by a midwife. It is not clear ifthe midwife did this on her own initiative or with the agreement ofthe mother. The family were noted to be undecided about whoshould care for the baby. The mother was noted to be ‘dazed’.Midwives referred the baby to the social care emergency dutyteam because there had been no antenatal care.3.11The mother wanted to return to her own home on discharge. Thisis understood to mean her parents’ home, rather than the father’s.The mother was told that social care ‘may visit today’ (at thehospital) but no visit was made as the local authority decided toundertake the initial assessment of the family at home. The socialcarereferralindicatedthattheparentswereconsideringrelinquishing the baby for adoption. During the night of 14 – 15April midwives cared for OY while the mother received a bloodtransfusion.3.12On 16 April the mother and OY were discharged to the maternalgrandparents’ home. The discharge letter sent to the GP identifiedthat the mother had not booked antenatal care and had been20‘unaware’ of the pregnancy. A midwife made a home visit on 17April (day 4). It was noted that the mother was shocked at thepregnancy but there is no further comment on the circumstancesof the birth or the attitude of other family members. A furthermidwifery visit was made the following day and then on day 10(24 April).3.13On 20 April 2009 a social worker SW1 made a visit and saw OYwith his parents. It is not clear where this visit took place. Thematernal grandparents were not seen. The father stated that hefelt trapped and depressed, but that he would offer support. Thefather stated that (as far as he was concerned) the couple had notintended to be in a relationship. The mother said that she hadsuspected that she was pregnant a week before the birth, but didnot tell anyone or do anything about it. The plan noted was that acore assessment would be undertaken and that the mother wouldcare for OY with the help of ‘a lot’ of family members. There is norecord to say exactly what this would mean in practice. The socialworker checked with the mother’s GP who had no significantinformation as there had been no antenatal contacts and nosignificant previous health history.3.14The same day the father saw his GP. This was a different GP tothe other family members and there was never subsequently anycontact between this surgery and other agencies. The father toldhisGPthathehadbeentraumatisedbythebirthofOY.(Redacted) This led to a referral to the Community Mental HealthTeam (CMHT) as there were no appointments available at the GPcounsellor. The CMHT refused the referral on the grounds that thefather did not have severe or enduring mental health problems.The father never subsequently had contact with the counsellor.3.15On 24 April 2009 the midwife discharged OY to the care of GP andhealth visitor. It is not clear what information was shared at thispoint (paragraph 28 in hospital IMR). The new birth visit wascarried out by the health visitor (HV1) on 28 April. Standardhealth checks were made and OY was assessed as requiring a core21health visiting service (i.e. the mother would be left to makecontact with the child health clinic and health visitor as she saw fitand standard developmental checks would be carried out). As aresult no health visiting record was opened and information aboutOY’s health was recorded on his PCHR. There is no indication inthehealthvisitor’selectronicrecordthatthemotherhadconcealed or denied the pregnancy, although the hospital birthnotification states this. There is no indication in the records as towho was present at the visit and it appears to have focusedexclusively on routine child health matters which is surprising andconcerning given the lack of antenatal care and the circumstancesof OY’s birth.This is discussed in the individual managementreview and in section 4.3 below.3.16On 6 May 2009 OY was seen at the child health clinic. He wasnoted to have made good weight gain and was now on the 75thcentile.3.17On 13 May 2009 the social care initial assessment concluded thatthe mother was able to meet the needs of OY with family support.The assessment had been based on one visit to the family, aphone call from the GP and one phone discussion with a midwife.The social worker refers to a discussion with the health visitor butit was not recorded by either professional. The health visitorclearly had no concerns as she had allocated OY to a core service.11 There is a reference to a further planned visit with the healthvisitor to identify any further need for support but there is norecord that a joint home visit took place. The social workerrecorded making a further visit on 4 June 2009 when the motherand OY were seen. The mother reported that the father was‘recovering from his shock’ and her family were supportive. Thecase was closed. The social worker was not aware of the father’s11 At this point as OY had been allocated to a core health visiting service there were noseparate health visiting records created and the health visitor would have had no record onwhich to note this enquiry. The position has changed since the introduction into the healthtrust of the RIO electronic recording system. All children have a RIO record, in addition totheir PCHR.22reaction and (Redacted) feelings and relied on mother to provideinformation about him. There had been no detailed discussionabout the reasons for the concealed pregnancy, despite the lack ofantenatal care and the very unusual circumstances.3.18The view of the manager was that the circumstances of OY did notmeet the threshold for continued social care involvement underSection17oftheChildrenAct1989(i.e.thathewasnotpotentially a child in need). On 25 June a manager decided thatdue to workload considerations the normal closing summary andletters to other agencies to inform them that there would be nofurther involvement would not be written.3.19On 20 May the mother took OY to the health clinic. His weight wasnow on the 90th centile (compared to 50th centile at birth). Whenthe health visitor (HV1) made a home visit on 2 June to carry outthe 6-8 week postnatal review OY was now noted to be on the 98thcentile. That day the mother was screened using the EdinburghPostnatal Depression (EPND) Tool,12 which is reproduced asAppendix 6 of this report. She scored 0 (out of a possible 30).There was no comment on how valid a score of zero might be. Theimplications of this are discussed at section 4.3.19 below.3.20The mother next took OY to the health clinic on 24 June 2009. Atthat point OY’s weight was recorded as being on the 99.6th centile.OY was weighed onfour more occasions before the end ofSeptember and each time recorded as being above the 99.6thcentile. Put in lay terms this meant that in a statistically normalsample of 250 male infants OY would have been the largest orclosetothelargest.OYreceivedhisfirstandsecondimmunisations routinely during May and June 2009. Other thanthe immunisations it is not certain how much direct contact OYhad with health professionals during this time because at theclinics he attended parents would ‘self weigh’ their babies and only12 Cox, J. L., Holden, J. M., & Sagovsky, R. (1987). Detection of postnatal depression: Developmentof the 10-item Edinburgh Postnatal Depression Scale. British Journal of Psychiatry, 150, 782-786.23speak to a member of the health visiting team if they hadconcerns. If there were discussions, no concern was recorded onhis records about this very fast weight gain.3.21In September 2009 the mother started to take OY to health andother sessions at a local children’s centre. The registration formgave a Maidenhead address. The mother was quite open with staffthat she had not known that she had been pregnant with OY untilshe went into labour. It was not part of the role of the twomembers of staff at the centre to assess the parents and so thiswas not discussed in any further detail. It is not clear if the fact ofthe concealed pregnancy was seen as being significant. Motherand child attended ‘Family Fit’ sessions which were attendedthroughouttheremainderof2009andthenhealthyeatingsessions until March 2010. Regular attendance at health clinicsthroughout this period recorded OY’s weight as being consistentlyabove the 99.6th centile.3.22The first occasion on which it was recorded that the mother wasgiven advice on diet was at the health clinic on 27 January 2010.OY was not walking at that point and it was hoped that OY wouldnotgainsomuchweightwhenhestartedtomovearoundindependently. On 8 February 2010 he was seen by a healthvisitor (HV2) for his 9-12 month developmental assessment. OYwas noted to be up to date with his developmental milestones andimmunisations. His mother agreed to continue to bring him toclinic to be weighed and he was noted to be attending theChildren’s Centre. This was a continuation of the plan that hadbeen in place since August 2009 which had so far had no impacton his unusually quick weight gain.3.23On 29 March 2010 the mother and OY made their final appearanceat the Children’s Centre prior to the birth of EY. There was norecording of any indication that she was pregnant. On 6 April and22 April 2010 she took OY to the GP and again her pregnancy wasnot noticed.24Significant events between the birth of EY (23 April 2010) and hisreturn to the care of his mother (19 November 2010)3.24The mother had moved to her own flat in November 2009.Confirmation of the details of the move was provided to the SCRby Thames Valley Police and had been established after the deathof EY. Other agencies knew that the mother and OY had movedbut the records gave no details of the date of the move or anyspecific reasons for it.3.25Like his brother EY was born at home. He was larger than hisbrother weighing 4.26 kg (75th centile). The mother and OY werebrought to hospital by ambulance.3.26The circumstances of this birth were different to the birth of OY.The father subsequently told his GP that he had suspected thatthe mother was pregnant, but that she had denied this. She statedthat she had thought she might be pregnant a week before thedelivery,butthatshetooknoaction.Thishistorywasnotobtained at the time but when the father spoke to his GP later andduring the course of the mother’s adoption counselling.3.27The initial referral to children’s social care from Wexham ParkHospital indicated that the mother wished to relinquish her babyfor adoption. The mother had given birth ‘at home’ assisted by thefather and she was believed to have been unaware that she waspregnant. The parents were noted to be in a state of shock. Theystayed in a separate room from the baby at the hospital.3.28Social care identified the case as one that had been open to theservice a year earlier following the birth of OY. A social worker(SW2) and a senior social worker (SW4) saw the mother inhospital with the baby and arranged to accommodate the babyunder Section 20 (Children Act 1989). The mother was dischargedthesamedayandEYwasdischargedtoafostercarerinMaidenhead. EY was not named at this point.3.29The same day (23 April 2010) the foster carer took the baby toregister at her GP (a different GP surgery to the ones used byother family members). She was unable to register the baby as25she could give no first name for him. This is not an unusualcircumstance and often babies are seen by the mother’s GP beforetheir births are formally registered. The receptionist alerted thehealth visitor linked to the practice (HV4) to the baby’s existenceand she started to make enquiries. EY was subsequently allocatedto the caseload of this health visitor in a different team and townto the one dealing with the mother and OY.3.30No further significant events are noted until 26 April 2010 when apostnatal midwifery visit was made to EY at the foster carers’home. A further visit was made on day 5, but the electronic recordholds no significant information about this.3.31On 26 April the foster carers’ support social worker (from thefostering team) phoned her to say that the mother and fathermight want contact that day. This did not happen and it is notclear what discussion had led to this possible request.3.32On 28 April a placement planning meeting was held. This is arequirement for every looked after child. It was attended by thesocial worker (SW2) from the Referral and Assessment Service,the senior social worker (SW4) the fostering social worker, thefoster carer, and the mother and father. This was the first contactbetween the parents and EY since the birth. Neither parent wishedto hold him and his father found it very difficult to be in the sameroom as the baby. The fostering social worker noted that themother was ‘emotionally detached’, though she was noted to actwarmly towards OY.3.33The key decisions of the meeting were 1) to make arrangementsfor routine delivery of health services 2) to support contact withthe parents and 3) to start adoption counselling to help theparents reach an informed decision regarding the long term plansfor EY. Subsequently the mother received a number of counsellingsessions. There were no separate discussions with the father. Hewas always clear in his view that the baby should be adopted.263.34It was also noted that an initial assessment would be undertakenin relation to OY by the Referral and Assessment Team. This wascompleted shortly afterwards and written up and signed off on 20May 2010. It noted that there were no concerns about thecapacity of the mother and father to care for OY, though it is notclear what steps were taken to reach this conclusion. OY wasnoted to be meeting his developmental milestones. At the end ofthe assessment no letters were sent to health agencies informingthem of the reasons for social care involvement or the outcome ofthe initial assessment. The reasons for this are not stated. No coreassessment was undertaken at this point, despite the highlyunusual family circumstances. The needs of OY were not assessedin the context of the complex circumstances surrounding the birthof his brother and the decision that needed to be reached over hisfuture. This is discussed further in section 4.3 below.3.35On 29 April 2010 a midwife carried out a postnatal visit to themother. This was carried out by a midwife in a different team tothe one who had visited EY in the foster home. These were treatedas discrete tasks and the two never spoke to one another aboutthe unusual circumstances of the birth. Neither midwife accessedthe notes relating to the circumstances of the birth of OY. As thereare only the briefest of notes relating to the birth of EY it is notclear whether either of these midwives was aware that there hadbeen a previous pregnancy with no antenatal care.3.36The postnatal visit was six days after the birth and it is not clearwhy there was a delay. It is not stated explicitly in the recordswhere this visit took place (i.e. whether it was at the father’shomeorthemother’sownaccommodation).Therewerenomedical complications. However the mother requested that ‘herhome phone number’ should be deleted from the hospital records.The specific reasons were not recorded though it seems mostlikely that following the first birth the maternal grandparents’home number was on the hospital records relating to the mother27and she wished it to be removed so that they could not accidentlybe made aware of the birth of EY.3.37On 30 April 2010 the social worker (SW2) visited the mother, thefather and OY. When seen alone the mother admitted suspectingthat she was pregnant but concealing it from the father and thatshe had ‘wanted the situation to go away’. She said that she hadbeen relieved to get ‘back to normality’ over the last weekend.The father was not seen alone.3.38On 4 May 2010 the final midwifery visit was made to the mother(day 11). The mother had no identified health problems and wasdischarged from midwifery care. The health visitor for the mother(HV5) was sent a discharge summary from the hospital stating‘baby for adoption’ as a handwritten comment.3.39On 11 May 2010 there was liaison between the Looked afterChildren (LAC) health team and social care to obtain consent forhealth treatment of EY, should it be required. This was a basicprocedure. Otherwise both of the children were seen in their ownway as having routine health needs at this point. EY was a healthychild who was likely to be relinquished by his mother for adoption.OY was understood to be well cared for by his parents. There wasno contact between the health professionals dealing with the twochildren at this point.3.40On 11 May 2010 the social worker (SW2) made a visit to themother and father. The mother said that she intended to name EYand register the birth (which she did on 1 June 2010). At thatpoint the maternal grandparents did not know about the birth ofEY. The social worker stated that the local authority would beseeking legal advice about the need to consult extended familymembers about EY’s future. The father was hostile to this. Mothersaid she understood why this needed to happen and was ‘thinkingof telling them herself’. Father said that if mother did keep thebaby it would completely change his relationship with OY. Thesocial worker recorded that she challenged the father about this28statement because she felt that the father was putting the motherunder a lot of additional pressure.3.41From this time social care staff developed the perception that thefather was bullying the mother. Linked to this was the perceptionthat the mother might want to look after EY if left to come to herown view without pressure from the father. With hindsight it isclear that this was an oversimplification of the situation and thatas a result the social care staff involved paid less attention toother factors relating to the mother. This is discussed in section4.3 below.3.42The social worker found the mother still difficult to engage inconversationthoughshestatedthatshewasworriedaboutlooking after two young children. Both parents were invited toattend EY’s looked after review meeting. The father said that hewould not as he was worried that he would become emotionallyattached to the baby, but the mother said that she intended toattend the looked after review meeting where she would havecontact with EY. The mother did not attend the looked afterreview, though she did visit EY later on the same day.3.43On 17 May the father phoned the social work team manager andcomplained about the proposed plans to involve members of themother’s extended family. He was told that EY had the right tohave his needs considered by the extended family. The localauthority had not taken legal advice on this issue at this point.Discussions about informing the extended family continued untilNovember 2010.3.44On 12 May the health visitor (HV4) made the new birth visit to thefoster home. EY’s weight was on 91st centile and he was allocatedto core health visiting. The health visitor was aware of the socialcircumstances. She made no contact with the mother’s healthvisitor.3.45On 13 May 2010 the hospital discharge summary was sent to themother’s GP. It contained no reference to the lack of antenatal29care or the circumstances of the birth. However it would havebeenclearfrom themother’s GP notesthatshehadagainreceived no antenatal care. The mother was invited to the GP for apostnatal check up.3.46On 17 May 2010 the father attended his GP surgery. He spoke of‘stress’ after the delivery of his second son one year after the birthof the first. The record states that he had helped deliver thesecond baby during the night. He stated that he knew that themother was pregnant but that she denied it when he asked her.He wanted the baby adopted and did not want her parents toknow about the pregnancy. He was advised to tell her parents butwas not keen. He stated that he was awaiting a social servicesmeeting. He did not consult the surgery again about it until 19November 2010, the day that EY left foster care. (Redacted)3.47The first statutory looked after review on EY took place on 20 May2010 at the foster home. EY’s mother did not attend, although shecame to the foster carers’ home after the meeting and saw EY.This was said to have followed a chance meeting with the fostermother the same day. This was the first time she had seen himsince his medical on 28 April and only the second time since hisbirth. The decisions of the meeting were to treat EY as a baby whohad been relinquished for adoption, a pre-adoption medical was tobe booked and adoption counselling was to be arranged.3.48There is some uncertainty as to the understanding that the socialworker had at this point. The decisions of the meeting recorded inthe chronology refer to plans to proceed as if EY were to berelinquished for adoption. This was four weeks after the birth. Atthis time there had been no indication that the mother had anyambivalence about relinquishing EY. However the managementreview refers to ‘parallel planning’, noting the possibility that themother would wish to resume the care of EY. This seems to bebased on the behaviour of the mother when she visited the fosterhome after the meeting when she agreed that she was going toregister EY’s birth and name him. She held EY for some time and30took away pictures taken by the foster carers. She agreed to bookanother contact session having been encouraged by the fostermother that she could visit whenever she wanted. The fostermother invited the mother to take the baby out and establishedthat she was happy to change and feed him if she did so.3.49On 21 May the LAC health team had contact with the fostercarers’GPaskingforEY’smedicalrecords.Themedicalinformation gathering was focused on EY and it was not the role ofthe team to make contact with the mother’s GP.3.50On 24 May the mother’s health visitor (HV5) (who knew themother and OY) attempted a home visit to the mother but she wasnot in. The management review states that this was not repeated.However on 26 May the social worker recorded that she had beentold by the health visitor (HV5) that the mother had given anindication that she was thinking about caring for EY at home. Sofar as can be established this was the first firm indication in therecords that the mother might want to care for EY.3.51On 1 June 2010 the mother had contact with EY at the fosterhome. No further details of this are recorded. The following dayshe attended the looked after child initial health assessment andsawEYagain.Thiswasundertakenbyapaediatricianandattendedby thesocialworker(SW2), themotherandbothchildren. Mother brought the children to the health centre. Motherindicated that she felt under pressure from the father to give EYup and it was recorded that ‘he could be quite domineering’. Shehad not told him that she had recently had contact with EY. Thesocial worker spoke to the mother about a possible referral to theFreedom Programme. This is a programme for women who havesuffered domestic violence, though there was no suggestion thatthe mother had ever been a victim of domestic violence. Thesocial worker thought it could help her become more assertive andconfident. The mother indicated that she might be interestedthough she never asked about it again.313.52This social worker had no further involvement. On 3 June 2010 thecase was transferred to a new social worker (SW5) in the lookedafter children’s team. There was no transfer summary because fora looked after child the case plan was summarised in the decisionsof the looked after review meeting. Subsequently the key issue inthe case was believed to be whether or not the mother wished toresume the care of EY. The issue of the mother’s action inconcealing the pregnancies was only mentioned in social carenotes in one of the adoption counselling discussions.3.53On 8 June the mother cancelled a scheduled visit to EY at thefoster home. She said she was disappointed that she had not seenhim, though the reasons for her cancelling were not noted. Thenew social worker (SW5) visited EY that day as did a member ofthe health visiting team. There were no health concerns about EYat this point or at any stage while he was in foster care.3.54The same day the mother registered herself and OY at a differentGP practice (in Windsor). OY’s records were received at thepractice on 30 September (3 months later) and summarised. Themother’s records did not arrive until 15 April 2011 (after thedeath) after having been chased by the practice. The reasons forthis substantial delay are not clear. The transfer of medicalrecords when patients transfer from one surgery to another isdiscussed in section 4.6 of this report. The mother’s reasons forchanging GP practice at this point are not clear. As her own noteswere never sent to the surgery staff there were unaware of herprevious medical history, including the nature of her pregnancies.3.55On 10 June 2010 the mother had contact with EY at the fosterhome. She had two more visits the following week (13 and 17June) and then two further visits on 24 and 29 June. There are nodetailed notes describing what happened at the visits made inJune. This was the only time in the period in which EY was lookedafter that the mother made any significant number of visits. Thevisits followed no regular patterns and there is no explanation ofthis. After June a number of planned contact visits were cancelled32and the mother did not attend the next statutory review on 21July 2010. The next recorded contact between mother and EY wason 4 September 2010 (after a gap of 68 days).3.56On 10 June a solicitor in the legal department sent an emailasking the social worker to make contact. It is not clear why thiscontact was initiated at this point. There appears to have beenearlier contact not entered in either agency record. The socialworker’s response (recorded in legal but not in social care) wasthat the mother was to receive adoption counselling and that shemightbewaveringaboutEYbeingadopted.Thisaccuratelyreflected the understanding that the social worker had at thispoint. The first entry in social care records in relation to legalservice involvement is after the next statutory review on 21 July.3.57On 25 June the mother had her first adoption counselling session.She had had contact with EY four times in the previous 15 days.She was noted to be ambivalent about the future care of EY.3.58The next social work visit to the mother was made on 1 July. Themother stated that she would ‘eventually’ like to take EY home.Her reasons for not wanting to do so straight away were notestablished. The social worker indicated that she would need todemonstrate this by increasing her contact with EY.3.59The second adoption counselling visit was made to the mother on2July.Shewassaidtobedemonstratingher‘continuingambivalence’ towards EY being adopted. The notes reflect thecounsellor’sperceptionthatthe mother’sconcealmentofherpregnancy was indicative of her tendency to disassociate fromissues that make her anxious. She had a tendency to pretend thatnothing would happen in the hope that her problems would goaway.3.60On 7 July EY’s (HV4) and health practitioner (HP1) made a homevisit to EY at the foster home. It was noted that the mother hadnot taken him for his first immunisations as she had apparentlyundertaken to do. The social worker (SW5) made a statutory visit33the following day. It was not recorded whether the social workerwas informed about the delayed immunisations.3.61On9Julythemothercancelledtheadoptioncounsellingappointment. On 14 July it was noted that the mother had onceagainfailedtotakeEYforhisfirstimmunisation.Shesubsequently provided a consent letter.3.62On9JulythemotherattendedherGPandwasgivenacontraceptive implant. During the consultation she stated that shehad only one child. What she meant by this and why she said itare not clear. The mother had no further consultations in thispractice.3.63On 19 July the foster carers’ supervising social worker (SW3)discussed progress with the foster mother. She reported that themother had not visited for ‘three weeks’. The same day EY’s socialworker recorded that she had indicated to a solicitor in legalservices that the mother did not want EY to be adopted andwished to care for him. This was said to be the reason that themotherhadcancelledthelastadoptioncounsellingsession,though this had not been noted at the time. The legal chronologystates that the mother had said that she did not want EY to beadopted but records that she had not said that she wanted to carefor him.3.64The second looked after review was held at the foster home on 21July. The review was attended by the foster mother, the socialworker, thehealth visitorforEY(HV4) andanindependentreviewing officer (UR). Neither parent attended. The health visitornoted that the mother had not had contact for four weeks. Sherecorded that she voiced her concerns at the review about anumber of aspects of the case history: the concealed pregnancy,the fact that EY had been born at home and rejected or deniedbefore the birth, the lack of contact, the delay in naming the babyand the delay in consenting for immunisations. This was the onlypoint in the case history in which any professional identified and34articulated such concerns. As the review focused on EY it is notclear whether it was recognised that the mother had also deniedor concealed her first pregnancy. The looked after review notedthat legal advice was now being sought as to how to progress theadoption.3.65The child’s health visitor (HV4) was sufficiently concerned todiscuss this with the mother’s health visitor (HV5) who assuredher that she was ‘fully aware of the situation’ and would befollowing up the mother to offer postnatal depression and healthscreening. This was noted to be the last entry in EY’s healthvisiting record and the health visitor had no further involvement inthe arrangements for EY being cared for by his mother. The healthvisitor did not receive minutes of the looked after review and shewas not notified by the local authority when EY was discharged tohis mother’s care in November 2010.3.66The individual management review of social care services statesthat this meeting ‘was unable to confirm a definitive plan forpermanency, owing to(the mother’s)continuingambivalenceregarding adoption’. The record of the meeting states clearly thatthe main decision of the meeting was to ‘secure an adoptionplacement for EY’ and to ‘refer EY to the fostering and adoptionservice for family finding and arrange a permanency planningmeeting to identify permanency planning tasks. The social workerwas asked to inform CAFCASS of the parent’s request for anadoption. At the same time the social worker was to ‘commencetwin track planning’. It is not clear if this is a reference toconsultation with members of the extended family in order to seeof they wished to be involved or a further reference to themother’s ambivalence about the adoption decision.3.67After the review the social worker made contact with the mother,indicating that the local authority was unable to agree a care planas she had not been clear about her agreement to adoption. Shedid not take the other actions agreed at the meeting. The motherasked for further time to discuss this with the adoption counsellor.35The social worker also had contact with the legal department. Thesocial worker provided information about the background to thecase and was advised on the procedure in relation to relinquishinga baby and the adoption process. Legal notes state that the socialworker was advised that as the mother was changing her mindabout the process a clear time-frame should be set in relation toany proposed rehabilitation home, so as to avoid any furtherdelay. If mother failed to work towards the return of EY and therewerecontinuedconcernsaboutherambivalenceabouthisadoption it would be important to consider proceedings to obtain aPlacement Order (this is an order authorising a local authority toplace a child for adoption where there is no parental consent, orwhere consent should be dispensed with). The social worker wasof the view that the maternal grandparents would be supportiveand might wish to care for EY (even though they did not at thattime know about his existence).3.68This discussion is recorded in the social care records and dated 23July, but the content is different i.e. that EY’s extended familywould need to be informed and consulted and that counsellingshould be continued with the mother so that she has every chanceof making a decision that reflected her genuine wishes. The needfor a timescale linked to the need to avoid delay for EY was notedbut no specific timescale was ever agreed between the socialworkerandhersupervisorordiscussedwiththemother.Notwithstanding the decisions of the LAC review meeting no actionwas taken at this point to find a family for EY because of themother’s continued uncertainty.3.69The mother attended the third adoption counselling session thefollowing day (22 July 2010). It was noted that the mother wasstill very confused. She said that when she was not with EY shecould cut off from thinking about him and she did not feel pressureto make a decision. She expressed anxiety about coping with twochildren and what family support she would get. The counsellorsuggested another meeting with the social worker and father to36discuss what support would be in place. At this point the positionwas essentially the same as it had been when the case had beentransferred to the team at the beginning of June. The drift inactivity on the part of the local authority is discussed in section4.4 below.3.70HV5 made a home visit to the mother on 27 July 2010. This visitclashed with an adoption counselling visit so it was rearrangedafter a brief discussion with the mother. She explained that EYhad been the result of a concealed pregnancy and that he was infoster care awaiting adoption. The health visitor noted that themother seemed not to understand how the adoption processwould proceed. The counsellor noted that the mother remainedunable to reach a decision and continued to be worried about howshe would cope with two young children.3.71Thecounsellorconfirmedthatcourtproceedingsmaybeconsidered to secure EY’s future. This would have meant seekingan application for a Placement Order under the Adoption andChildren Act 2002. The mother spoke about going on holiday withher parents during August and indicated that she would not bethinking about EY during this time. The worker noted that themother appeared not to realize the impact on delays for EY, andfailed to internalise discussions following visits. At this point themother had had no contacts in the previous four weeks and shewas proposing to go away for the next four weeks.3.72It is not clear if this information about the mother’s attitude andplans was made known to the social worker responsible for EY orher manager. There are no recordings to this effect. The workerundertaking the adoption counselling, EY’s social worker and hermanager may not have read the two sets of notes which were heldon two different electronic records, but they did have discussionsabout the case as they were sitting in the same office.3.73On 30 July the mother was phoned by the social worker who hadhadtocancelaplannedvisitduetosickness.Themother37indicated that she wanted to give up EY for adoption. On 2 Augustthe team manager of the Child in Need Team confirmed in theelectronic records that a letter had been sent to the motheroutliningthedepartmentalexpectationsregardingthere-unification or adoption of EY. Although there are references to thisletter in the records no copy of it was saved as part of the localauthority records. 13 It cannot be certain what the letter said aboutthe timeline and the options open to the mother or whether itmentioned the need to contact the grandparents. The mother senta text message the same day to EY’s social worker confirming thatshe wanted to proceed with the adoption.3.74In contrast on 6 August the mother told her health visitor (HV5)that she felt ‘detached’. She wanted EY back when she saw him,butdidnototherwisethinkabouthim.Thehealthvisitorencouraged her to visit the local children’s centre to make moreyoungfriends.ShealsocarriedouttheEdinburghPostnatalDepression Scale (EPDS – See Appendix 6) screening, recording ascore of 12 (which is within normal limits). There was a fullassessment of OY who at this point was aged 15 months and saidto be developing well. He was not weighed.3.75The social worker’s next actions are not easy to follow from therecords available. It appears that no further social work action wastaken until 10 August (when there was contact with legal servicesand the foster mother). Legal department records state that on 10August 2010 the social worker was asked for an update on thecase. The social worker told legal services that counselling wascontinuing. The following day the social worker informed the legaldepartment that the mother had decided to relinquish EY foradoption. There is no note of these discussions with legal in socialcare records. On 12 August the legal department advised thesocial worker of the protocol and procedures in relation to the13 Extensive but unsuccessful efforts have been made to find any version of this significantletter. The most likely explanation is that it was typed and sent but not saved properly on theelectronic recording system. However staff recollect discussions about sending the letter andthe mother’s text message would appear to be a response to it38decision to relinquish a baby. A date was needed for the adoptionpanel and CAFCASS needed to be informed of the circumstances(the CAFCASS role would be to obtain consent from the mother).Thesocialworkerupdatedthefostermotheraboutthesedevelopments on 13 August 2010 stating that mother wished tocommence the adoption process, though she gave no indication asto what action would be taken.3.76On 17 August the legal advisor asked whether EY had beenbooked into the Adoption Panel and gave advice about the fostercarers taking him on holiday abroad. There is no parallel recordingabout this in social care. On 20 August the social worker told legalservices that there had been no contact between the mother andEY since 21 July 2010. (This was in fact the date of the last reviewbut the mother had not attended it, her last recorded contact hadbeen three weeks before then). It was stated that the adoptioncounsellor was to offer further counselling sessions when themother returned from her holiday. As the adoption had beenagreed the counselling would have continued with a focus on theimpact of the decision on the mother herself and to make sure thedecision was final.3.77There is no record of the social worker taking any action toprogresstheadoptionthroughoutAugust.Accordingtothemanagement review there was no supervision session during thisperiod (because of leave and training commitments) and it wasnot until September that work was begun in relation to theproposedadoption.Themanagementreviewstatesthatthisincluded the social worker beginning work on a Child PermanencyReport, booking an adoption medical for November 2010 and anAdoption Panel for December 2010. There is no indication as todiscussions taking place about the legal advice about contactingthe maternal grandparents.3.78If the local authority had done this (in order to progress theproposed adoption) it would have opened up the possibility thatthey would have sought to become actively involved and possibly39offered to care for EY. Implementing the legal advice in relation tothis was potentially complex. In the event no progress was madeinrelationtocontactwiththematernalgrandparentsuntilNovember 2010.3.79At this point it appears that the focus of attention in the localauthority was on the difficulty that the mother had had (andperhapscontinuedtohave)indecidingaboutwhethertorelinquish EY for adoption and on the difficulty that she washaving in telling her parents that she had a second child. The legaladvice that had been given was that the focus of attention shouldbe on what was in EY’s best interests and the adverse effect thatfurther delay would be likely to have on him. The question ofwhether the maternal grandparents needed to be involved wasone which needed to be actively addressed by the local authorityfrom the perspective of what it believed was in EY’s best interests.The difficulty that this posed for the mother needed to be takenintoaccount,butitshouldhavebeenarelativelyminorconsideration. This is discussed further in section 4.4 below).3.80On 4 September the mother had contact with EY at the fosterhome, the first recorded contact since 29 June 2010 (almost 10weeks previously). A further visit was made on 11 September.There was no further contact visit until November by which timethe mother had decided that she wished to look after EY.3.81On 10 September legal services sought an update from the socialworker. This was provided on 14 September following the visit tothe family home that day. Again the discussion with legal was notrecorded on the social care files. The allocated social worker(SW5) and the social worker who had been undertaking adoptioncounselling saw the mother and the father. The purpose was todiscuss the local authority’s intention to disclose the proposedadoption to the extended family. The local authority repeated theview that the manager had explained to the father some weeksbefore (i.e. that the mother’s family would be told). This wasbased on an interpretation of the legal advice given, though it was40not stated why the local authority had decided that it would bebetter for EY to disclose his existence to the grandparents (againstthe wishes of the father and in the face of the mother’s failure todo so).3.82The father stated that he felt that it was unfair to tell the familybecause it would be a trauma for them. He spoke of the difficultieshe had had since the birth of EY. He was noted to have dominatedthediscussionandputtingthemotherunderconsiderablepressure. The social workers and the mother spoke of the supportthat the maternal grandparents had already given the family overOY.3.83It is clear that at this point the discussion about contacting thefamily (which the local authority had decided was necessary inorder to progress the adoption) had reopened the discussion aboutthe agreement to the adoption. The mother had made a clearstatement about this at the beginning of August and had thengone away on holiday. There was clearly an assumption on thepart of everyone involved that if the mother’s family knew aboutEY they would offer to care for him or persuade the mother to doso with their help.3.84The outcome of the meeting reported to the legal service was thatthe mother wanted to proceed with adoption, the extended familywould be contacted and that the father was opposed to this andsaid he would be seeking legal advice.3.85On 16 September the mother re-registered at the children’s centreafter a five month break. She may have attended sessions earlierin the month but this was the first time her attendance wasrecorded. 14 Mother attended with OY and did not mention havinghad a second child in between. The mother registered at thechildren’s centre as a single parent with one child living at aWindsor address. The centre worker and the centre coordinatorwere not aware of the birth of EY or of any involvement of14 Given the nature of the service that not recording an individual attendance would not beunusual41agencies in between. Mother attended a variety of sessions withOY and then with EY until shortly before the death of EY. Shebegan a parenting programme run at the centre in March 2011.3.86On 21 September 2010 the adoption counsellor made a furtherhome visit. The mother said that she had not yet informed herparents of the birth of EY but intended to do it ‘next weekend’.She said that if her mother offered her support she said she mightchange her mind3.87On 27 September the social worker provided an update to thelegal department. She stated that the mother would be telling herparents about EY and that she would do so if the mother hadfailed to. No timescale was placed on this.3.88On 28 September the social worker (SW5) made a statutory visitto EY. He was noted to be developing appropriately and wasobserved laughing and smiling and he was able to hold the balloonand other toys. He was able to sit up supporting his weight. Hiscarer had begun weaning him; he had a good appetite and waseasy to feed. EY was reported to be sociable and happy duringmeal times. He was sociable in public and sought out socialinteraction.Thisisanaccountofahappychild,developingnormally and benefitting from good physical and emotional care.There was a minor concern about his ‘tongue tie’ which was saidto be very mild.3.89The social care records contain an email setting out the advicegiven by the legal service on 1 October 2010. It states that ‘thebest course of action is for the social worker to write to themotherstatingthesocialworker’sintentiontovisitthegrandparents to discuss permanency plans’.This part of theadvice is entirely consistent with the legal advice given in July2010 after the looked after review. However the email continuesthat ‘this action should only be taken if this is assessed to be inEY’s best interests and if mum is in agreement with the approach’.This strongly suggests that the mother needed to consent to any42approach to her family. It is very likely that the emphasis placedon securing the mother’s agreement in this email contributed tothe further drift in the case. The SCR believes that the secondaspect of this legal advice did not properly reflect the case law orthe interests of EY. This is discussed further at section 4.4.18below.3.90On 12 October 2010 a further adoption counselling visit wasmade. The mother confirmed that she wanted to proceed withadoption, even if her parents were to offer support. However, themother had still not yet informed her parents of EY’s birth. Themother discussed preferences that could assist in matching EY toprospective adoptive carers. Again it is not clear at this pointwhether there had been liaison between the two social workersinvolved.3.91EY’ssocialworkerdidsetadatetovisitthematernalgrandparents (18 October) but the mother postponed this on themorning saying that her parents were on holiday. The socialworker replied setting a definite date and seeking the return ofadoption medical forms which had been delayed with the mother.On 2 November the mother tried again to delay the meeting onthe grounds that her parents were away again. The social workercalled at their home on 4 November and left a compliment slip.They were clearly not away and phoned immediately to ask whythe social worker had made contact. The next day following afurther discussion with the mother, the social worker informed thegrandparents over the phone about the birth of EY and that hewas in care. The grandparents blamed the father. The socialworker agreed to visit in a week. It is not clear why she delayedher visit by a week. During this period the family took control ofthe situation.3.92On 8 November the mother sent texts to the social worker statingas follows:she wished to have contact with EY the next day43her parents had agreed to support her if she wished to bring EYhomeher heart was also saying that she wished to bring him homeand she was relieved that her parents knew what washappening.At this point the mother had had no contact with EY for nearly twomonths.3.93On 9 November the mother visited EY and after this she phonedthe social worker and told her she wanted to take EY home. Shesaid that her parents had told her that they would give herfinancialandpracticalsupport.Thefollowingdaythefostermother advised her support worker that she had no reservationsabout this. This is discussed in section 4.3 below. The socialworker emailed an update to the legal service on 10 November.This was the last contact with legal advisors.3.94EY was taken to the health clinic on 12 November. He weighed8.72kg (just below the 75th centile).3.95On 12 November a planning meeting was held at the foster carers’home to plan for the discharge of EY to his mother’s care for thefirst time. This was attended by a manager, the social worker(SW5), the senior social worker, the adoption counsellor, themother and the maternal grandparents. There are no details of thearrangements made in the local authority records. The socialworker informed the mother’s health visitor (HV5) the next day byphone but did not consult with the health visitor (HV4) who hadattended the looked after children review and raised concernsabout the mother’s potential capacity to care for EY at the reviewin July. It is impossible to know what she would have said had shebeen asked. However none of her concerns had been addressed inthe intervening four months, EY had grown up considerably andthe mother had had even less contact than during the periodpreceding the looked after review.443.96Between 12 and 19 November (when the handover took place) themother visited on a number of occasions. It is not recorded howlong these visits lasted or what took place in any detail. There isno record of the social worker observing the contact sessions,though she spoke to the foster mother. None of the qualified socialcare staff who had been involved in the meeting visited the fosterhome during this time. The adoption counsellor spoke to themother on 16 November on the phone. She said things were goingwell, although OY had been a little jealous of EY. The fostermotherwaspositiveoverallbutshemadeanumberofobservations which she felt were concerning which she reportedon the phone to the social worker on 18 November. Twice shenoted that the mother kept EY on her lap facing away from her;mother made little eye contact; she did not know how to respondwhen OY was jealous of the attention that she was giving EY andshe was not very effective at stopping OY from scratching EY. Thefoster mother believed that the mother might need advice on‘bonding’. The social worker recorded these comments but it is notclearifsheunderstoodthereasonsforthefostermother’sconcerns or if she discussed them with her supervisor.3.97The foster carer’s observations were very similar to some madelater by staff at the Children’s Centre.3.98So far as can be established the social worker did not see themother and child together or speak directly to the mother betweenthe planning meeting on 12 November and 24 November (fourdays after she resumed the care of EY). During this transitionalperiod there is no record of contact with the father or his attitude.Discussions with the maternal grandparents had triggered themother’s decision to care for EY. They attended the planningmeeting that agreed to the placement of EY with his mother, butthere is no indication any professional had further contact withthem. Their actual role in supporting the care of either child wasnever established.453.99The mother’s health visitor (HV5) visited her ahead of the returnof EY. She made no detailed notes except that she advised aboutplaygroups and reminded the mother of the support available fromthe health visiting team. When interviewed for the SCR she statedthat the mother had talked about her visits to EY at his fosterplacement, she appeared relaxed and happy and she reported thatshe had no concerns about EY coming home.3.100The local authority did not seek legal advice about the position ofEY at this point. If it had done so it is clear that the local authoritywould have been advised that there were no grounds to seek toprevent the mother from taking over the care of EY. He had notsuffered significant harm as he had been looked after in fostercare since his birth. There was no evidence – based on the carethat had been provided to OY by the mother and her family – thatEY would be likely to suffer serious harm in the future. Howeverthere were good reasons to be concerned about aspects of thehistory, particularly the fact that the mother had concealed twopregnancies and the very limited contact that she had chosen tohave with EY when he was in care. There was no question at thispoint of preventing the mother from taking EY home. Attentionshould have been focused on the sort of intervention required inorder to monitor how the mother was able to care for EY, how thechanged circumstances impacted on her care for OY and what sortof provision was needed to best support her in caring for bothchildren.3.101These factors were not identified as significant and EY was placedwith his mother after a brief period of contact visits with no planfor further intervention and no arrangement for coordinating theinputof the professionalsinvolved. Asa result each of theagencies and professionals involved was left to make individualdecisions about how to respond to the family. Other professionalswho became involved (such as GPs who knew little or nothingaboutthechildren)respondedtoeventswithlittleorno46knowledge of the children and their history. This is discussed indetail in section 4.3 and 4.6 below.Significant events between the mother assuming responsibility forthe care of EY (19 November 2010) and 15 December whenprofessionals first observed injuries to EY3.102On 19 November the mother took over the care of EY. The sameday the father visited a locum GP and spoke again about hisfeelings (Redacted), first triggered by the birth of OY. He saidthat he had wanted to give up the boy for adoption but that his‘parents in law’ were not happy about this and wanted to lookafter their grandson. (Redacted)3.103The records of this consultation are confusing because they createthe impression that there was only one child (OY) aged 18months. The reasons for this are not clear but there is no reasontothinkthatthiswassignificantasthefatherhadalwayspreviously been clear about the details of both of the children. TheGP did not discuss this with any other professional.3.104Thefamilyhealthvisitor(HV5)madeahomevisiton23November. She saw both parents and both children. She offeredinformationaboutlocalservicesandadviceonthesupportavailable from the health visiting service. A core health visitingservice was offered. The notes from the health visitor who hadknown EY in foster care were never requested. The father was saidto be ‘very engaged’ indiscussions. None of the potentiallycomplex aspects of the situation were identified or discussed.There was no exploration of the mother’s long standing ambiguityabout caring for EY and the sudden change of mind. There werehuge gaps in the knowledge that the health visitor had about therelationship that the parents had with EY, for example the father’shostility to EY being cared for by the mother and the very largegaps in contact between the mother and EY while he was in care.The local authority had not provided this information and thehealth visitor had not sought information from the local authority47or from EY’s previous health visitor in order to carry out a properassessment.3.105Taking over the care of a child at the age of seven months is achallenging task in any circumstances and in this case there wereadditional complicating factors which needed to be explored andunderstood. The circumstances at the time of this contact meriteda full individual, family and environmental assessment at least ona par with a normal health visitor’s new birth visit. This did nothappen and this is discussed further in section 4.3 below.3.106On24Novemberthesocialworkervisitedthemotherandchildren. The social care management review reports that therewas evidence of positive parenting and attachment observed bysocial worker, though the only example given is that the motherencouraged OY to be gentle with his brother and not to hit him.The mother said that she was following the same routine as thefoster carers and that this was working well. The mother statedthat the father had visited every day to help. He was said to bemaking caring for EY easier by caring for OY. The mother said thatshe had introduced EY to her parents and would be introducinghim to her friends ‘that evening’. She felt that she did not needhelp from any voluntary services and now did not feel concernedabout coping. The social worker assessed all aspects of the careprovided and family circumstances as being positive. She neversubsequently spoke to the grandparents to find out what role theywere playing.3.107The social worker and her managers did not perceive this as beinga potentially complex situation in which they should insist on therebeing a need for continuing involvement to monitor the childrenand coordinate the provision of services to the family.3.108On 30 November EY was taken to the child health clinic. Hisweight was 8.90kgs just below the 75th centile. This showedcontinued growth since his attendance on 12 November.483.1091 December 2010 is the likely first date of EY’s attendance at thechildren’s centre. EY was added to the register when he started toattend regularly in January 2011, but it would not be unusual for amother to bring a child to a few sessions without registering him.The mother did not register EY’s details and told staff at the centrethat he was the child of a cousin whom she was looking after. Shemaintained this deception – which she also told other parents atthe centre - until EY’s last attendance shortly before his death.3.110This was also the date when the mother registered EY at her GP.His records were received two months later. They had not beenreviewed and no summary had been added to the electronicrecord at the time of his death. The GPs at this surgery were notaware that he had been looked after for the first seven months ofhis life and that his mother had only just started to look after him.15 The practice did not have his mother’s records from his previousGP until after the death of EY. The health visitor (HV5) was awareof this history but she did not tell the GP when they laterdiscussed concerns about EY.3.111On 14 December 2010 the LAC health team was informed by thehealth trust’s systems section that EY had returned home. Thissuggests an automatic notification from the information system ofthe local authority to the health trust. The local authority hadinformed the health visitor for the mother and OY (HV5) directly.She did not request the health records from HV4 who in turn didnot know that EY had been placed with his mother.3.112On 15 December the social worker made a visit to the mother andchildren. EY was seen asleep and had scratches on his face whichhis mother said had been caused by OY. The social workerdiscussed routines and coping strategies with the mother who saidthat she was coping well. She gave the mother photos of EY takenby the foster carers. The records do not indicate that the social15 There were however some references to this in EY’s personal child health record and theseare described and discussed in detail in section 1.18 and at several other points in the report.They were not obvious and a number of health professionals did not notice them49worker asked any more about how the scratches had been causedand she did not query the explanation. This was a concerningpresentationwhichmighthavebeenanindicationofpoorparenting or abuse. This was the last social work visit before thecase was closed on 22 December 2010. The social worker neversaw the father or members of the maternal family with EY after hemoved to his mother’s. No evidence was ever obtained (other thanthe mother’s general comments) to establish exactly what role thefather and the maternal grandparents were playing.3.113There was no detailed account of the supervisory discussions thatsupported the decision to close the case at this point. The authorof the social care management review was asked to address thisspecifically with the manager involved who has cited the followingfactors which he believed justified it at the time:the father and the mother’s extended family were seen asinvolved and supportivethe mother was understood to have cared effectively for OYthere were no known history or neglect or abuse or anyobvious risk factor such as mental illness or domestic violencein the familyit was perceived as being a ‘good outcome’ for EY to be unitedwith his mother and family in what was viewed as a stablefamily settingthere was a perception that the history of OY was ‘repeatingitself’3.114Section 4 of this report evaluates these judgements and theextent to which evidence which did not support them was notgiven sufficient weight. The social work supervisor also believedthat there were no significant risks in the mother taking over thecare of EY because he had been an easy infant to look after. Thefact that he had been an easy infant for foster carers to look afterdid not of course mean that he would be an easy child for hismother to look after. This assessment underestimated the specificsignificance or ‘meaning’ that EY may have had for his mother.50This is a recognised factor in many cases in which children arekilled or seriously injured.16 This is discussed further in section4.4 below.3.115EY was taken to a ‘stay and play’ session at the Children’s Centreon 5 January 2011. The children’s centre has two members ofstaff (a worker and the centre coordinator). References to ‘staffmeetings’ in the remainder of this report refer to minuted weeklydiscussions between the two. That day staff observed scratches onEY’s face. They were not viewed as being significant and recordswere only made retrospectively when a second set of marks wasnoticed on 2 February 2011. Staff remember the mother sayingthat the injuries had been caused by EY’s older sister. The exactlocation of the scratches was not recorded. This presentationappears to be similar to the one which the social worker had seenon her visit on 15 December 2010 and should have been viewedas concerning in a child of this age. 173.116On 12 January 2011 EY attended the children’s centre again. Thescratches had faded. The mother now said that she was caring forEY 3 days per week as an unpaid child minder. The informationwas not recorded at the time, though later centre staff took adviceabout this.3.117On 19 January the mother’s GP saw EY with his brother andmothertoundertakethe9–12monthdevelopmentalassessment. This would normally have been undertaken by thehealth visitor, but it was the practice of this experienced GP tooffer this service. He was unaware that EY had been ‘looked after’as he had not received a notification from the looked after healthteam or the social worker and the mother did not tell him. Thesurgery had not at that time received EY’s medical record from hisprevious GP which contains many references to his looked after16 P Reder, S Duncan and M Gray, (1993) Beyond Blame – Child Abuse Tragedies Revisited,Routledge.17 The social worker only saw EY asleep. The children’s centre workers believed that the childthey were seeing was a member of another family.51status.18 The GP did have access to the Personal Child HealthRecord (PCHR) which contains two indications that EY had beenlooked after. The first is a reference to his foster carer in one ofthe health records completed by his health visitor. The PCHR alsocontained a copy of the form giving parental consent to medicaltreatment for a looked after child (which would have been foldedin a separate section at the back of the small ring binder whichholds the record). This was not part of the PCHR which the GPwould normally refer to. The earlier health visitor entries alsomake a number of references to actions that would be taken byEY’s ‘carer’ rather than his mother or parent which at best give aslight clue that he was not living with his mother. The nature ofthis record and the fact that this significant information was notobviously visible is discussed further in sections 4.6 and 4.11below.3.118The GP noted that EY had three scratches on the right hand sideof his head and a bruise behind his right ear (recorded as 2x1cm). He also had fading bruises on his right forehead and rightcheek (measured as 2x7mm) and vertical scratches on his nose.No bruises were noted on his torso, his testes were both down andhisnapkinareawasnotedtobehealthy.EY’sheightwasmeasured as 46cm (75th centile) and his weight was measured asbeing 9kg (on the 50th centile). This was noted to have ‘fallen incentile position slightly’. The GP could tell this from the part of thePCHR that he accessed and he plotted the current weight on theheight and weight chart (See Appendix 7). The notes confirm thatthe GP accepted that the bruises and scratches had been causedby EY’s brother (who was present in the surgery) as he recorded‘2 year old brother-spiteful’ (although OY was not yet age two atthat point). The records note his intention to refer the family tothe health visitor for follow up, which he did.18 These arrived shortly after this consultation but had not been reviewed and summarisedonto the patient electronic record by the surgery at the time of EY’s death.523.119Two days later the GP phoned the health visitor (HV5) anddiscussed his findings. The GP record shows that ‘Health visitor(named) is aware and will visit next week.’ The GP confirmed hisview that OY had caused the bruising and scratches. There is norecord of what HV5 said apart from that she would visit.3.120The scratches seen by the social worker in December 2010 andthechildren’scentrestaffinJanuary2011wereunusualpresentations in a baby of this age. The bruising observed by EY’sGP was the first clear indication of possible physical abuse seen byprofessionals. They occurred 10 weeks before his admission tohospital with serious injuries.3.121The health visitor’s (HV5) notes (which are written up in her workdiary) state that she received the phone call on her mobile phonewhileoutmakingvisitson24January2011.Thereisadiscrepancy in the dates but the content of the GP and healthvisitorrecordingsisconsistent.ShenotedthattheGPhadobserved bruises on EY’s ‘face and head’ during a developmentalcheck. The health visitor’s perception was that she was beingasked to visit to advise on sibling rivalry, not to visit to check onthe bruises. There is nothing in the GP’s notes to suggest that hethought anything more was needed or that he asked for anythingelse to be done.3.122The health visitor (HV5) knew a significant amount about thefamily history at this point, including the fact that EY had been infoster care from birth to the age of seven months. However shedid not explain this to the GP. Although she took the call on hermobile phone while away from her base and she had no access torecords the health visitor did identify the particular child that wasbeing discussed and recalled his circumstances. Her recollection isthat she would have assumed that the GP already knew thisbecause he would have had access to the medical records.3.123The health visitor (HV5) made the requested home visit on 26January 2011 (seven days after the GP consultation). EY was seen53sleeping in his cot during the visit. No details of the bruises wererecorded because the health visitor did not believe that it was hertask to evaluate the bruises. The mother reported that there wereno problems and that she had a lot of support from her family andthe father. It was planned that the mother would attend the childhealth clinic and that she would contact the health visitor if sherequired further support or advice. The health visitor discussed theproblem of ‘sibling rivalry’ and gave what is described as ‘standardadvice’ to the mother. The health visitor recorded in the PCHR thatshe had discussed EY’s ‘excellent weight gain’. It is not clear whythe health visitor recorded this remark or what it referred to. EYwas not weighed as he was asleep and there was no facility to doso on this home visit. This is now described as being a ‘recordingerror’ which the practitioner involved has been unable to explain.3.124This may be significant because – even if it was recorded in error– another health visitor who saw the PCHR might have taken it atface value and been less concerned about the subsequent failureof EY to gain weight at the expected rate. EY was not in factgaining weight. Five days previously he had been weighed at theGPs and his weight was static (representing a fall in percentileterms, though not yet one that on its own would be consideredworrying). The height and weight chart is reproduced as AppendixVII3.125On 2 February the children’s centre worker observed bruises onEY. She did not record a detailed description of these bruises(colour, size or location) and so it is not possible to be certain ifthese were the same bruises that the GP had first observed on 19January or new injuries (or a combination of both). This was thesecond clear indication of possible physical abuse to EY seen byprofessionals, six weeks before his admission to hospital withseriousinjuries.Thiswasthesecondpotentiallyconcerningpresentation at the children’s centre.3.126The appearance of these bruises prompted the worker to make anote of the scratches observed on 5 January 2011. The mother54was attending the centre with both of her children. She gave afalse name for EY and continued to mislead staff about herrelationship with the child. Once again she was asked to registerEY and again she did not complete the registration form. Althoughno record was kept, at around this time children’s centre staffsought advice about the legality of the arrangement (i.e. a womanwho was not a registered child minder looking after the child of acousin for three days per week). The (correct) advice given wasthat it was not illegal so long as no payment was being made. Thisadvice was not recorded. At around this time the parents ofanother child attending the centre reported concerns about thesame bruises. These were backed up by a number of observationsof the mother’s behaviour and emotional responses to EY but werenot acted on by centre staff.3.127On 7 February 2011 the children’s centre coordinator referred themother to attend a parenting course due to be held at the centrein March. The centre coordinator said her reason for referring themother was to positively influence the mother’s parenting skillsandtoimproveherchildmindingskills.Noconcernswereexpressed about the parenting of OY. The underlying reason forthe referral was not disclosed to the parenting team membersrunningthecourse andnoinformationwasprovidedto theparenting team about the scratches and bruises.3.128On 9 February 2011 the mother attended a ‘stay and play’session. This was a busy session, with 12 adults and 15 childrenmarked as attending. On arrival, EY was left in his pushchair withthe hood up facing the wall. During the session the centre workerwent to look at him and observed that he was awake and had twobruises on his face (‘one on the side and one on his forehead’). Atleast one of these bruises must have been a new injury as onlyonebruisehadbeenobservedthepreviousweek.Hewasobserved to be happy when interacting with other adults. On theassumption that these were not the same bruises that had beenseen a week earlier, these were the third indications of possible55physical abuse seen by professionals, and the third concerningpresentation at the children’s centre. The mother was again askedfor her completed registration form and claimed that she hadforgotten to fill it in. She was asked to bring it the next week. Thecentre staff discussed the injuries after the session and the centreworker completed an incident record. This was not part of anindividual record because the children attending the centre did nothave individual records or case files. It was an individual sheet ofpaper (akin to the sort of form that might be used to report anaccident). These forms were filed in broadly chronological order soit was difficult to easily draw together a history of all the incidentsrelating to an individual child. This is discussed further in section4.9 dealing with the training of the staff working at the centre.3.129On 14 February 2011 EY was raised as a concern at the weeklyteam meeting between the centre worker and the coordinator. Theagreed action was ‘awaiting registration form, the mother has it athome and will bring on Wednesday to Stay and Play’. There wasno specific action recorded in relation to the bruises.3.130On 14 February 2011 EY’s former foster mother had a chancemeeting with the mother and EY. The foster carer made no notesof the encounter at the time but at her interview for the SCR shesaid that EY seemed quiet and subdued and that he had ‘lost hissparkle’ and that she wondered how the mother was coping. Sheremembers what she described as a ‘fading bruise’. This is likelyto be the same bruise seen at the children’s centre five daysbefore. She phoned the social worker (SW5) about this on 16February 2011. The social worker made no record of this contactso it is not possible to know exactly what she was told. She latertold a colleague (who made a record of the discussion – seeparagraph 3.140 below) that she phoned EY’s health visitor andleft a message on her voicemail passing on the foster carer’sconcerns and suggesting that the health visitor might visit to seehow the mother was coping. There is no record in the health trustof this voicemail and the health visitor does not recall receiving56such a voicemail. It is not possible to state with certainty whethera message was left or not. This may not have been a new incidentofabuse(becausethebruisemayhavebeenseenbythechildren’s centre a few days previously). However the significanceis that at this point the foster carer and either one or two furtherprofessionals knew about bruises on EY’s face.3.131On 1 March 2011 the social worker was reminded of this incidentby a colleague who had visited the foster carer (for reasonsunrelated to EY). The action taken at that point is described inparagraph 3.140 below.3.132On 16 February the mother attended ‘stay and play’ with OY andEY. Both centre staff observed bruises on EY’s forehead andcheek. These were the fourth indications of possible physicalabuse to EY seen by professionals and the fourth concerningpresentation observed by centre staff. The mother was askedabout them directly. She became defensive (to the point ofwalking away and refusing to discuss it) and said that the bruiseson the forehead were from EY hitting his head on the floor. Duringthe session staff observed that he seemed to have good control ofhis head and neck. The mother said that she did not know wherethe bruise on his cheek came from. EY was fully clothed and noother bruises were observed. The mother again said that theregistration form was at home but she had forgotten it. Inconversation with other mothers and staff, the mother said thatshe was going on a skiing holiday and would not be attending‘stay and play’ the next week. Staff thought that the excuse aboutthe registration form was ‘probably true.’ Another two parentsraised concerns about EY’s bruises. One remarked on his mother’slackofconcernandresponsiveness,theotheronhowhisbehaviour was unusual for a child of his age. The other parents’comments were not written down, but were recalled in staffinterviews for the SCR.3.133The same day the centre manager discussed the case of EY insupervision with her manager, though she did not mention the57name of the mother or the child. It is assumed that this occurredafter the incident that day at the centre.3.134The account that she gave to her manager are not recorded.There are recorded ‘shorthand’ notes of the action agreed but it isnot possible to be certain from the notes what was intended andthis is the subject of disagreement. The meeting record reads‘discuss with carer + then (poss) Mother. HV? Find out who… D Offreferral’.Thesenotesareclearlyopentodifferentinterpretations. The actions taken are likely to be those listedbelow on 16 February.3.135The children centre incident form states that social care wasphoned and gave advice that the registration form needed to becollected and then the parent identified. The parent should bequestioned.3.136The same day (16 February 2011) an access officer in the dutyservice made a record of a discussion in a notebook which mayrelate to these incidents. Access officers are administrative staff,with no social work qualification, who support the referral andassessment service. Responsibilities include answering incomingtelephone calls, acting as a triage for requests for information,recording initial contacts and referrals for the duty social workerand manager. The notes do not name a child and they do notstate who the conversation was with. They refer to a 10 month oldchild who had a fading scratches and a new bruise. It does not saywhere the bruise was located. It gives no indication that there hadbeen a history of bruising and scratches on the child’s face. Thereis no record of any advice given and no record was made on theelectronicsocialcaresystem.Accordingtothesocialcareindividual management review this was not recorded as a contactin the social care Integrated Children’s System because the accessofficer considered the telephone call to be a consultation, ratherthan a referral. The access officer did not discuss the informationthat she had received with a qualified member of staff. This isdiscussed in section 4.9.583.137On 17 February 2011 children centre staff sought advice fromtheir link health visitor (this was a health visitor who offeredsupport and advice to the centre, but she was not one who hadhad any involvement with the family). Attempts were made toidentify EY from child health administration records. As the namechecked was a false name no relevant child was found. Themother’s name was not checked because no one at the children’scentre had any suspicion that EY was the mother’s own child.3.138At around this time the children’s centre coordinator and herservice manager had a follow up conversation. The conversationwas not recorded and could have taken place on 17, 18 or 21February. The centre coordinator agreed that she was confidentabout following the concerns up. Both parties agree about this,despite their conflicting earlier accounts. This was after the call tothe access officer but it is not clear if this preceded or followed thecalls to the healthvisitor and the administrator. The centrecoordinator did not mention the case again to her manager,despite the subsequent failure to identify the child, the refusal ofthe mother to complete a registration form for EY and the furtherpresentations with bruising. The service manager did not ask heragain what the outcome of her actions had been. This is discussedin section 4.9.3.139There are no further entries in any agency records until 1 March2011. That day the mother attended the first session of the TripleP parenting programme run at the centre. Both children were leftin a crèche. There were no negative or significant observationsrecorded.3.140The same day the supervising social worker for the foster carersvisited. The foster mother repeated her account of seeing EY andhis mother to this social worker. The fostering social worker (SW3)in turn contacted the previously allocated social worker (SW5).She said that she had called the health visitor (HV5) and left avoicemail message and that she would chase this up as she had59not heard back. She did not try to contact the health visitor again.The social worker (SW3) did record this conversation.3.141On 2 March the mother attended a further ‘stay and play’ sessionwith OY and EY. The centre worker observed two bruises andscratches on EY’s face. The mother who had raised concerns aboutEY’s injuries did so again. These were not recorded on an incidentform. The incident record states that ‘the mother came with hercousin’s baby. He was taken out of his car seat and played withand he appeared happy. EY had a bruise on his forehead whichwas blue; he also had one on his cheek under his eye. He had twosmallscratches nearhiseye. Ilooked athisnails(unclearwords)…they are fairly long’. The incident record does not recordthe exact location of the bruises. They are likely to be new injuriesas the bruise on the forehead is noted as dark blue. This was thefifth indication of possible physical abuse of EY and the fifthconcerning presentation at the children’s centre. It occurred twoweeks before EY’s admission to hospital with serious injuries. Theaction recorded was for the staff to ‘continue to observe. Gave themother another registration form for him as said she lost the lastones’. The centre worker told the centre coordinator about thebruises some time later in the week. The delay in discussion andthe continued emphasis on asking the mother to complete theregistration form strongly suggests that the staff involved did notconsider the bruising on EY’s face to be indicative of a risk of childabuse.3.142On 8 March the mother attended the second session of the Triple Pparenting programme. OY and EY were left in the crèche. Nothingnegative was recorded or noted. It is not clear why the staff didnot notice the bruises that appear to have been very evident sixdays before.3.143The following day the mother attended a ‘stay and play’ sessionwith OY. It is not known where EY was. There is no indication thatshe was asked (though as he was believed to be the child ofanother woman this would not have been seen as significant).603.144On 14 March EY was seen by a GP (GP4) with a cold and coughwhich his mother said he had had for five days. He was noted tobe ‘alert, interacting and comfortable’ and otherwise well. Giventhe reason for the consultation it is likely that very little of EY’sbody would have been examined.3.145On15March2011themotherattendedthethirdTriplePparenting programme session. OY and EY were left in the crèchewhere staff observed bruises on EY. The incident record noted thatEY had a ‘dark blue bruise on the left side of his face close to hiseyes. He has a lighter bruise on his forehead’. The centre workerhad a look down the front and back of his vest and could not seeany more bruises. No bruises were observed on his legs. Thecrèche staff were very concerned about his bruises as they weresure that EY was ‘very stable sitting up and didn’t fall over’. Theaction noted was for staff to ‘continue to observe him’. This wasthe sixth indication of possible physical abuse of EY and the sixthconcerningpresentationatthechildren’scentre.Theywereobserved two days before he was taken to hospital with seriousinjuries.3.146The following day (16 March 2011) the mother and both childrenattended ‘stay and play’ session at the children’s centre. Staffrecalled in interview that both children seemed poorly and that EYwas lethargic. It is not clear whether the bruises were observedagain. They may not have been recorded because they had beenrecorded the day before.3.147On 17 March 2011 the mother took EY and his brother to a childhealth clinic between 1.30pm and 3.00pm. The clinic was beingconducted by a health visitor (HV7). The health visitor had noprior knowledge at all of EY, his family or his history. She madebrief notes during the clinic in the PCHR and she made a note ofEY’s name in her work diary because she intended to speak to hisallocated health visitor about her observations. EY had beenseriously injured before she was able to do this. Section 4.11 ofthis report will describe in more detail the arrangements for the61clinic and the circumstances in which this health visitor wasworking that day.3.148The most recent recordings on the PCHR had been made by theGP on 19 January and the health visitor (HV5) on 26 January2011. The history of bruising observed at the children’s centre hadnot been recorded in any health record as the true identity of EYhad not been obtained so there could be no consultation with ahealth professional.3.149EY’s weight was recorded in his PCHR and plotted on the weightand height chart. It showed that he had gained only 100 grams inweight since his previous clinic attendance on 30 November. Thehealth visitor recorded EY’s weight as static and advised hismother to bring him to attend for a weight check in four weekstime. EY’s mother stated that he was eating three meals a day andsleeping through the night. EY had dropped two centile bands onthe growth chart since he had left foster care, from just below the75th to between 25th–50th. This was a very noticeable departurefrom the established growth pattern. Visually it is very striking onthe growth chart, shown as Appendix 7, especially since children’sweight does not usually deviate outside one of the marked bands.EY’s plotted line becomes effectively horizontal. As she did notknow that he had been in foster care as a baby this health visitordid not appreciate that the period of static weight coincidedentirely with EY’s period in his mother’s care.3.150The health visitor (HV5) observed EY to have bruising to his face.She noted this on the PCHR, but not the details. During herinterview conducted for the SCR the health visitor recalled that hehad a bruise on his left forehead and a bruise on his left cheekbone. Both were approximately the size of a one – two pence coinand yellow / brown in colour. This was the seventh indication ofpossible physical abuse of EY. It was recorded in EY’s PCHR thathis mother reported that the bruising was a result of a fall at asession at the children’s centre the previous day. The healthvisitor states that she directly asked the mother on two separate62occasions how the bruises were caused, suggesting that she wasconcerned. The mother was adamant that EY had fallen off a toyat the ‘stay and play’ session the day before. The health visitorasked if EY had shown any signs of excess drowsiness or if he hadvomited. The mother stated that he had not and the health visitoradvised her to see the GP if EY showed any of these signs. Thisindicates that she was concerned to establish that there were noconcerning after effects indicative of an injury and to warn themother to watch out for them. This suggests that she was actingon the assumption that the account of the fall was genuine.3.151The mother also stated that OY was very jealous of his brother.The health visitor (HV5) recalls advising her not to leave the twochildren alone together. She suggested the mother enlist morehelp from her own mother to have EY while the mother spentmore time alone with OY. The health visitor recalls that both themother and the children were appropriately dressed and sheremembered that OY spent some time interacting with otherchildren at the clinic. EY was held in his mother’s arms (exceptwhen being weighed). The health visitor made a note of themother’s name in her diary with the intention of liaising with herhealth visitor (HV5). Despite the bruising and the very marked falloff in weight gain the health visitor did not seek advice from thenamed nurse for child protection or from the local authority.3.152On the morning of 18 March 2011 EY was taken to hospital byambulance. Ambulance service records refer to an account of aninjury at a ‘play park’. It is not certain if this refers to thechildren’s centre or not. EY was quickly identified as having aserious head injury. He died on 20 March 2011 and was found tohave suffered a number of other fractures in addition to the fatalhead injury. So far no explanation has been provided as to thecircumstances in which the head injuries that caused the deathand other injuries believed to be of different ages. The mother wassubsequently arrested and is suspected of having caused thedeath of EY.634EVALUATION OF THE SERVICES PROVIDED FOR THECHILDREN4.1Introduction4.1.1ThischapteroftheSCRoverviewreportevaluatestheeffectiveness of the actions taken and the services provided tosafeguardthechildren.Itexaminestheprovisionmadebyagenciesindividuallyandbythenetworkofchildprotectionprofessionalsasawhole.Ithasdrawnextensivelyontheindividualmanagementreviewsanddoesnotrepeatallthefindings of those reports. As well as drawing on the individualmanagement reviews the overview report has taken full account ofdiscussions in the SCR panel meetings as well as discussions withindividual members of the panel and the authors of individualagencyreviews.Anumberofmembersofstaffwereaskedsupplementaryquestionsabouttheirinvolvement.Alloftheauthorities involved have made relevant documents available tothe SCR author and the panel.4.1.2The aim of the SCR overview report author has been to prepare areport that represents shared and agreed findings. If at any pointthere are substantial differences in emphasis and understandingbetween the author and the SCR panel or between panel membersthese are made explicit. The evaluation contained in sections 4.2 –4.12 provides the best account that can currently be given of theeffectiveness of the services provided to the children, based onthe information available from all agencies at this point. For thereasons explained in section 1 it has not yet been possible to takeinto account the views of family members.4.1.3In this SCR the evaluation in the overview report serves twofunctions. Its first objective is to evaluate whether the actions anddecisions of agencies with child protection responsibilities had anybearing on the death of EY. The SCR has sought to establishwhether agencies had any evidence to suspect that the childrenwere at risk of suffering serious harm and whether his death could64have been prevented if agencies had taken different decisions oracted differently. This is the focus of section 4.14 of this reportwhich presents its overall conclusions.4.1.4The second function of the SCR is to provide a wider evaluation ofthe services provided to the children and their family during keyepisodes in the case history. The objective is to identify whetherthere are any lessons that can belearnt so as to improvesafeguardingservices.Theremaybeimportantlessonsforagencies and the LSCB independently of the death of EY.The structure of the evaluation and the topics considered4.1.5This chapter of the SCR overview report addresses all of thematters set out in the specific terms of reference of this reviewand others that all SCRs are required by Working Together toSafeguard Children to address. The evaluation in this chapter ispresented as follows:4.2Concerns about parenting capacity relating to the familyhistory4.3Assessment and decision making4.4Implementation of plans4.5Focus on the child4.6Information sharing4.7Factors that impeded engagement with the family4.8Policies and procedures4.9The skills, knowledge and experience of the staff involved4.10The impact of supervision and management4.11Organisational matters - the impact of resources, lack ofcapacity and other organisational issues4.12The impact of diversity4.13What do we learn from the case?4.14Conclusions as to whether there were missed opportunitiesto protect the children and whether the death of EY couldhave been preventedJudgements about shortcomings in practice and good practice654.1.9The Working Together guidance requires that the SCR shouldbring hindsight to bear in evaluating the actions of professionalsand public bodies.19 Self evidently there is value in seeking to lookback objectively at a case history, with a fuller knowledge of theevents and the actions taken by professionals and knowing theoutcome. As well as the insight that comes from hindsight the SCRis aware of the danger of what is termed ‘hindsight bias’.204.1.10So far as is possible the SCR has therefore sought to avoid this. Itis easy to view decisions as being wrong because we now knowthat they were part of a chain of events that had a tragic outcome.It is harder but much more useful to seek to understand andexplain why actions were taken and decisions were made and toconsider the influences over professionals arising from the contextwithin which they were working. In this way it may be possible tolearn lessons that are relevant to other professionals who findthemselves working in similar circumstances.4.1.11Whenevaluatingtheactionsofindividualpractitionersandmanagers and groups of professionals and agencies the SCR hastaken the following approach:judgements about actions and decisions take into account theinformation that was available to those who took themat points it is necessary to evaluate actions and decisions inrelation to information that was known to the network of childprotection professionals as a whole and would have beenavailable if relevant information had been sought and provided.the review has sought to judge the actions of professionals andagencies against established standards of good practice as theywere believed to apply at the time when the events in questiontook place19 Working Together to Safeguard Children 2010, Chapter 8 describes the evaluation in theoverview report as being ‘the part of the report where reviewers can consider, with the benefitof hindsight, whether different decisions or actions may have led to an alternative course ofevents.20 David Woods et al, Behind Human Error, Ashgate (2010) second edition; Sidney Dekker,The Field Guide To Understanding Human Error, Ashgate (2006)66the evaluation will seek to distinguish and outline the influenceof individual and wider organisational factors in the decisionsand actions takenUnderstandingwhytherewereshortcomingsinprofessionalpractice and in the provision made4.1.12The SCR has identified a number of missed opportunities toprotect EY and his brother. There were also episodes in the casehistory when the standard of provision that was made fell short ofthe expectations that agencies have about how their staff operate.Viewed with hindsight it is usually easy to see what should havebeen done. On the face of it the local child protection proceduresset out the steps that should have been taken and there has beenmuch training for local professionals which was directly relevant totheproblemsthattheywereconfrontedwith.TheSCRhastherefore sought to understand why it was that this case proved tobe very difficult for staff to deal with in situ.4.1.13The approach adopted in this evaluation is a ‘systemic’ one whichpoints up the potential significance of factors relating to the child,the family, the wider professional network and the context withinwhich staff are operating.21 In the biennial analysis of SCRscovering the period 2003 – 2005 Brandon et al 22 identify some 30‘themes’ in the profile of the cases included in their retrospectiveevaluation. These are organised in relation to three domains:‘child factors and experience’, family and environmental factors’and practice / professional / agency factors’. The evaluationhighlights information relating to these factors.21 P Reder, S Duncan and M Gray, (1993) Beyond Blame – Child Abuse Tragedies Revisited,Routledge. This is not the same thing as a ‘systems review’.22 Brandon M, Belderson P, Warren C, Howe D, Gardner R, Dodsworth J, and Black J (2007)Analysing child deaths and serious cases through abuse and neglect: what can we learn? Abiennial analysis of serious case reviews 2003-2005. DfES674.2Concerns about parenting capacity relating to the familyhistoryIntroduction4.2.1This section addresses the following points from the terms ofreference:Identify any historical information (prior to 1 July 2008) on thefamily members that may have impacted on the parentingcapacity of the mother, GY, and father, PO;Information about family members before July 20084.2.2There was very little information in theagency records about thefamily lives of the parents in the period before July 2008. Theinformation that there was has been set out in sections 3.1 – 3.4of the narrative above. None points to any indication of risksassociated with the parenting capacity of the father or mother orany significant events in their family history.4.2.3Neither the initial assessments undertaken by the local authoritynor the new birth assessments carried out by health visitorsexplored the family background of the parents in any detail,despite the fact that the mother had concealed two pregnanciesand given birth to two children in circumstances which might haveplaced the children at risk. Midwives usually have their bestopportunity to identify relevant background family information inthe antenatal period, but the mother did not access antenatalcare.Midwivesdidnotrecordanysignificantbackgroundinformation during postnatal care of either child.4.2.4The assessments undertaken in the case history are evaluated inthe next section of the report.684.3Assessment and decision makingThis section deals with the following terms of reference:What were the key relevant points/ opportunities forassessment and decision-making in this case in relation tothe child and family? Do assessments and decisions appearto have been reached in an informed and professional way?Establish the quality of assessment of circumstancesrelating to either and both children and their family;Establish what risk factors in the family were known toagencies during the period under review;Establish how well agencies identified and responded tochildren’s injuries and other indicators of harmDid actions accord with the assessments and decisionmade? Were appropriate services offered /provided, orrelevant enquiries made in light of assessments?Analyse the extent, and professional understanding, of thesupport from the extended familyIntroduction4.3.1Thissectionofthereportevaluatestwodifferenttypesofassessment. Firstly it considers the opportunities that were opento professionals to undertake an assessment of need and potentialrisk in relation to both of the children. This will deal with thefollowing episodes:assessments by midwives immediately following the birthsof the childrenhealth visiting assessments (the new birth assessments andthe opportunity for assessment that existed when EY’smother took responsibility for caring for him at the age ofseven months)the initial assessments undertaken by the local authorityfollowing the birth of OY and again following the birth of EY4.3.2Secondly (from paragraphs 4.3.65 onwards) the report evaluatesthe actions taken by professionals when they were aware ofinjuries to EY.694.3.3Separate consideration is given in section 4.4 to the planning thattook place before EY was discharged to the care of his mother inNovember 2010. This was an opportunity for assessment but nonewas undertaken.Key opportunities for assessment. The quality of the assessmentsundertaken, the decisions made and the services provided as aresultAssessments by midwives4.3.4Midwivesusuallyhavetheirbestopportunity toidentify anyrelevanthistoryandsocialorhealthriskfactorsduringtheantenatal period. This takes place through screening (such asaskingroutinequestionsaboutdomesticviolence)andmoregeneral discussion about the kind and level of support that theparents will have. Missed antenatal appointments, high levels ofanxiety or depression and unusual responses to routine eventssuch as scans often point to concerns. In this case there was noopportunity for midwives to undertake assessments prior to thebirthofthechildrenbecausethemotherconcealedthepregnancies and did not book for antenatal care.4.3.5After the birth of OY the mother and infant spent three days inhospitalandtherewasroutinepostnatalfollowupinthecommunity.Themidwifemostinvolvedinthehospitalimmediately referred OY to social care. It is not clear what sort ofassessment of risk or need had taken place because the actualreasons for the referral were not recorded in the hospital notes.The only detailed account of the behaviour of the mother andother family members during her hospital stay is that the fathercuddled OY.4.3.6Attention during the mother’s hospital stay was also focused to aconsiderable extent on the medical problems that she experiencedas a result of the lack of antenatal care. These were not grave,although she required a blood transfusion which prevented herfrom caring for OY during one night. The individual managementreview focuses on the role of midwives, but OY and his mother70were also seen by doctors during the stay and before discharge.None identified or recorded any risks or concerns.4.3.7The local authority records indicate that the referral was madebecausethefamilywishedtoconsiderrelinquishingOYforadoption and not that there was any immediate concern about hiswelfare or safety. As a result the local authority decided toundertake the assessment at home. The hospital managementreview(paragraph59)findsthat‘variousassessmentswerecarriedoutinrelationtothenewbornrequirementsasrecommended by national guidelines’ and that ‘the decisions aboutassessments and interventions carried out appear to have beenreached in an informed and professional manner’, but there islittle evidence to support this finding because of the lack ofrecords.Themidwivesinvolvedmayhavebelievedthatbyreferring the family to the local authority they had ensured that afull assessment would take place. If so this is the wrong approachtotake.Midwivesshouldhavebeenundertakingtheirownassessment of the history they knew and should have also beenexpecting to contribute to the wider social care assessment.4.3.8Leaving aside completely the question of whether the parentswanted OY to be adopted or not, hospital staff should haverecognised that the potential social and psychological risks for thechild associated with the concealed pregnancy and the lack ofantenatalcarepointedtotheneedforapsychologicalorpsychiatric assessment of the mother and an assessment of thewider family circumstances.4.3.9After the discharge of OY and his mother they were seen in thegrandparents’ home on three occasions by the same midwife. OYhad no health problems and the midwife did not identify anyconcerns about the attitude or behaviour of the mother. When shewascontactedbythesocialworkerundertakingtheinitialassessment on OY she indicated (according to the social workrecords) that she had no concerns. She either did not believe thatthe nature of the pregnancy and the lack of antenatal care71presented a risk or she must have believed that the social workerundertaking the assessment would already be taking this intoaccount. The midwife involved should have recognised the unusualnature of the circumstances, recorded this and underlined it in herdiscussion with the social worker.4.3.10At the time of the birth of EY there were fewer opportunities forstaff working within the hospital to undertake an assessment. Atthe time of OY’s birth the extended family had been contacted bya midwife. It is not clear if this was what the mother wanted orjust the midwife’s instinctive response to the situation. In relationtoEYthemother andfatherpre-emptedthishappeningbyindicating immediately that they wanted EY to be placed in careand relinquished for adoption. The mother later asked for herhome phone number to be deleted from the hospital records andasked not to be phoned there. The reasons for this were neverestablished. There was no opportunity for antenatal assessment orany significant assessment in hospital.4.3.11The postnatal care for the mother and child took place in unusualcircumstances. The mother was at home and EY was in fostercare. The postnatal visits were undertaken by different midwives.There are no postnatal records but it appears that they treated thevisits to the mother and to EY as separate and routine tasks.There were no concerns in relation to either the mother’s or thechild’s physical health. There is no evidence that the two midwivesspoke to one another and neither referred to the records of thefirst pregnancy and the birth of OY. It is not even possible to knowifeitherofthemidwivesrealisedthatthiswasthesecondconcealed pregnancy. There is no evidence that any considerationwas given to making a referral for a psychological assessment ofthe mother. The discharge note sent to the GP in relation to EY’sbirth does not mention the circumstances of his birth or theconcealed pregnancy.4.3.12The individual management review has made recommendationswhich include the following areas of practice and service provision:72policy, procedure and practice in relation to concealedpregnancythe information pathway between maternity services andcommunity practitionerstraining on the importance of information sharingrecord keeping to support holistic family assessmenta checklist form to standardise information on postnataldischargebetter management of referrals to the local authority and otheragenciesThis covers most of the key responsibilities of the obstetric andmidwifery service in relation to safeguarding and interagencyworking.Health visitor new birth assessments4.3.13The individual management review dealing with the provision byhealth visitors refers to the Healthy Child Programme.23 This isreflected in local trust procedures and practice guidelines referredto as ‘Fit for the Future, Universal Children’s and Young People’sHealth Services (Health Visiting)’ November 2010’. All of thesedocuments are rooted in the National Service Framework forChildren, Young People and Maternity Services first published in2004. 24 Although there are variations in the terminology used, allofthesedocumentsstresstheimportanceofthenewbirthassessment visit by the health visitor and all of them underline theneed for a holistic assessment of the needs of the child andparents at key points in the child’s early life.4.3.14Despite the highly unusual circumstances of the birth of OY therehad been no handover of information from the midwives who hadbeen involved to the health visitor undertaking the new birth23 Department of Health (2010) Healthy Child Programme- Pregnancy and the First FiveYears of Life.http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_118525.pdf24http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_408910173home visit. However the new birth notification to the communityservice noted that the pregnancy had been concealed. The healthvisitor’s (HV1) home visit was undertaken when OY was aged 15days, which is within the timeframe expected locally. However incontrast to the approach set out in local and national guidancethere is no evidence that a holistic assessment of the child andfamily’s needs was undertaken. The records suggest that - despitethe very unusual circumstances of the birth and the lack ofantenatal care - the visit focused exclusively on routine childhealth matters, the interaction that the health visitor observedduring her visit between the mother and the child and the positivereassurances that the mother gave her about the support that shewas receiving from family members. There is no indication in thehealth visitor’s electronic record that the mother had concealed ordenied the pregnancy. There is no indication in the records as towho was present at the visit and no indication of the role andresponse of the father or other family members. The concealedpregnancy was not referred to in the health visiting record. Itappears that it was not viewed as being significant because OYwasassignedtothecorehealthvisitingserviceandnoconsideration was given to the potential psychological needs of themother arising from her behaviour during the pregnancy.4.3.15The health overview report is critical of the standard of practiceevidenced by this visit and identifies a list of issues which shouldhave been explored. Whereas the national and local guidanceemphasises the need for a holistic assessment of needs, this newbirth assessment appears to have been conducted more like atriage exercise to identify serious or pressing problems (which thismother did not seem to have). No clear explanation has beenprovided as to why this happened. It is not clear whether it was aone off example of practice falling short of expectations. There area number of possible explanations. These might include:74The nature of the responses from the mother who was able toreassure almost every professional that she came into contactwith that – despite the history – everything was ‘fine’Thelackofspecificguidanceaboutconcealedpregnancy.However regardless of this the lack of antenatal contacts andthe nature of the birth should have been sufficient to identifythe need for targeted provisionThe workload and capacity of the health visiting service mayhave been a significant factor. This is discussed in detail insection 4.11 below.Personal factors in relation to the health visitor undertaking theassessment4.3.16Neither the management review nor the health overview reportmakes any reference to audit of the standards met in healthvisiting practice. Given the lack of any clear explanation it is arecommendation of the SCR that the health trust takes steps toestablish the quality of new birth assessments in a sample ofcases giving particular emphasis to the wider family, social andenvironmental issues that are highlighted in the national and localguidance. This should include an audit of the quality of informationprovided by midwifery services from contacts in the perinatalperiod. The findings and any recommendations arising from thisaudit should be reported to the LSCB as well as to the trust boardand to commissioners of child health services.4.3.17The new birth visit in relation to EY was carried out by the healthvisiting team in the locality of the foster carers. He was identifiedas being in need of a package of care from the health visitor as alooked after child. The health visitor remained actively involvedand made a useful contribution to the one looked after reviewmeeting to which she was invited. There is no indication that thehealth visitor dealing with the mother and OY was informed aboutthe outcome of the new birth visit to EY by the health visitor whocarried it out (or even that she had been informed about the birthof EY). As a result the mother did not have a new birth visit75following the birth of EY and was only visited by her own healthvisitorthreemonthsafterthebirthofEY.TheBECHSmanagement review identifies the concern about this stating that:‘she was entitled to this visit in her own right and was of highneed due to the circumstances of EY’s birth and his voluntaryplacement in foster care. The mother and OY were at risk ofpsychological trauma and a health visiting assessment, of eachfamily member would have been of benefit at this time. Themother did not have her 6–8 week postnatal review on time; thereis no explanation why this was carried out late and the new birthvisit did not happen’.4.3.18The lack of information sharing between EY’s health visitors was afurther indication of a narrow task-focused approach to the carebeingprovided,ratherthanprofessionalstakingawiderperspective about the needs of both of the children and the wholefamily. Although it was not seen as being the role of the lookedafterchildren’shealthteamtoinformallofthehealthprofessionals involved with the family about the fact that EY hadbecome looked after, it was very well placed to have done so andcould have offered a safety net in the event that other informationsharing arrangements did not work. The role of the team isconsideredmorewidelyinsection4.6whichdealswithinformation sharing.The assessment of postnatal maternal depression4.3.19At OY’s 6-8 week review (May 2010) the mother’s health visitor(HV5) carried out a screening for postnatal depression using theEdinburgh Postnatal Depression Scale (see Appendix 6). The scaleincludes 10 items giving a maximum score of 30 and a cut offpoint of about 12 indicating potential risk of depression. Themother scored zero, indicating that she had no symptoms ofdepression or anxiety whatsoever. Given the concealed pregnancyand the initial conflict over the care of OY this seems verysurprising. In the experience of the SCR panel scores of zero arevery rarely recorded for the EPDS and scores within the normal76range reflect the many potentially unsettling changes that thepostnatal period can bring. Given the history in this case the zeroscore was particularly surprising and may have been an indicationof the mother’s continuing denial of difficulties and problems. Thehealth visitor did not consider this possibility.4.3.20There are other aspects of the EPDS that might have made it aless than reliable indicator of the mother’s state of mind. Thedesign of the EPDS questionnaire makes it extremely easy to ‘rig’.It is self reported and self completed; on every item it is obviouswhat the non-depressed answer is and the scoring system is listednext to the questions.Health visiting assessment prior to and after discharge of EY to hismother’s care4.3.21The mother’s health visitor (HV5) saw her shortly before and afterEY moved to live with her in November 2010. These visits wereorganised on the basis of information received from EY’s healthvisitor (HV4) and it was sensible of the mother’s health visitor toassess how the mother was managing to take on the care of EY.4.3.22EY was a lively, sociable and therefore demanding seven monthold baby. He was already attached to the carer that he had knownsince birth. His mother had never looked after him and had notvisited him for long periods of time. Taking over his care would bea challenging and complex task for any parent and for his motherit might be particularly difficult given that she had denied hisexistenceandthennotwantedtolookafterhim.Inthesecircumstances a visit akin to the type of new birth visit envisagedin the Healthy Child Programme was called for. This did nothappen. The visits that took place provided only a superficialassessment based on brief impressions of interaction and thepositive account given by the mother. The visits did not establishhow little contact the mother had had with EY over the course ofhis life. The assessment is very similar in nature to the new birthvisit undertaken in relation to OY and the initial assessmentscarried out by the local authority which are described below.774.3.23It does not state in procedures or in the Healthy Child Programmethatthesewerecircumstancesthatrequiredamuchmorecomprehensiveassessment.Procedurescannotcovereveryconceivablesituation.Thisshouldnotbenecessary.Healthvisitors’trainingandinparticulartheirknowledgeofchilddevelopment and attachment should have indicated that a fullerassessment was necessary.The initial assessments undertaken by the local authority4.3.24The management review provided by the social care servicerecognises that the two initial assessments undertaken by thelocal authority were missed opportunities to develop an in depthassessment of the needs of the children and the risk factors thatexisted as a result of the concealed pregnancies. The first initialassessment took place immediately after the birth of OY while hewas living at home. The management review states in relation tothe first that ‘this initial phase of social care assessment andinterventioncouldhavebenefittedfromamoredetailedconsideration of the nature / implications of the concealment ofthe pregnancy on the parenting capacity of the family, and acomprehensiveunderstandingofthedynamicswithintheextended maternal family for the long term support for (themother and OY).4.3.25The April 2009 initial assessment document makes references toconcerns about the mental health of both parents, in particularthatthereasonforundertakingtheassessmentwas‘thedepressive state of both parents’. This is a much more stronglystated description of the concern in relation to the mother thananyotherhealthrecordcontains.Theassessmentdocumentcontains evidence that the father spoke to the social worker abouthis feelings of shock and depression in similar terms to thediscussions that he had had with his GP. The record suggests thatthe social worker had no direct discussion with the mother abouther mental health, but that the father indicated that she wasdepressed and that she was ‘seeing a counsellor’ for this. It is very78surprising that this was not followed up with the mother and itwasnotestablishedwhetherinfactthiscounsellingwashappening.4.3.26Thesocial workerwhoundertook the assessmentmay havebelieved that this would be explored further during the coreassessment that she recommended. The manager who reviewedthe assessment did not agree that there was any further role forsocial care. She judged that the circumstances did not indicatethat OY was a ‘child in need’. In theory this was a valid conclusionbut the judgement gave insufficient weight to the very unusualcircumstances and the numerous unknowns in the history. Whenthe case was closed after the initial assessment a manager agreedthat because of resource constraints the social worker did notneed to write letters notifying other agencies of the closure (this isdiscussed as an issue in its own right in section 4.6 below).4.3.27The second social care initial assessment took place after the birthof EY but focused exclusively on the care of OY. The social caremanagement review notes that after the birth of EY there shouldhave been a detailed and comprehensive assessment of ‘all thechildren’s physical and emotional development needs, parentingcapacity (including a detailed assessment of the nature of theparental relationship), and the community and extended familynetworks’. (page 34). The initial assessment that was undertakenfocused exclusively on OY whereas his needs should not havebeen viewed in isolation from the impact of the birth of EY and thefuture plans for EY (which at that time were undecided). Onceagain the assessment undertaken failed to address the concealedpregnancy and the impact that having a brother (whose existencehad at that time not been revealed to other family members)could have on OY.4.3.28The pattern of two concealed pregnancies should without doubthaveledprofessionalstobecuriousaboutthemother’spersonalityandmentalhealth,evenifsuperficiallyshewasoffering good care to OY. A professional consultation with a79psychiatrist or psychologist over this was the absolute minimumthat should have been expected at this point, particularly as themother was undecided about the future care of EY and might wishto resume his care.4.3.29In fact there was an aspect of the health and development of OYhimselfwhichcouldhavegivenrisetoconcernabouthiswellbeing. He had put on weight extremely quickly, consistentlyweighing above the 99.6th centile, despite monitoring by healthprofessionals and attendance at a ‘Family Fit’ and ‘Healthy Eating’sessions at the children’s centre. The overfeeding and very rapidweight gain of OY could have been an indicator of his mother’sdysfunctionalparentingandshouldhavebeenexplored.Responsibilityfornotaddressingthisinarobustwaylayprincipally with health visitors who were monitoring his weight andchildren’s centre staff who saw him regularly. However it is aconcern that a social worker undertaking an initial assessment onachildwouldnotmakesomecommentaboutthiswhencompleting the element of the initial assessment relating to thechild’s health.4.3.30The recommendations in a number of management reviews pointto the need for professionals to recognise the importance ofconcealed pregnancy as a risk factor that should trigger an indepth assessment. Concealed or denied pregnancy is in fact justone example of any number of historic or static risk factors thatmight point to the need for a more in depth assessment whichprofessionals in all agencies and their supervisors need to be opento.Why was there no core assessment undertaken while EY waslooked after4.3.31No core assessment was undertaken during the seven monthsduring which EY was in foster care, despite the fact that his casebecame more, rather than less, complex as time progressed andtheneedtogatherevidenceforpossiblePlacementOrderproceedings appeared to be becoming more, rather than less,80likely. No core assessment was undertaken at that point becauseit was not required by procedures and no one in the local authorityrecognisedthatthecomplexityofthecasemeritedamorethorough analysis. Staff and managers had adopted the view thatthe case would end positively if EY went to live with his mother ashad happened to his brother. This period in EY’s life is discussed inmore detail in section 4.4.The assessment of the role of the extended family4.3.32At no point was there a proper assessment of the role of theextended family, including the role of the father.4.3.33The mother’s extended family were seen as being an importantsource of support for the parents (and particularly the mother) ata number of points in the case history, most critically when theparents decided to take OY home from hospital after his birth andwhen the mother decided to discharge EY from care. Both of theseplans – and the decision of the local authority to close the case inDecember 2010 – relied on the maternal family giving the motherregular support.4.3.34Although the maternal grandparents were seen as being extremelyimportant in the care plans there was minimal professional contactwith them. So far as can be established (based on the chronologyand the management reviews) this was as follows:The maternal family visited the parents in hospital after thebirth of OY (its not clear how many times)the social worker spoke to the maternal grandmother on thephoneafterattemptingtoarrangeameetingwiththegrandparents in early November 2011the maternal grandparents attended the planning meeting atthe foster home on 12 November 2011It is perhaps more telling to set out how they were not involved:so far as can be established the maternal grandparents werenot seen during either of the social care initial assessments,81though both assessments concluded that their role was positiveand importanttheywerenotseenbythesocialworkerduringtherehabilitation assessment (and they did not visit the fosterhome during this period so far as can be established)they were not seen or contacted by the social worker once EYhad been returned to his motherthe details of the parents’ siblings are noted in the social caremanagement review Genogram but they did not feature at allin any agency records4.3.35In addition the maternal grandparents were never seen by healthvisitors.Likethesocialworkerstheyreliedentirelyonthemother’s presentation of her close and supportive family. TheBECHS management review documents how the health visitor whocarried out the new birth visit to the foster carers’ home, wasinformed that the maternal grandparents lived close by and weresupportive. Their details were not recorded’. When the mothermoved home she ‘informed her health visitor (HV5) that hermother was very supportive and helped her with the children; thiswas recorded within the record on 26/01/11. Actual details of thegrandparents were not part of the record’. The managementreview notes that ‘at the last clinic contact, (before the death ofEY)HV7establishedthattherewassupportfromthegrandparents’. The final contact with EY before the injuries thatcausedhisdeathisdiscussedindetailfrom paragraph4.3.onwards and in section 4.11.4.3.36These descriptions are typical of the records across health andsocial care. The mother’s descriptions never went beyond theextremely general, and yet so far as we can see they were neverchallenged and the mother was never asked to describe exactlyhow they helped or how often they visited. The actual nature ofthe relationships was never tested. This was particularly significantas it was clear to social care staff in November 2010 that thegrandparents were hostile to the father, yet the plan was that they82were working closely with the mother (who was in turn relying onthe father) to support her care of EY.4.3.37Sometimes professionals’ misconceptions about the role of theextended family supported and reinforced one another. The 2009social work initial assessment of OY records that ‘health visitorobservation / assessment is that there is positive support to themother from maternal grandparents’. As has been shown therewas no health visitor observation of the grandparents and the only‘assessment’ was the word of the mother.4.3.38In reality no professional knew anything concrete about the rolethat the grandparents really played, except what the mother hadtold them and the commitments that they made at the planningmeeting (which have not been detailed). No one ever explored theparadox that pervades every aspect of the case history. Why wasit – if the mother has such close support from her family – thatshe had been unable to inform them of her two pregnancies? Whywas it that she could not bring herself to mention to them that shehad a second child for almost seven months? Rather than being aclose supportive relationship, this tends to suggest a much morecomplex relationship.Assessment of the role of the father4.3.39Very similar concerns apply to the role of professionals in relationto the father, though there are some distinct aspects. He was seenmore often: at the hospital after the birth of OY in 2009, duringtheinitialassessmentsandindiscussionsaboutproposedadoption of EY. He was seen once briefly by a health visitor (afterEYhadgonehomeinNovember2010).Howevertheoverwhelming majority of references to the father are records ofthe mother’s comments about him. He was taken to have been asupport to the mother in relation to the care of OY, but no onetested what this meant in practice.4.3.40In relation to EY social care staff formed a view early on that itwas largely the result of the father’s influence that the mother did83not want to care for EY or at least that she was ambivalent. Hewas seen and described as ‘domineering’. This led to the ratherunusual approach of asking the mother whether she wanted to bereferred to a domestic violence programme, even though therewas no evidence to suggest that she had been a victim ofdomestic violence. She did not take up the offer. Adherence to theview that pressure from the father was preventing the motherfrom making a free choice about whether or not she wished torelinquishEYhadtwoadverseeffectsontheassessmentsundertaken.4.3.41Firstly the father’s actual circumstances and views were neverproperly assessed. No other information was gathered from him orabout him. Potentially important information about his response tothe births of the two children held by his GP was never obtained.His clear view that the mother could not cope with caring for twochildren was never tested and explored.4.3.42Secondly the adherence of the local authority to the view that itwas largely the father’s influence that was preventing the motherfrom caring for EY led it to give insufficient weight to evidence ofother factors which should have been assessed. For example themother had no contact with EY for nearly 10 weeks between Juneand early September and told social workers that she gave nothought to EY when she was not with him. However domineeringthe father was, the mother’s indifference to EY was not entirelydue to him.4.3.43It is a long established finding of Serious Case Reviews that men(including fathers) are often marginalised in the assessment ofrisk.25 The most recent review of SCR findings adds an additionaldimensionwhichclearlyappliesinthiscase.Repeatingthefindings that there was a dearth of information about men andthat they were often ‘absent from assessment’, Brandon et al alsoidentify the danger of ‘rigid or fixed thinking’ about men ‘who were25 For example Brandon et al, (2009), Understanding Serious Case Reviews and their Impacta Biennial Analysis of Serious Case Reviews 2005-07 DCSF84perceived in a polarised way as primarily ‘good’ men (good dads)or ‘bad’ men (bad dads)’. Paradoxically in this case history thefather was perceived as both ‘good’ and ‘bad’ in different ways butthe complexity of both aspects was never explored. He was ‘good’to the extent that he was believed to help look after the children,though this was never evaluated in detail. He was ‘bad’ becausehe was stopping the mother from looking after EY though his‘domineering’ behaviour. He had his reasons for thinking that thiswas not a good idea. Some of them reflected his own needs, hehad not planned to be in a relationship and have children, butsome of them may have been very sound. These were neverexplored.4.3.44There is a complete contrast to the attitude of the local authorityto the influence of the father over the mother and the influence ofthegrandparents.Assoonasherparentsknewabouttheexistence of EY they persuaded her very quickly that she shouldlook after him. Considerable concern had been expressed aboutthe need for the mother to be able to make a choice free of thefather’sinfluenceandconsiderabletimewasdevotedtocounselling her over this. In contrast the local authority had nodisquiet whatsoever about the mother’s very rapid decision to carefor EY, despite the fact that it was clearly heavily influenced by thegrandparents and despite the fact that she had earlier said thather parents’ attitude would not affect her decision.4.3.45The evaluation in the preceding paragraphs has focused on therole of the local authority because it has the lead responsibility forassessment and decision making. However the weaknesses inrelation to the engagement of the father apply to all of theagencies involved to different degrees:health visitors saw the father only once (November 2010) andotherwisedidnotenquireabouthisroleoracceptedassurances about himthe children’s centre had no contact with the father and thereis no evidence that the mother was ever asked about him85the father’s GPs heard repeated stories from him about theimpact of fatherhood, but they all concentrated exclusively onhis needs as an adult patient and showed no curiosity aboutthe children involvedthe legal advice given does not touch on the role of the father(though his views about adoption were always clear).4.3.46The impact of failing to work with the father is distinctive andimportant in this case history, but the nature of the problem islongestablishedinsafeguardingwork.Agenciesneedtounderstand why it is that despite this being well trodden groundprofessionals once again ignored or marginalised the father inassessment and decision making.4.3.47The BECHS report makes a specific recommendation on the issue.Thelocalauthorityviewisthatiftherehadbeenacoreassessment then the father would have been more fully engaged.Other than this the individual management reviews are not criticalabout the failure to consider or attempt to work with the fatherand they make no recommendations. If agencies feel that theapproach to working with fathers is a ‘one off’ departure fromnormally good practice then they should be asked to demonstratethis to the LSCB. If this is not the case and wider concerns arerecognised then the LSCB needs to consider how it can influenceagencies to address this issue in a more constructive way and tomonitor the way in which agencies do engage with fathers andother carers. The LSCB should do everything it can to ensure thatagencies improve the engagement of fathers in assessments andcontinuing work and the SCR will make a recommendation inrelation to this.Why did no-one attribute sufficient significance to the two deniedor concealed pregnancies?4.3.48Although many agency records note that both children were bornas a result of concealed pregnancies the individual managementreviews note that professionals paid very little explicit attention tothis, beyond the immediate period after the children’s births.86Neitherwasmuchpaidtothepracticalconsequencesofconcealment. The BECHS management review spells these out,including the lack of antenatal care and the birth of two children inpotentially perilous circumstances (paragraph 5.3.6).4.3.49Inordertounderstandaswellaspossibletheprofessionalresponse it is important to be as clear as possible about theknowledgethatprofessionalshadabouttheconcealedpregnancies. In particular it is important to understand whichprofessionals knew about both of the pregnancies. In their studyFriedman et al 26 note a prevalence rate for denied or concealedpregnancies of 0.26% (roughly 1 in 400) of live births, indicatingthat this is a relatively unusual occurrence. They quote anotherstudy with a prevalence rate of 1 in 475. Strikingly the Friedmanstudy makes no reference whatsoever to any women having twosuch pregnancies, though they would not have been able toinclude pregnancies after their study or women who delivered atanother hospital. This strongly suggests that having two concealedpregnancies would be an extremely rare phenomenon and thatindications of risk arising from one concealed pregnancy wouldincrease disproportionately if a mother had two such pregnancies.4.3.50Midwifery staff dealing with the second concealed pregnancy areunlikely to have known about the first, because they did notconsult the mother’s records relating to the birth of OY. Littleuseful information was provided to other health professionals bythe midwifery service and discharge letters did not give sufficientemphasis to this information or highlight it in a way that wouldhave ensured that it was likely to be spotted. This is addressed inarecommendationarisingfromtheindividualmanagementreview.4.3.51The GPs dealing with EY after November 2010 did not know thatthepregnancyhadbeenconcealedthoughtheymighthave26 Op cit ( at page 118)87noticed from closely reading all of the documents in the PCHR thatEY had been in care.4.3.52The health visitor dealing with EY after he had been returned tohis mother knew that his pregnancy had been concealed and thathe had been looked after by the local authority. However it is notclear that she knew that OY’s birth had also been concealed as shehad not dealt with him as an infant. He had no separate healthvisitingrecordandthisinformationwasnotrecordedinhiselectronic records.4.3.53Children’s centre staff knew that the pregnancy with OY had beenconcealed but did not attribute any particular significance to this.The centre coordinator had had only basic safeguarding trainingand the children’s centre worker had received no single or multi-agency training (this is discussed further in section 4.9).4.3.54Local authority records on the two children make it clear that bothpregnancies had been concealed pregnancies though no extrasignificance was attributed to this.4.3.55Professionals only drew attention to concerns associated with thenature of the pregnancies at two points in the case history. Therewas discussion with the mother about her pregnancies in hercounselling about adoption. The mother’s tendency to deny and‘disassociate’ from issues that caused her anxiety and conflict wasnoted but this important insight was never integrated into thethinking of the local authority in terms of how it might affect themother’s ability to look after EY.4.3.56At EY’s second looked after review meeting his health visitorstated her concerns about the history of concealed pregnancy andplacement in care, the delay in naming EY, delay in obtainingconsent for his immunisations and the long periods of time duringwhich the mother had not visited EY. This could have been thestarting point of an analysis linking the mother’s denial of EYduringpregnancytoconcernsaboutherrecentattitudeandbehaviour. A thoughtful assessment would have gone on to ask88questions about the impact of this in the parenting capacity of themother, perhaps not in general, but in relation to EY specifically.Noneoftheotherprofessionalspresentappeartohaveunderstood or felt that it was necessary to take up this agenda.These static or historical risk factors were never treated as beingsignificant. The health visitor did not receive minutes of themeeting and was not invited to participate in further discussionsplanning for the discharge of EY from care. She did not pursue thisfurtherherself.Shemayhavebeenputoffunderliningtheimportance of this when discussing the case with OY’s healthvisitor because when she spoke to her about EY being dischargedfrom care, her colleague told her that she was ‘fully aware’ of thecircumstances.4.3.57Friedmanetalsuggestthatthefailuretoappreciatethesignificance of concealed pregnancy is not unusual. In their studythey found that because the professionals dealing with the birthunderestimatedthelevelofpotentialconcern‘psychiatryconsultationswererarelyrequested,althoughinfantswerefrequently discharged to the care of mothers who had denied orconcealed their existence’. As a result service provision was farlowerthantheresearchershadexpected.Itseemedtobeparticularlyhardforprofessionalstoaddressthisissuewithmothers 27 and that as a consequence ‘the lack of attention to thephenomenon of pregnancy denial mirrors the silent stance’ of themother and family (page 121). It is noted that women who havebeen unaware of their pregnancy or unable to discuss it with theirpartner or parents are likely to be dazed, confused, defensive orblandly reassuring after the birth (or a combination of these). Thesame individual psychological, family and environmental factorsthat led to concealment before birth will often continue to apply.Some women remain in denial even after the birth. Mothers whohaveconcealedtheirpregnancyareunlikelytoseekhelpvoluntarilyandarelikelytobeadifficultclientgroupfor27 The authors focus exclusively on mothers89professionals to engage. In such cases good supervision of staffwill be critical to aid recognition and assist staff in discussing theissue with women.4.3.58An additional factor that may have reduced the likelihood ofprofessional recognition in this case history was that no otherobvious risk factor was present. Insofar as professionals are usedto concealed pregnancy at all they are used to dealing with itwhere there are other clear risk factors which go some waytowardsexplainingthelackofawarenessofsymptomsofpregnancy or poor take up of antenatal services: particularlyparental drug misuse, domestic abuse, mental illness and learningdisability. In recent years professional thinking has been stronglydirected to these risk factors, understandably because they areassociated with the majority of serious and fatal cases of abuse.Brandon et al show that taken together one or more of the firstthree of these factors was present in 87% of the cases subject toSCR during 2003-200528 All of these risk factors will usually intheir own right trigger further assessment and intervention withinwhich the issue of concealed pregnancy may be discussed.4.3.59This case history highlights the potential for serious child abuse incases which do not have the predisposing risk factors mostcommonly associated with the highest levels of risk to children. If87% of fatal and serious cases feature domestic abuse, mentalillnessordrugmisuse,13%featurenoneofthemandprofessionalsneedtocontinuetobealerttounusualpresentations.4.3.60Most of the individual management reviews highlight the lack ofspecific guidance in the local child protection procedures aboutconcealed pregnancy. However ‘concealed pregnancy’ is currentlyincluded as the first on the list of factors that professionals should28 See page 81 of Brandon M, Belderson P, Warren C, Howe D, Gardner R, Dodsworth J, andBlack J (2007) Analysing child deaths and serious cases through abuse and neglect: whatcan we learn? A biennial analysis of serious case reviews 2003-2005. DfES90be aware of in relation to risks to the unborn baby and ‘denial ofpregnancy’ is included in the list of parental risk factors pointing tothe need for referral to social care, along with failure to take upantenatal care. In line with this the children were referred to socialcare, but the assessment of risk by all agencies was inadequateand only on one occasion did any professional point to theconcerning factors in the case.4.3.61The case made by the management reviews is that the currentdocumentationdoesnotgivemorespecificguidanceontheassessment of risk where there has been a concealed pregnancy.The LSCB should produce additional guidance on this, but it isrecommended that it is brief and that equal attention is paid to theneed to assist professionals and supervisors to be flexible in theirthinking and to develop their capacity to recognise risk when itarises in cases that fall outside of the presentations that childprotection professionals have become used to dealing with. Inaddition to offering additional guidance on the specific issue ofconcealedpregnancyorganisationsneedtofindawayofimproving the capacity of professionals to identify more unusualpresentations. By their nature it cannot easily be predicted whatthese will be and it is not possible to write guidance about all ofthem.Provision of services as a result of the assessments4.3.62The impact on service provision can be easily and briefly stated.Poor assessment led on several occasions to service provision thatdidnotmatchtheneedsofthechildren.Theindividualmanagement reviews identify these episodes:a proper discharge planning meeting, continuing social careinvolvement and a fuller assessment following the birth of OYwould have been beneficialadditional health visiting provision was merited after the birthof OY and after EY was discharged from careEY should have been treated as a child in need at the pointwhen he was discharged from care914.3.63The final episode listed was a critical turning point in the casehistory. A child in need plan would have enabled provision ofcoordinated support, monitoring of EY’s health and developmentat a level in keeping with his needs and monitoring of his progressthrough periodic review. It would probably have prevented themother from deceiving staff at the children’s centre as to theidentity of the child because there could have been a closeworking relationship between this children’s centre and the localauthority. It would also have offered an easy point of contact forall professionals and prevented the confusion that occurred whenstaff spoke to administrative staff in the referral and assessmentteam.4.3.64The social care management review states that carrying out achild in need assessment and arranging a child in need plan at thepoint when a child ceases to be looked after were proceduralrequirements in the local authority in November 2010 and thatthey are now reflected in statutory guidance. The social worker’smanager knew this but believed that there were so many positivefeatures in the case that it was decided that there was no need tocomply with the procedure. This was because the potential risksassociated with the mother’s long period of little contact with EYand the inherent difficulty of taking over the care of a sevenmonth old child who was becoming attached to another carer werenot recognised or understood.The identification of injuries and other indicators of potential harm4.3.65Thissectionwilldealwiththeactionsanddecisionsofprofessionals in the following episodes in the case history:GP and Health visitor (January 2011)Children’s Centre and parenting programme crèche (January –March 2011)Socialworkerandcolleague(respondingtoinformationprovided by foster carer February 2011)Accessofficer(respondingtoinformationprovidedbythechildren’s centre February 2011)92Health visitor at child health drop in clinic (March 2011)4.3.66Descriptions of all of these events are set out in section 3 above.This section will seek to evaluate why professionals responded asthey did. This will be considered in the context of the local childprotection procedures. The guidance on ‘bruising’ is reproduced asAppendix 8 to this report. It specified that ‘any bruising or othersoft tissue injury to a pre-crawling or pre-walking infant or nonmobile disabled child’ or ‘bruising around the face’ …’must beconsidered as highly suspicious of a non-accidental injury unlessthereisanadequateexplanationprovidedandexperiencedmedical opinion sought’.29 This guidance is discussed further insection 4.8.4.3.67According to SCR panel members the need to refer children undertheageofonewithanybruisingonthefaceforfurtherassessment has been strongly reinforced in all local training,especially for health visitors and GPs.4.3.68EY’s GP recorded bruising and scratches on EY at his 9-12 monthdevelopmental check in January 2011. It is not normal practice forGPstocarryoutsuchassessmentsbuttheGPconcernedcustomarily did so as he had an interest in child health. As thisexamination took place as part of the developmental assessmentthere was an opportunity for a full examination.30 The GP notedbruises and scratches on EY’s face and to his credit made a verydetailed record of them on EY’s GP medical records.4.3.69It is significant that the GP did not summarise them on the PCHRwhich was the record that every other health professional who sawEY would have been most likely to access. The only recording thatthe GP made on the PCHR was to complete the up to date entrieson the height and weight chart. These would be routine actionsarising from the developmental check.29 Berkshire Child Protection Procedures (section 5)30 On 14 March 2011 when EY presented at the GP surgery with cold symptoms it would nothave been necessary to remove his clothes to examine him934.3.70This is significant in relation to subsequent events because had herecorded information about the bruising in the PCHR (whatever hebelieved to be the cause) it might have made a difference to latercontacts of health professionals with EY, particularly to the contactat the health clinic on 17 March the day before EY was admitted tohospital. It is also significant because it indicates that GPs are lesslikely to complete the chronological entries in the PCHR. This mayapply to other doctors and medical professionals as well. It is notclear why this is so but there are a number of obvious possibleexplanations:time constraints make recording duplicate information on tworecords less likelythe PCHR may be seen by doctors as a record of height, weightand development which is largely a tool for parents and healthvisitors rather than acute medical concerns.It may therefore be viewed by doctors as a secondary and lessimportant place to record information than the GP or hospitalmedical records that will be seen by colleagues within their ownsetting.4.3.71Given that so many other professionals will see and rely on thePCHRthisindicatesthatallmedicalprofessionalswhohavecontact with children may need to change their practice and adoptan approach to recording that takes more account of the needs ofother health professionals.4.3.72The GP did not challenge the mother’s explanation that OY (then21 months) had caused the bruising and there is no indication intherecordsorinsubsequentdiscussionswithhimthatheconsidered the possibility of non accidental injury. He made nofurther investigation or evaluation into the cause of the bruising.The GP decided to address the sibling rivalry by referring thechildren to the health visitor for advice. This was an error ofjudgement and it is clear that within the existing child protectionprocedures he should have referred EY to children’s social care. Ifhe did not feel sufficiently sure about the level of concern he94should at the very minimum have sought the advice of a namedprofessionalandreferredthechildforanurgentpaediatricappointment, following up the referral to make sure that the childhad attended.4.3.73The SCR panel believes that the GP would have been more likelyto have been concerned about the bruising and therefore morelikely to have acted in a different way if he had known that EY hadbeen looked after for a considerable period by the local authority.He might have viewed this as an indication of potential risk. Itwouldalmostcertainlyhavereducedanyinhibitionaboutcontacting the local authority if the GP had known that social carehad already been involved. The GP had received no notification ofthe local authority’s involvement either directly from the localauthority or from the health team responsible for looked afterchildren. Both of these issues are addressed further in section 4.6dealing with the coordination of services and information sharing.The GP also had no access to EY’s original medical records whichhad numerous references to him being looked after. This is alsoaddressed in detail in section 4.6 of this report.4.3.74Close examination of the PCHR (which the GP completed) showsthat the document itself did contain a number of entries whichindicate that EY had been looked after:one entry from his previous health visitor is marked ‘in fostercare’the PCHR contains a form with the letter head ‘Windsor andMaidenhead Council’ signed by both parents consenting tomedical treatment for a looked after childthere are a number of entries which refer ambiguously to EY’s‘carer’ (but not foster carer) rather than his parent taking himto appointments4.3.75The SCR has scrutinised these entries and discussed the natureand design of the PCHR at some length to understand why it wasthe GP did not notice them. The entries referring to ‘carers’ and toEY being ‘in foster care’ were made in the chronological contact95section of the record that had been completed by health visitorsandotherhealthpractitioners.Thissectionoftherecordisseparate from the parts of the record that would normally beaccessedinordertoregistertheinformationaboutthedevelopmental check. The looked after consent form is folded in aperspex pocket at the back of the PCHR ring binder where parentsare encouraged to keep appointment letters and other additionalinformation. Important lessons follow from this in relation to thedesign of the PCHR, the recording of key events and history in itand the scrutiny that health professionals give to the historicalinformation already recorded when they use it. Both sets ofentries which gave a clear indication that EY had been looked aftercould in the opinion of the SCR be easily overlooked by the GP.4.3.76A similar argument applies to the health visitor who saw EY on 17March. She would have had much less opportunity than the GP tonotice this significant historical information because of the muchmore limited time that she had with EY and the difficult context inwhich she was working. This is discussed further in section 4.11below.4.3.77It would be unrealistic to expect health professionals to read theentire PCHR at every consultation. This would never be practical.It is clear that the design and use of the PCHR needs to berevisited so as to ensure that any significant information whichcouldinfluencethefutureassessmentofriskisprominentlydisplayedandismuchmorelikelytobeseenbyhealthpractitionerseverytimetheyconsultthePCHR.Thisneedsdetailed work and consultation with all users of the PCHR inprimary care, community health and acute hospital settings. Oneapproach would be to have a sheet containing key informationlocated in the sections of the PCHR which are most commonlyaccessed that all health practitioners are required to review ateach contact. Steps also need to be taken to ensure that alldoctors are much more consistent in their practice in adding96significant information to the PCHR as well as to GP, hospital andclinic medical records.4.3.78Seeing significant historical information (such as the fact that achild had been in foster care from birth) would still of courserequire the correct professional interpretation and action, but atleast one potential barrier to recognition of a risk factor would beremoved by better design and use of records. Section 6 contains arecommendation in relation to this.4.3.79EY’s weight is recorded in the PCHR in a table and in a traditionalheight and weight growth chart (See Appendix VII). These parts ofthe records were seen by the GP who entered the up to dateweight on it. This showed that EY had gained only 100 grams (4ounces) in the seven weeks between 30 November 2010 and 19January 2011. On the weight chart the line of EY’s growth wasnow close to horizontal, instead of matching the percentile linethat it had tracked consistently while he was in foster care). Thispointed to a marked decline in EY’s rate of growth over theprevious two months. This might not have required a referral orfurther action in its own right but it should have raised the indexof suspicion created by the facial bruises in an infant of this age.4.3.80The GP involved was very knowledgeable and experienced. As withthe poor assessments referred to earlier in this report the SCR hastried to understand why the professionals involved found it difficultto take the action that they probably knew was necessary. Againthere may be a number of factors that made it difficult to act inthe way that training, procedures and experience indicate isrequired.4.3.81All of the accounts given about the mother (both prior to and postthe death of EY) indicate that she was capable of being utterlyconvincing, even when she was being untruthful. This will haveplayed a part. It is also important to recognise that many staffwho are involved in providing universal health services for childrenfind it very difficult to voice suspicions of child abuse. This requires97them to switch from their normal care-giving mind set in which itis assumed that the practitioner and the parent are both operatingin the best interests of the child to a mind set based on suspicionof wrong doing. Intellectually it is easy to say that the child is thepatient, that child abuse is a significant cause of child healthproblems and that the interests of the child are paramount. Inpractical terms it often proves much harder for professionals to beprepared to consider abuse as a possible explanation and to act inthe way that they have been trained to act and which they knowthey should.4.3.82Themanagementreviewofprimarycarerecommendstheadoption of a new pathway for dealing with bruising in infancy.The SCR endorses this recommendation. It will be useful toconsiderhowinadditiontothepathwayunderliningtheimportance of referral to social care in appropriate cases thepathway can ensure that medical practitioners feel able to makean urgent paediatric referral in appropriate cases. This is a usefulrecommendation but it is important that the pathway and anytrainingandguidanceassociatedwithitalsoaddressthepsychologicalandinterpersonalbarriersthatcanpreventprofessionals identifying and referring suspicions of child abuse.4.3.83After the consultation the GP spoke to the health visitor, told herabout the bruises and asked her to advise the mother aboutsibling rivalry. There is no discrepancy in the records about thisand the health visitor did what she was asked. As the BECHSmanagement review puts it, ‘the health visitor was not beingasked to check any bruising’. This helps explain her subsequentresponse but it does not justify it. When she visited she did notask to see EY (who was said to be asleep) and instead focused herattention on OY. It is impossible to know how the health visitorwould have reacted had she herself discovered this bruising on anine month old, but her training would have told her to be veryconcerned. As the BECHS management review points out, healthvisitors are qualified, experienced and highly trained professionals98andwiththiscomestheresponsibilitytoexercisecriticaljudgement not only about children and families but also about theopinions of other professionals. Unlike the GP the health visitor didknow that EY had been looked after and she also knew about thatthe pregnancy had been concealed. She does not appear to havetaken the additional risks into account, nor did she inform the GPabout them. There is no reliable way of knowing why she did notdo so. There is significant learning here about the need forprofessionals to be able to challenge one another’s judgement.4.3.84There is no doubt that when she visited EY and OY the healthvisitor should have asked to see the bruising for herself and madeher own judgement. There is no way of knowing what she wouldhave seen. The visit took place a week after the GP consultationand the bruises might have been less marked. However EY wasnoted to have more bruises five days later when he was seen atthe children’s centre so more bruising might have been visible.4.3.85The presentations of bruising and other potential indicators ofabuse at the children’s centre are documented in section 3 above.These incidents included:direct observation of bruises and scratchesreports of concerns from staff running a crèche associatedwith a parenting programmereports of concerns from other mothers4.3.86The individual management review of family support servicesdescribesthesecontacts,thoughtheyarebasedonlimitedrecordsbecausenotallkeyeventswereproperlyrecorded.Accounts given to the police after the death of EY suggest that theseriousness of the concerns of staff and parents exceeded theinformation in the records at the time.4.3.87The mother deliberately deceived both staff and parents at thechildren’s centre by saying that EY was her cousin’s son. Herspecific reasons for doing this are not clear. She also consistentlysaid that EY’s injuries were caused by the child’s four year old99sister or by toppling over. The effect of the deception was to makeit very difficult for the staff to identify EY and contact professionalswho knew him. It may also have made staff more likely to accepther accounts (since a four year old would be more likely to leavebruise marks on a baby than OY who was a toddler). Mostimportantly it distracted staff from concerns about the mother’sown parenting onto an imaginary family. The deceit sabotagedattempts to identify EY but there remain fundamental concernsabout the response of the children’s centre staff to the injuriesthat they and other parents reported. These are comprehensivelyidentified and explained in the family support service individualmanagement review:Recording systems used in the centre were not child-centred –they reported a range of incidents that had occurred in thecentre in date order making it difficult to form a picture of thenumber and range of incidents related to any one child and totrack the actions taken in response to themIndicators of abnormal parental behaviour were recognised asparenting problems and not indicators of possible child abuseAlthough it was highly unusual for other parents to expressstrong concerns about a parent, these concerns were nottreated seriously enough. More weight should have been givento them and they should have been recorded in more detailbecause these parents had more contact with the mother thanthe staff didManagement advice given about the case was not clearlyrecorded leaving room for ambiguity and there was a lack ofpersistence in implementing itThe children’s centre staff and coordinator lacked experienceand training in dealing with child abuse allegations. Thismeant that they were too willing to accept the advice given bythe access officer from social care, even though they say thatthey had misgivings about it100More senior managers had failed to ensure that centre staffadequatelyunderstoodtheirrolesandresponsibilitiesinrelation to child protection. Training for the centre staff andmanager on safeguarding was not given sufficient priorityThe evidence suggests that one reason for this was that thechildren’s centre service was being required to pursue toomanypotentiallyconflictingpolicyandservicedeliveryagendas. This is discussed in more detail in section 4.11It is not possible to be absolutely certain what information wasgiventothesocialcareaccessofficerwhenthecentrecoordinator spoke to her. Even if she believed that the call wasa consultation and not a referral she should definitely havereferred a call about a 10 month old baby with bruises to aqualified member of staff and she should have asked for thename and details of the family members involvedThe roles and responsibilities of access officers in the localauthority social care service were not understood by familysupport service staff and so they believed that they werereceiving advice from a qualified social worker and not anadministrative worker 314.3.88The reasons for these shortcomings are explored in more detail inthe relevant sections of this report.4.3.89Twice staff at the children’s centre sought external support inidentifying EY and responding to the injuries that they had seen.GiventhevulnerabilityofEYandthelackofanyconcreteinformation about who he actually was the centre coordinator andher manager should have placed responsibility for dealing with theconcerns squarely in the hands of the local authority social careservice by insisting on referring the child to a manager in thereferral and assessment service. Staff working in such settings31 The role of the Access Officer in the referral and assessment team was also unclear to healthmembers of the SCR panel and IMR authors demonstrating that this was not an isolatedmisunderstanding of the role. It is noted that this was not a new role or service innovation andthat the same individual had fulfilled the role for a number of years.101need to have the confidence and structures in place to be able todo this in future. The SCR accepts that the recommendationsmade in the family support service should if implemented achievethis so long as the service recognises that it has a specificresponsibility towards vulnerable children. This issue is exploredfurther in section 4.11.4.3.90Section 3. above describes the actions taken by the foster carerand the social worker reporting on her chance meeting with EYand his mother in February 2010. The previously allocated socialworker says that she left a voicemail message for the healthvisitor, but the health visitor made no note of this. If it did containan account of bruising and she did receive it and took no actionthis would be very concerning because it would have been afurther report of bruising, three weeks after the GP report. Havingleft the voicemail message the social worker should have followedit up to establish what had been done. She (and her much moreexperienced colleague in the fostering service) should also havetreated this as a proper referral of possible abuse to the authorityaboutEY.Thepreviouslyallocatedsocialworkerwasveryinexperienced and this is discussed further in section 4.9.4.3.91The final opportunity to identify EY as a child who was at riskoccurred the day before he was taken to hospital with seriousinjuries.Hewasseeninaclinicwithbruiseswhichweredocumented by the health visitor. The health visitor did not knowthat EY would be seriously injured within hours of this consultationand in evaluating her actions this needs to be set aside fromconsideration. The health visitor recognised that the bruising wasconcerning because she says that at two points during the briefconsultation she deliberately and pointedly asked the mother howthe injuries had occurred and the mother twice gave the sameaccount. Essentially the injuries that she saw were of a similarnature to the ones seen by GP and reported to EY’s own healthvisitor two months before and the ones seen at the children’scentre over the previous three months. However the health visitor102did record that EY’s failure to gain weight had now persisted for afurther two months. This should have raised the index of concern.4.3.92The action taken by the health visitor on that day was not inaccordancewiththelocalchildprotectionprocedures.Theseclearly state that she should have referred the injuries to the localauthority that day or at least consulted the trust’s named nurse. Itis clear that this was not due to a lack of knowledge or training.The BECHS management review specifically notes that relevanttraining had been provided to health visiting teams as recently asNovember 2010 but that the health visitors actions ‘did not followthe approach recommended’.4.3.93The health visitor also noted her concerns about the lack of weightgain. EY’s weight had been static for three and a half months andhad declined from the 75th centile to a point mid way between the25th and 50th, a clear indicator of his failure to thrive or a serioushealth problem. She noted her intention in her diary to speak toEY’s own health visitor as soon as possible the following day (theclinic was an afternoon one). Taken in isolation this was a veryconcerning presentation, but not one which required an instantresponse and the health visitor’s decision to note this and discussit the next day with the allocated health visitor was appropriate.Taken together with the bruising the persistent failure to gainweight should have added to the level of suspicion.4.3.94There is no suggestion from BECHS that this health visitor was notcompetent. In these circumstances it is important to understandthe factors that made it difficult for her to act in keeping with herjudgement and training. Some of the factors have already beenidentified:the mother once more gave a convincing but (very probably)untrue account of how the bruises had been caused.thehealthvisitordidnotknowthatthiswaspartofapersistent pattern of bruising or even that the GP and theallocated health visitor had seen bruises in January. There is no103way of knowing whether she might have reacted differently ifshe had known this4.3.95It is also important to be mindful of the context in which thehealth visitor saw EY and the other family members. This healthvisitor had never met EY or his mother before. The contact wasnot planned and she knew nothing of EY’s history other than thefacts she had time to obtain from his PCHR. She knew nothing ofthe nature of the concealed pregnancies. For the same reasons asthe GP she did not know that EY had lived in foster care. The SCRhas also discussed the arrangements for child health clinics suchas the one in which EY was seen that day. In these health visitorsseelargenumbersofchildren,manyofwhomwillnotbepreviouslyknowntothehealthvisitororontheirallocatedcaseload. The clinics are busy, because they are popular and therearefewofthem.Childrenareoftenweighedbyparentsthemselves rather than by health staff and often health visitorsspend as little as 3-5 minutes with a child. Health visitors haveaccess only to the PCHR. As has been described the PCHR may notcontain important information or make it obvious on a quickreview.Dependingonthevenuethehealthvisitorandhercolleagues may have no access to electronic records or any otherbackground information or parental history (or no time to accessthem). Recordings cannot be made on the electronic records andcontact with colleagues (in health and other agencies) is limited tomobile phone.4.3.96There can be no doubt that this is a very difficult environment inwhich to offer a service to vulnerable children, not least because itwill often not be clear whether the child who is being seen isvulnerable or not. The concerns about the difficulty of practisingsafely in this setting are discussed further in section 4.11 whichdealswithcapacityandotherorganisationalmatters.Someaspects of the analysis apply both to these child health clinics andto the children’s centres.104Overall conclusions in relation to assessment of the risks to EY andthe injuries known to professionals4.3.97Overall conclusions in relation to assessment of the risks to EY andthe injuries known to professionals are set out in section 4.14below.4.4Implementation of plansWhere relevant, were appropriate child protection or care plansin place, and child protection and/or looked after reviewingprocesses complied with?Establish what advice was given and what services wereoffered to the parents concerning adoptionEvaluate whether there was sufficient focus on the needsof the child EY in relation to actions taken in relation toadoption by the local authorityEstablish whether sufficient attention was given to issuesrelating the reunification of EY and his mother followingthe period when he was in foster care.Key dates and events4.4.1EY was born on 23 April 2010 and immediately accommodatedwith the agreement of both of his parents. At the placementplanning meeting held five days later it was decided that adoptioncounselling would take place to assist the parents in making aninformed decision about EY’s future. This was the correct course ofaction. Counselling of the mother began on 25 June 2010 after adelay caused by internal confusion about the referral betweenteams. The counselling continued until October 2010 when themother confirmed that she did not want to care for EY, regardlessof any support that was available from her family.4.4.2Following a home visit on 11 May 2010 the local authority took theview that the mother was ambivalent about adoption and that thefather was pressurising her to give EY up. From this point localauthority records show that there was an understanding of thepossible need to involve the maternal grandparents. The reasonsfor doing this were not clearly recorded at the time and legal105advice was later sought to clarify the position. Discussions aboutinforming the grandparents about the birth of EY continued untilearly November 2010.4.4.3The first statutory review took place on 20 May. The parents hadbeen invited but neither attended. However the mother visited thefoster carer later that day and started to have contact with EY.The review minutes note that the mother named EY after thereview meeting.4.4.4The decisions of the review meeting refer to a process of twintrack planning whereby work to secure the adoption of EY wouldproceed alongside counselling of the mother to help her make aninformed choice about adoption. The parents were informed thatlegal advice was being sought to determine whether the localauthority needed to inform the mother’s parents and that thisrelated to the possibility that members of the extended familymight wish to care for EY.4.4.5On 3 June 2010 the case was allocated to a new social worker(SW5) in another team. The initial period of allocation coincidedwith the period in which the mother had most contact with EY. Themother saw EY twice at the end of May and four times in June.Apart from the week before he was discharged to her care inNovember,thiswastheonlyperiodinwhichshesawhimreasonablyoftenduringhissevenmonthsinlocalauthorityaccommodation.4.4.6During this period and early July the mother spoke on a number ofoccasions about how she would like to care for EY, but no definiteplan was made in relation to this. She was encouraged to increaseher level of contact, but did not do so and she did not attend EY’ssecond LAC review on 21 July. The social worker took legal adviceand was advised to set out a timescale for decision making withthe mother in order to avoid undue delay for the child.4.4.7On 22 July the mother expressed her continuing difficulty inmaking a decision, though she admitted that when she was not106with EY she did not think about him and saw no need to make adecision rapidly.On 30 July and 2 August the mother indicated(on the phone and in a text message) that she had decided thatshe definitely wanted to give EY up for adoption. No action wastaken in relation to this during August (when the mother was onholiday with her family) and a further adoption counselling sessionwas fixed for September. It was only in September that discussionbegan about the arrangements for an adoption medical (plannedfor November) and an adoption panel meeting (in December2010).4.4.8Legal services records show that updates were requested by asolicitortwiceduringthisperiod(inmidAugustandmidSeptember). The local authority made a decision in principle on 14September to tell the maternal grandparents about the birth of EYbecause his mother had now agreed that she wanted to relinquishhim for adoption. The mother confirmed on 12 October that shewanted to proceed with the adoption, even if her family offeredsupport in caring for EY.4.4.9The mother continued to delay telling the maternal grandparents.After some delay the social worker forced the issue and informedthem on 4 November. It is not clear what discussions took placebetween the mother and her parents but almost immediately shedecided that she wanted to care for EY. This decision was madebetween the mother and her parents and the social worker playednoactiverole.Thesocialworkermadenorecordofthegrandparents’reasonsormotivation.EYwasplacedinhismother’s care on 19 November following a planning meeting and ashort series of visits to the foster home.Delays in reaching decisions and taking action in relation toadoption4.4.10Based on this summary of the key events it is self evident thatthere was undue delay in making and implementing decisions andin the provision of services. There are a number of reasons whythis happened.1074.4.11Misunderstanding between two managers led to a delay in thereferral for adoption counselling. One manager assumed that averbal request had been accepted while another had expected anelectronic referral for the service. The individual managementreview of social care services indicates how this will be avoided infuture and makes a recommendation in relation to this.4.4.12After the allocation of the case to the new team (following the firstreview)therewereanumberofperiodswhentherewasconsiderable drift in the case. It is accepted that during June themother showed signs of ambivalence about whether or not to carefor EY. She visited him about once a week. This was more than atany other time but it was hardly an indication of a strong desire tolook after him. She signalled a lack of interest in him by ceasingvisits at the end of June and then by not attending his looked afterreview on 21 July. In early August she confirmed her decision torelinquishEYforadoptionandwentaway foramonth.Nosignificant action was taken during this period and when the stepsin the proposed adoption were pencilled in during September thetimescale was protracted. This is attributed to the fact that thesocial worker was given no supervision between 2 August and 10September due to leave arrangements. There were a number ofperiodswhenafterreceivingadviceordecisionshadbeenreached, the social worker took a long time before acting.4.4.13Having achieved some clarity as to the mother’s intentions in lateJuly the issue of adoption was briefly re-opened by the adoptioncounsellor in September. Then the mother confirmed that shedefinitely wanted EY to be adopted, regardless of her parents’views. There was then a delay of almost two months while themother overcame her inhibitions about informing her parents.4.4.14It is clear that on a number of occasions the local authorityallowed its intervention to be unduly influenced by the pace atwhich the mother felt able to move and did not act at a pace thatwas consistent with the best interests of EY. The records and themanagement review strongly suggest that this was largely due to108the inexperience of the social worker. She was not confident aboutwhat to do. Arrangements were made for her to receive practicalguidance from her supervisor and more experienced colleaguesbut they did not result in the action required being taken. Thepoor quality of the supervision and support provided for her isdiscussed further in the sections dealing with supervision andtraining (Section 4.10).4.4.15The legal advice given in the email of 1 October 2010 (see section3.89 above) may also have contributed to this drift because itplaced undue weight on the need for the mother to agree to herparents being involved and consulted. This advice was at oddswith the correct legal position as understood by the SCR which isthat the action of the local authority should always be determinedby what it judged to be in EY’s best interests and that in somecircumstances this might require consulting with members of theextended family without the consent of, or even against thewishes of, the mother.4.4.16The thinking of the local authority in relation to the role of thegrandparents lacked clarity. It should have been clear from anearlypointthatwhateverthedecisionofthemotheraboutadoption, the grandparents needed to be informed about the birthof EY. If he were to be cared for by his mother then thegrandparents would know and they would need to be able tosupport the mother practically and emotionally. If EY was to beadopted careful consideration needed to be given to informing thegrandparents, not least so that they could consider whether theyor other members of the family could care for EY. The view of thesocial worker was that the grandparents were potential carers.Even if this were not an option then legally there might also beother important factors which would point to the need to for thegrandparents to be involved (for example EY’s right to haveknowledge of his family, questions of contact etc). In due coursean adoption panel would need to determine whether adoption wasin EY’s best interests. It would need to know that all of these109issues had been explored and that any proposed adoption matchhad taken these factors into consideration.4.4.17Reviewing the case history it is clear that the local authoritytreated the decision about adoption and the decision to inform themother’s parents as two separate issues: first the mother woulddecide on adoption and then the grandparents would be told whatshehaddecided.Theadoptioncounsellingfocusedonthemother’s views. The contribution of the extended family wasviewed as being something that would come later. In practicalterms these issues needed to be addressed in parallel because theattitudeofthegrandparentswouldinevitablyinfluencethemother’s attitude to adoption.4.4.18This is exactly what happened. As soon as the extended familyknew about EY the mother was persuaded to care for EY.4.4.19It would have been unreasonable to expect a newly qualified socialworker to have thought through this quite complex issue on herown, especially if this was the first adoption case that she haddealt with. This was a set of problems that her supervisor and thestaff in the fostering and adoption service who were advising hershould have recognised at a much earlier point. The failure to doso meant that for some months the actions of the local authoritywere heavily influenced by the pace at which the mother felt sheneeded to make decisions and not by the timescale that wasappropriate for the child.The action taken by the local authority in relation to adoption,including the advice given to the parents4.4.20The preceding paragraphs demonstrate that while the action taken bythe local authority complied with the agency procedures there wasundue delay in implementing the steps agreed.32 The legal advicegiven on 21 July which emphasised the need for a timescale forfurther action to be fixed with the needs of EY in mind was correctand helpful, but it was not implemented. The legal advice given on 132 CAFCASS (who would have had to take the mother’s informed consent to the adoption in aprescribed format) was never contacted at all.110October placed too much emphasis on the need for the mother toagree that her family should be informed. This may have contributedto the drift in the case.4.4.21There are some more general concerns. Much of the legal advicegiven was given in emails, most strikingly the advice given on 1October. This may have led to it being less well considered than itshould have been. Much of the legal advice given was not recorded inthe social care files (or it may have been stored in emails which werenotattachedtothemainrecords).Insofarasitcanbereconstructed accurately the audit trail of emails suggests that moreoften than not it was the legal advisor who was taking the initiativeand chasing progress. This should not have had to happen. Adoptionlaw as it applied to this case is complex and leaves much to thediscretion of the local authority, based on its assessment of thecircumstances of the specific case. On many occasions it is unclearwhether the social worker fully understood the advice that was givenor received clarification from her manager.4.4.22Although it is not explicitly stated the evidence strongly suggests thatthroughout this period the local authority’s actions were based on theassumption that the best option would be for the mother to look afterEY with the help of her parents and some involvement from thefather. The social worker certainly believed that this could happen.The starting point was a legitimate one based on the legal frameworkand research about outcomes for children. It was initially quite rightfor the mother to have the time to make a considered choice aboutadoption. There are sound ethical and legal reasons for this. Therearealsopragmaticconsiderationsbecauseconsentnotproperlyconsideredmightbewithdrawnatanypointwhichcandelayplacement or the making of an adoption order considerably. The localauthority had no evidence that OY had not been cared for properly.4.4.23Although the starting point of the local authority was correct, theconflict between the delay in making a decision and the best interestsof EY had become apparent by the end of June 2010. Evidence aboutthe mother’s lack of interest in him and lack of contact throughoutJuly and August accumulated and should have reinforced this. At this111point the focus of the local authority should have shifted to beexclusively concerned with identifying what was in EY’s best interestsand it should have been more decisive in implementing the plan foradoption that the mother had agreed to. The reasons are not clearbut it is apparent from the records that key professionals in the localauthority continued to think that the best option for EY would be tobe cared for by his mother and wanted her to succeed in being ableto do this beyond the time when an objective and dispassionateassessment of the circumstances would have pointed to the need forthe local authority to pursue other options. The lack of interest andcontact during July – August and the mother’s agreement to adoptionat the beginning of August should have been decisive. It remainsunclear why the local authority did not at that point move aheaddecisively with the planning for adoption.4.4.24The inexperience of the social worker and the poor quality of thesupervision provided to her were clearly significant; the character andpersonality of the mother may have been important (as they were inrelation to the response to the injuries to EY described above). Staffand managers had a sense that this was ‘history repeating itself’ andthat events would follow the same course for EY as they had with OY.4.4.25It is also important to recognise that the situation which the localauthority was dealing with was not commonplace. It is highly unusualfor a healthy newborn baby to be relinquished foradoption incircumstances where the child is not believed to be at risk of harm.Indications are that in the East Berkshire area this might happenonce or twice per year and that there are usually specific cultural andreligious factors 33 involved, which did not apply in this case.4.4.26Was sufficient attention given to the potential difficulty of thereunification of EY with his mother?4.4.27The report will use the term reunification although EY had beenaccommodated since birth and his mother had never cared forhim. The understanding of the local authority in November 2010when the mother stated that she wanted to care for EY was as33 For example a mother with a religious objection to the termination of an unwantedpregnancy might have a clear wish to relinquish a healthy infant from a very early point.112follows. He was developing normally and had no special healthneeds. He was sociable and outgoing and was viewed as being achild whom it would be easy for other carers to look after. It wasbelieved that the mother had been through a similar process inrelation to OY, but her doubts about caring for OY had beenovercome. If she did not want to look after EY it was in large partbecause the father had been ‘domineering’. EY’s mother hadsuccessfully looked after OY with the help of the father andgrandparents and there was no evidence that he had come toharm. No complexities or risks were recognised.4.4.28However there were equally a number of complicating factors thatwere not recognised as being significant. The mother had deniedor concealed two pregnancies. There was no evidence of overtmental health problems, but the two concealed pregnancies mayhave been evidence of psychological conflicts or problems infamily functioning and communication which the mother had notbeen able to resolve. The mother’s indecision over OY had beenquickly resolved and she took him home from hospital aged 3days. Even then the only recorded reason might be consideredunusual (she had noted that OY shared a birthday with hisgrandmother) and the significance of this was not explored. Thiswas very different to the position in relation to EY whom themother had never cared for and not visited for long periods.Repeated comments gave a strong indication that she often hadlittle interest in him and she had twice said (without there beingany evidence of pressure from the father) that she did not want tocare for him. It is a challenge for anyone to take on the care of aseven month old baby such as EY who was beginning to formattachments to its main carer and to actively explore the world.This is recognised by the careful way in which adopters and fostercarers are selected and supported and in which children areintroduced to new carers.4.4.29None of this assessment relies on the benefit of hindsight. Thedifferences should have been obvious. Everything that has been113listed in the preceding paragraph could and should have beenrecognised at the time. All of the knowledge set out above shouldhave been commonplace for experienced social care social workers(such as those in the fostering and adoption service) and thesocial worker’s supervisor.4.4.30It was also wrong to equate what had happened with OY andassume that the same would apply to EY. It is important torecognise that every infant has an individual temperament andpersonality and different children often have a different meaningfor their parent or caretaker. An early review of serious casereviews suggested (albeit speculatively) that the meanings whichsome carers attribute to individual children can lead to them beingsingled out for abuse, in contrast to siblings who are relatively wellcared for. 34 It is not known what specific meaning EY had for hismother. No one asked, but clues might have been obtained by askilful worker.4.4.31The approach that the local authority took followed from theunderestimation of the complexity of reunification in this case. Itwas agreed that EY would move to his mother’s after a shortnumber of contacts which were supervised and assessed only bythe foster mother. The social worker played a very passive role inthis and as far as can be established she did not observe orparticipate in any of the contact sessions that took place before EYwent home. She knew how things were going only through herphone contact with the foster mother. There is no record ofcontact (even by phone) with the mother until after EY movedhome, though this may reflect gaps in recording. The fostercarers’ supervising social worker had one phone contact with themother.4.4.32The contact sessions gave an indication of concerns, such as theevidence of the mother’s difficulties in interacting with EY andmanaging EY and OY at the same time. Given the very limited34 Reder, Duncan and Gray (1993) Beyond Blame: Child Abuse Tragedies Revisited,Routledge (pages 52-59 in particular)114contact that she had previously had with EY it is not surprisingthat the mother had difficulties. The evidence is that these werenoted but that their potential significance was not understood.There is no indication of any discussion with the supervisor aboutthe progress of the reunification. There was no supervision sessionbetween 2 November and 3 December – though it would be safeto assume that the progress of the case was discussed lessformally. It is clear that there should have been a more protractedseries of contacts and a fuller assessment of the circumstances,basedonamorerealisticunderstandingofthepotentialdifficulties.4.4.33There is now an increasing body of research indicating howcomplexthereturnofchildrentotheirfamiliesafteraconsiderable separation can be.35 In Farmer et al’s study of 180reunifications of looked after children, 47% had broken downwithin a 2 year period, and a third of those remaining at homewere receiving care of a ‘poor quality’. Key lessons from theresearch were that:Early and prolonged separation can affect parental bondingSuccess is associated with careful preparation and plan ofsupport and behaviour management, regularly reviewedIn this case some specific negatives could have been identified.ThemotherhadneverlookedafterEYandbydenyinghispregnancy had missed the opportunity to form an attachment tohim in the antenatal period (for example through seeing scans andpreparing psychologically and practically for the baby).4.4.34Careful thought was needed about the mother’s ability to be openand honest with professionals about her feelings in relation to EY.The history of two concealed pregnancies demonstrated that (for35 For example Farmer, E., Sturgess, W., and O’Neill, T (2008) ‘Reunification of looked-afterchildren with their parents: Patterns, Interventions and Outcomes”, Research Brief for DCSF,October 2008. (University of Bristol), it is recognised that not all of the lessons from researchare relevant because EY had not been directly harmed by his mother before separation,however many of the lessons about attachment and separation apply. I am grateful to SallyTrench for bringing this research to my attention115psychological reasons that remain unclear) she was unable to dealwithconflictorconfideinotherswhenshefacedseriousdifficulties. More reflective discussion between the practitionersand supervisors might have predicted that the mother would bevery unlikely to confide in professionals or be open with her familyif problems did develop. So far she had coped with her problemsby denying them to herself and concealing them from others.4.4.35Farmer’s study recommends that local authorities consider thevalue of skilled and purposeful social work to support reunificationpractice.Suchpracticewasabsentinthiscaseanditisrecommended that the local authority develop a plan to ensurethat all relevant staff are made familiar with relevant research andable to apply it. Other agencies who may be involved in thereunification of vulnerable children should consider how relevantstaff can be made aware of the complexity of reunification oflooked after children so as to be able to contribute to discussionand decision making.4.4.36It is important to note that even if there had been a thoroughassessment of risk and needs the local authority would have hadno grounds to prevent the mother taking over the care of EY.However careful observation of the transfer of care would haveprovided a solid basis for deciding if there were any risks and howEY’s needs would best be met over the following months. Acoordinated child in need plan would have allowed his progress tobe monitored and reviewed and would have ensured that therewas a single point of contact for all of the agencies who becameinvolved.4.4.37Health professionals were not consulted about the plan to moveEY to his mother’s. EY’s existing health visitor was not invited tothe planning meeting, though she was told about the decision.There was no coordinated plan to inform all of the relevant healthprofessionals about the discharge of EY from care. Had thishappened it would have assisted in the judgements that they latermade about EY.1164.4.38The looked after children health team played no active role at thistime and it appears that the team only acted when officiallynotified of the discharge some weeks later (apparently through itssystems / IT section). The team had no role in the discharge,because its role was limited to overseeing the provision of childrenwho are looked after. Given the lessons learnt it would be wise toreview the role of this service to consider whether it is possible toexpand its brief to include children who are ceasing to be lookedafter and discharged to friends or family. In this case it wouldhavebeenextremelyvaluableifsomeonehadhadtheresponsibility to ensure that all of the relevant health professionalsinvolved with the family were identified, that they all had relevantbackground information and that they all knew what the plan forthe child was going to be. The SCR will recommend that the localauthority and health commissioners review the role of the lookedafterchildrenhealthteamtoensurethatsuitablehealtharrangements are made for children who are discharged from careas well as those who become looked after.The decision of the local authority to close the case4.4.39The decision of the local authority to close the case was entirelyconsistent with the assessments that had gone before it and theunderestimation of the likely needs of EY that had marked the endof his period looked after by the local authority.4.4.40The social worker made two visits to see EY with his mother andOY after he returned home (on 24 November and 15 December).Theobservationsrecordedonbothoccasionswerelargelypositive. The mother stated that she was following the fostercarers’ routine and that the father was visiting and being helpful.OY was noted to have attempted to hit EY on the head and themother prevented this and showed him how to treat EY gently.The mother claimed that her family were being supportive andthat she was introducing EY to her friends. No further details wereever obtained of the role of family and friends.1174.4.41At the second visit EY was noted to have a couple of scratches onhis face which were said to have been caused by OY. Thisexplanation was accepted without further enquiry. Although thisexplanation was consistent with the behaviour that the fostercarer had previously observed this was a potentially concerningpresentation about which the social worker should have beenmore curious.4.4.42The case was closed on 22 December in the belief that the plan tounite EY with his mother had been successful. The local authoritydid not notify other agencies that the case had been closed. Thelack of communication with other agencies is discussed further insection 4.6 below.1184.5Focus on the childWere practitioners aware of and sensitive to the needs of thechildren in their work, and knowledgeable both about potentialindicators of abuse and neglect, and about what to do if theyhad concerns about a child’s welfare?When, and in what way, were the child(ren)’s wishes andfeelings ascertained and taken account of when makingdecisions about the provision of children’s services? Was thisinformation recorded?Observation of the children to identify needs and risks4.5.1Given the ages of the children establishing their wishes andfeelings through discussion was not possible. Professional practiceshould therefore focus on accurate and thoughtful observation ofthe children and discussion with carers in order to identify theirneeds and the ability of their carers to meet them.4.5.2Observations of OY while in the care of his mother and father waslargely positive and gave no cause for serious concern. OY put onweight very rapidly and this was monitored by his health visitors.His mother was encouraged to attend fitness and healthy eatingsessionsatthechildren’scentrewhichsuggestthatitwasbelieved that this arose due to lack of knowledge about diet andexercise.4.5.3Observation of EY while living in foster care were all very positive,reflecting the very good care that he was receiving and theattachment that he was forming with his foster carers.Professional understanding of possible indicators of abuse andpoor parenting and the action required4.5.4Section 4.4 above deals in full with the possible indicators ofpossiblephysicalabuseandpoorparentingnotedbyhealthprofessionals, children’s centre staff and the social worker. Anumber of professionals failed to recognise potential indicators ofabuse or to act on them in a way that was in keeping with thevulnerability of EY.1194.5.5Staff in the children’s centre noted their concerns about moresubtle signs of emotional abuse and poor attachment (for examplethe fact that EY was left in his pram with the cover pulled upfacing the wall and away from the activities in the centre).However they interpreted these in the light of the mother’sstatements that EY was her cousin’s child. They believed that themother needed help to be a better child minder, and this is whyshe was referred to a parenting programme. Because they hadbeen misled they did not realise that this was a sign of possiblepoor attachment to the mother’s own child. They were not toknowthatthefostercarerhadnotedandreportedsimilarconcerns (the mother not making eye contact with EY and keepinghim facing away from her).4.5.6As well as noticing the bruises on EY the parents of other childrenwho attended the centre raised concerns about the mother’s lackof warmth and responsiveness towards him and about him beinguncharacteristically quiet. These parents had considerably morecontact with EY and his mother outside of the Stay and Playsessions at the centre and so had the opportunity to observe theinteraction over a longer period of time and in a number ofdifferent settings. It was unusual for other parents to raise suchspecific concerns about another parent with centre staff. Thecentre staff appear to have recognised this and that the otherparents were breaking a trust with the mother by going behindher back and raising their concerns with professionals. However ashas been described in section 4.4 above the action they took inresponse to their concerns and those of the other parents was toolimited.A final, poignant clue about the mother’s lack of interest in EY iscontained in the PCHR. The standard booklet has pages on which parentsare able to note developmental milestones in relation to movement, finemotor skills, speech, social interaction and attachment of the infant. Onmost pages the parent has only to add in the age at which their childaccomplishes something; one page invites information about the child’s120favourite games and nursery rhymes. The record is comprehensivelycompleted by the foster carer, but there is only one entry (referring toEY crawling at 10 months) after his mother took over his care. It isunlikely that any busy professional would have looked at this section inthe PCHR, which is clearly intended for parental use. In this case itcontained additional subtle evidence of the mother’s lack of attachmentto EY.1214.6Information sharingWere there any issues, in communication, information sharingor service delivery, between those responsible for workingduring normal office hours and others providing out of hoursservices?The transfer of information and records between GP practices4.6.1The slow transfer of medical records between GP surgeries and thetime taken to summarise them at the receiving GP practice issignificant in the case history. The slow transfer of EY’s medicalrecords from one GP practice to another may have adverselyaffected the way in which his GP was able to carry out hissafeguarding responsibilities.4.6.2The mother registered herself and OY at a new surgery in earlyJune 2010. She had been a patient at the same GP surgery sincechildhood, though there was little significant information heldabout her until she had her first child. The new surgery was nearerher home but her reasons for transferring at this time are notclear as she had moved house the previous November. Herreasons were not established at the time and she was actingwithin the normal parameters of ‘patient choice’.4.6.3Following the transfer OY’s records arrived from the previouspractice on 30 September 2010 (over 3 months later) and weresummarised. The transfer took longer than is normally expected,though there is no evidence that this had any impact on theoutcome of this case.4.6.4The mother’s records had not arrived at the time of EY’s death inMarch 2011 and were only transferred when they were chased bythe practice in April 2011. The reasons for this delay have notbeen established. As a consequence any GP consultations with herwould have taken place without the benefit of notes. Her recordswould not normally have been consulted when the children wereseen so the failure to transfer the notes would not have made acriticaldifferencetotreatmentoroutcomesinthiscase.122Nevertheless in other cases it might – if for example a parentsuffered from a mental illness which was impacting on parenting.4.6.5The mother registered EY at the same surgery on 1 December2010, two weeks after he moved to live with her. The recordswere received 2 months later and had not been summarised at thetimeofhisdeathinMarch2011. Thismay havemade animportant difference to the safety of practice with him becausewhen he was seen with bruising on 19 January 2011 the GP reliedentirely on the information in his Personal Child Health Record andhe had no other background information. EY’s previous medicalrecords contain very clear references to him having been in fostercare. 36 If properly summarised this information would have beenincluded in the computer summary of his records which is openedwhenever a patient is seen. This might well have influenced theactions of the GP who identified bruises.4.6.6In the light of this the SCR has sought to understand in detailwhat the arrangements are for the transfer and summary of GPrecords. In Berkshire GP records are transferred from one practiceto another through the Thames Valley Primary Care Agency (PCA),responding to patients’ changes of GP practice. Patients register atthe practice of their choice and the process of record transfer canonly begin when the practice receiving the patient asks the PCA toobtaintherecords.Accordingtothemanagementreviewofprimary care involvement, the process of recalling the recordsfrom the previous practice and sending them to the patient’s newpractice takes approximately 3-8 weeks when there is an internaltransfer of notes within Berkshire. Transfer from further afieldtakes longer. On receipt the practice is required to summarise the36 The primary care IMR underlines the full extent of the information that would have beenreadily available if the records had been transferred within a reasonable timescalesummarised: On review of the GP records EY’s records were clearly summarised as ‘lookedafter’ as an active problem on the front computer page in the GP records of the first practicehe was registered with. There was a copy of the Health Care Plan in the records from theinitial health assessment on 2/06/10 done by the Berkshire East Health Team for LookedAfter Children and Young people. The foster carer was to facilitate attendance for routineimmunisations and relevant developmental checks.123noteswithineightweeksfromthedateofreceivingthem.Arrangements for summary are the responsibility of individualpractices. GP notes are usually reviewed by a member of thesurgery team who has nursing or medical secretary background.The purpose is to ensure that significant information is enteredonto the computer records of the current practice.4.6.7Some practices transfer information electronically via a nationalsystem called GP2GP which enables the immediate transfer ofcomputerrecords.CurrentlyinBerkshireaboutonethirdofrecords are transferred through this system. Both surgeries haveto be registered for this access and they must use compatiblebrandsofmedicalrecordsoftware.Themanagementreviewindicates that work is being undertaken by the NHS in Berkshire toincrease the participation of Berkshire surgeries in this system.4.6.8The gap of 14 weeks between the registration of EY at a newsurgery and his death during which his notes had not beensummarised was permissible and probably not unusual within thecurrent arrangements. There is no reliable information to indicatehow typical it might be but it is clear that the GP author of theindividual management review of primary care services did notfind it surprising.4.6.9The view of the SCR is that this case history demonstrates thatcurrentarrangementsforGPrecordtransferarenot‘fitforpurpose’ in relation to the protection of vulnerable children. Mostadult patients with complex medical conditions can bring theirneeds to the attention oftheir GP or have carers whoaremotivated to do so. Vulnerable children will not have made thechoice to change GP practice and cannot articulate their needs inthe same way. Vulnerable young infants cannot ask the new GP toget their records quicker and check for significant history. Many ofthe parents of vulnerable children will not be motivated to ask forrecords to be obtained and will not bring relevant information tothe attention of the new GP. Some parents will move house and124change GP deliberately in order to avoid continuing contact withservices.4.6.10The specific concerns in this case need to be put in the widercontextoffindingsfromSCRsaboutthestrongassociationbetween serious child abuse and families who move frequently.Such families are hugely over represented in cases subject toSCRs. Moving frequently is likely to be in part a symptom of otherrisk factors (such as unemployment and poor access to housing)butitalsoexacerbatestheotherriskfactorsinacasebydisrupting professional knowledge of children and involvementwith them. The national review of SCR findings for 2003 – 2005states that ‘the most startling environmental feature was thenumber of families who were noted in reports to have movedfrequently (more than a third of the intensive sample). The needtolocateandprotectchildrenmorerobustlyinthesecircumstances was exemplified in many of the cases.’ 37 (page 47)The follow up study of SCRs 2005 – 7 noted an even higherrepresentation with ‘evidence that almost half of the children andyoung people (45%) had moved numerous times’ (page 42). 384.6.11The movement of families and the slow transfer and summary ofrecords may leave children at risk but also means that GPs are leftprofessionallyvulnerablebecauseasthiscasesoclearlydemonstrates they are working with incomplete information. Aswell as being in the interests of vulnerable children it is in thedirect interests of every GP in the country to take action to resolvethese problems and to press for the policies and practices of allrelevant departments and services within the NHS to be amended.Action is needed at a number of levels:37 Brandon M, Belderson P, Warren C, Howe D, Gardner R, Dodsworth J, and Black J (2007)Analysing child deaths and serious cases through abuse and neglect: what can we learn? Abiennial analysis of serious case reviews 2003-2005. DfES38 Brandon et al, (2009), Understanding Serious Case Reviews and their Impact aBiennial Analysis of Serious Case Reviews 2005-07 DCSF125a higher standard should be set for the transfer and summaryof children’s medical records. For the reasons given in thepreceding paragraph there are good practical reasons for GPsurgeries and the NHS to prioritise the transfer and summaryof children’s recordsin Berkshire specific targets need to be set for the take up ofthe GP2GP system and progress needs to be reported regularlyto senior managers in the NHS and to the LSCBother agencies may need to take action to mitigate the riskthat arises in relation to children who have been subject tochild protection plans or looked after by the local authority. Insuch cases the looked after children’s health team needs toplay a more active role and other professionals need to ensurethat they have sent relevant information directly to the new GP4.6.12TrainingandbriefingsessionsarisingfromthisSCRshouldemphasise:the vulnerability of GPs who do not take steps to improve theirsystems for transferring and summarising children’s recordsthe need for other agencies to recognise that they may need totake into account the fact that when families with vulnerablechildren have recently moved the GP may be working on thebasis of partial information 394.6.13The action that can be taken locally will have little or no impactwhen children move across health borders and the SCR will makea national recommendation to the Department of Health on thismatter so that it can address the problem at a national level.Other aspects of information sharing between health professionals4.6.14The father had a different GP to other family members. Section 3of this report notes that the father’s GPs treated his reaction totheconcealedpregnanciesandthebirthoftwochildrenaspotential mental health problems in isolation from the wider family39 For example social workers need to be mindful of this when undertaking child protectionchecks or when a child subject to a child protection plan changes GP126context. The GPs did not show any curiosity about the childreninvolved and did not share any information or make any enquirieswith the local authority or other health professionals. An honestappraisal of this however is that it would be very unusual for a GPin these circumstances to do so, unless there were very seriousimmediate concerns. This does represent a missed opportunity toshare information which GPs can learn from.4.6.15Sections 3 and 4 of this report have noted that the assessmentscarried out in the midwifery and obstetric services were superficialand that professionals dealing with the second birth did not haveaccess to information about the pregnancy and birth of his olderbrother from previous births. The individual management reviewhas noted the lack of useful information highlighting risk factorsand unusual circumstances contained in discharge summaries toGP and health visitors. It has made recommendations on thiswhich the SCR endorses.4.6.16Sections 3 and 4 of the report highlight the lack of communicationbetween health visitors and GPs except on the occasion when theGP asked EY’s health visitor to advise the mother on managementof sibling rivalry. On this occasion the health visitor failed to tellthe GP during their discussion on bruising that EY had been lookedafter. It is not clear whether she had this information to handduring the discussion, though she must have when she saw thefamily.4.6.17Earlier sections of this report have identified missed opportunitiesto share information between the two health visitors involvedbefore his discharge from care and after. The details are fully setout in the BECHS management review:When the previous health visiting team were notified by the LAChealth team that EY had moved, the records were not forwardedto the receiving team…. From the perspective of the receivinghealth visitor ‘there was no communication with EY’s previoushealth visitor and his records were not requested; family contactwas documented in his mother’s record’ (paragraph 5.5.7)127It is clear that both professionals should have recognised the needto transfer the records as a matter of urgency and in a case whichhad complexities there should have been phone communication.The reasons for this shortcoming in the service have not beenidentified, but section 4.11 below will examine more generalconcerns about the lack of capacity in the health visiting servicesand the impact that this may have had.Information sharing between agencies4.6.18The SCR has identified six occasions on which local authoritymissed (or delayed) opportunities to notify health professionals ofsignificantdevelopmentsandtoenablehealthcolleaguestobecome involved in planning and decision making. (1) There wasno discharge planning meeting before OY was discharged fromhospital. Both hospital staff and social care staff could have takentheinitiativetoconvenesuchameeting.Thesocialcaremanagement review rightly recognises that ‘it would have beenmore appropriate if at the point of (hospital) discharge, a multi-agency planning meeting had been arranged, which would haveaffordedaforumthatpotentiallycouldhaveexplored,orhighlighted the need to further examine the implications of aconcealedpregnancy’.Thiswouldhaverequiredthatotherprofessionals were alerted to the significance of the concealedpregnancy and to have recorded and shared their observations ina more systematic way.4.6.19(2) The local authority notified the LAC health team that EY was infoster care on 11 May 2011. This was 19 days after EY becamelooked after. This is discussed further in paragraph 4.6.22 below.4.6.20(3) Other agencies were not notified of the outcomes of the initialassessments of OY or the decision of the social care service toclose the case. This was said to be because of a lack of capacity inthe service at the time. (4) The same occurred in relation to thesecond initial assessment of OY. (5) Health professionals were notconsulted or involved during the process that led to the placement128of EY with his mother. EY’s health visitor was not consulted aboutthe likelihood that EY would be moving to live with his mother.EY’s new health visitor was told about the plan on 12 Novemberbut not involved further in assessment or discussions. There wasthus no agreed plan of support and follow up between the twoagencies. (6) Following EY’s discharge home to his mother thesocial worker and the family health visitor did not communicatewith one another.4.6.21Taken individually some of these episodes could be explained byfactors (such as the lack of resources). Some are consistent withthe overall underestimation by the local authority of the possiblecomplexity of the case. However taken as a whole they form aworrying pattern, bearing in mind that no manager or qualityassurance system identified any of these episodes as being aconcern. This suggests that some staff and managers may haveunderestimatedthevalueofconsultingcolleaguesinotheragencies andinformingother agencieswhat action thelocalauthority is taking. This is potentially harmful if it leaves otheragencies believing that the local authority is still involved indealing with a case when its involvement has actually ceased. Thelocal authority needs to be satisfied that this is not a morewidespread problem.The role of the looked after children’s health team4.6.22TheagreedEastBerkshireIntegratedCarePathwaysystemrequires that social care notify the LAC health team within fivedays that a child becomes looked after. Notification consists of acompleted notification form and a signed consent for LAC healthcare. In this case the LAC health team became aware that EY wasin foster care following communication from EY’s health visitor(who had discovered it fortuitously at the GP surgery). Officialnotification was not received until 11 May 2010; 19 days after EYbecame looked after. This could have resulted in late provision ofLAC health services and a late medical assessment. EY’s GP was129officially informed of his looked after status by fax on 21 May 2010(a delay of a further 10 days).4.6.23While EY was looked after his health needs were appropriatelyaddressed. The LAC health team were notified that EY was tomove to live with his mother and brother on 12 November 2010.On 22 November the team received a further message from socialcare that the pre-adoption appointment arranged for that day wasto be cancelled as the mother was taking EY home. The team onlythen communicated the plan for EY to live with his mother to thehealth visitor who had been working with EY on 10 January 2011by email. She already knew this.4.6.24TheBECHSmanagementreviewcommentsthat‘therewasevidence of liaison between the health visiting team and socialcare and the LAC health team and social care’. The social carereview makes no specific mention of communication with the LAChealth team. Close examination of the reports and the chronologyindicates that while the LAC health team was effective in itsresponsibilities towards EY whilst he was looked after (for exampleby arranging and conducting his LAC medical examination) itplayed only a marginal role when he ceased to be looked after. Inrelation to his discharge from care the LAC health team played norole in ensuring that all of the health professionals who were to beinvolved had access to all of the relevant information.4.6.25Until now the scope of responsibility of the LAC health team hasbeen limited to the health of children who are looked after. Thisreflects the exclusive focus of guidance on the health of childrenwho are in care rather than the health and safeguarding of youngchildren who are being discharged from care. For example theextremely extensive NICE guidance 40 on the health of looked afterchildrenandtheassociatedselfassessmenttooldocontainreferences to placement of children on care orders with family(because services and support tend to be poorer than in foster40 NICE (2010) Promoting the Quality of Life of Looked after children and young people, NICE/ SCIE public health guidance No 28130placements) and to children leaving care age 16-18 (mental healthsupport for adolescents, transition to adult services etc). Howeverthey do not address the sort of simple, practical issues that wererelevant in this case history - such as the need to notify all thehealth professionals involved when a child is discharged from careand make sure that they know relevant history and are involved inthe child in need plan.4.6.26It is clear from the findings of this SCR that – taking particularaccount of the slow movement of records between GPs and thepoor communication between health visitors – there would beconsiderable value in reviewing the remit of the LAC health teamso as to consider whether it can take more responsibility for 1)identifying all of the health professionals who need to be notifiedof the fact that a child is ceasing to be looked after and 2) sharingkey information with them. The SCR recognises that broadeningthe remit of the team might require additional resources ordifferent use of resources. It also recognises that regardless of theremit of the team and the procedures that are in place thesuccessful performance of all tasks will rely on close working withallocated social workers who need to appreciate the importance ofthere being a coordinated health input to children who return totheir families after being looked after.1314.7Factors that impeded engagementIdentify factors that helped or hindered the engagement withthe family4.7.1The narrative in section 3 of this report shows that professionalsachieved only a very superficial understanding of the lives andhistory of the individuals with whom they had contact. This hasbeen emphasised in the health overview report but it appliesequally to other professionals as well. The result is that – with theexception of the period when EY was in foster care - none of therecords of the professionals involved or the interviews with themconducted for the SCR process give any detailed knowledge of thedaily lives of EY and OY and the care that they received.4.7.2The principal reason for the very superficial engagement of thefamilywithprofessionals.Thesocialworkerundertakingtheadoption counselling with the mother did point out to her that shehad a tendency to deny or disassociate herself from anything thatshe found difficult. With this exception the professionals involveddid not appreciate that it was necessary to seek a closer or morechallenging engagement with the mother and other members ofthe family. This was because professionals largely underestimatedthe potential complexity of the circumstances that they weredealing with and the potential concerns. The details of how andwhy this occurred have been set out to the extent that it ispossible to do so at this point in section 3 and section 4.3 (dealingwith assessment).4.7.3Specific opportunities to understand the tensions and conflicts thatsurroundedtheconcealmentoftwopregnanciesandtheunexpected births of two infants were missed. The only member ofthe family who gave a frank account of how the birth of thechildren had affected him was the father. When he gave accountsto his GPs they were not shared with other professionals involved.When he spoke to social care staff his frankness and the strengthof his feelings were interpreted as him bullying the mother who132wasmuchyoungerthanhimandperceivedasbeingmorevulnerable.4.7.4Shortcomingsinprofessionalpracticeoccurredwithinanorganisational context which sometimes made it more difficult forprofessionals to engage with the family. Sections 4.2 – 4.12 ofthis report sets out the findings of the SCR in relation to these.Rather than repeat these findings (or anticipate them in detail)this section of the report will highlight some of the key findingsand point out why they made engagement with the family moredifficult.4.7.5There was a pervasive belief among social care staff that it wouldbe beneficial to EY to be united with his family and no risks wereidentified in doing this. This was not challenged from within theservice. This has been discussed at length in section 4.4 above.Sections 4.9 and 4.10 deal with the skills and knowledge of staff,their training and supervision. Professionals in other agencieswere not concerned with decision making about EY’s future in thesamewaybuttherearealsoconcernsabouttheskillandknowledge that they brought to bear.4.7.6Thelackofcapacityinthehealthvisitingserviceimpairedengagement with the mother and opportunities to reflect on thecircumstances faced by staff and the history. This is discussed indetail in section 4.11. This section of the report also evaluates indetail the impact of the settings within which some staff operated– with particular reference to the child health clinic and children’scentres.4.7.7On a number of occasions professionals might have engaged moreeffectively if they had had access to relevant information thatmight have influenced their decision making. This is considered indetail in section 4.6 which deals with information sharing.4.7.8Contact with family members may shed more light on theirattitudes and beliefs. If at a future time there is an opportunity fordirect contact with family members there may be scope for more133learning for the SCR. However it is also apparent from the caserecords and from interviews with some staff that the character,personality and background of the mother played a significant roleat key moments in the case history. She maintained a polite butextremelysuperficiallevelofengagementwithmostoftheprofessionals that she encountered. The relatively comfortableeconomic circumstances of her and the family may have played apart in shaping the response of professionals. This is considered insection 4.12 dealing with ‘diversity’.4.7.9It must also be recognised that the mother deliberately andpersistently deceived other parents at the children’s centre andthe staff there as to the identity of EY and her relationship withhim. The evidence strongly suggests that she repeatedly gavefalse accounts of the cause of EY’s injuries, while at the same timebringing EY to settings where his injuries would be noticed. At thispoint it is not possible to fully understand what her reasons werefor acting as she did or the different factors that may have shapedher behaviour. However it is clear that the mother’s compliancewith many services disguised poor parenting and a high level ofrisk to her younger child.1344.8Policies and proceduresDid the organisation have in place policies and procedures forsafeguarding and promoting the welfare of children and actingon concerns about their welfare?Was the work in this case consistent with each organisation’sand the LSCB’s policy and procedures for safeguarding andpromoting the welfare of children, and with wider professionalstandards?Single and multi-agency safeguarding procedures and guidance onthe bruising4.8.1Local multi-agency child protection procedures contain guidanceon how to respond to safeguarding concerns, including bruising.They specify that ‘any bruising or other soft tissue injury to a pre-crawling or pre-walking infant or non mobile disabled child’ or‘bruisingaroundtheface’…’mustbeconsideredashighlysuspicious of a non-accidental injury unless there is an adequateexplanation provided and experienced medical opinion sought’. 41The relevant section of the procedures is included as Appendix 8.4.8.2However carefully written and crafted, the wording of procedurescan always be improved. However these procedures leave thereader in no doubt as to the particular vulnerability of younginfants and the potential significance of bruising. Bruising on theface of a 9 – 11 month old child requires referral to the localauthority and detailed evaluation by a doctor with expertise inchild protection.4.8.3With one exception the individual management reviews confirmthat the staff had access to the local interagency child protectionprocedures and that all of the staff involved had attended multi-agency or professional training which underlined the importance ofmessages about the significance of bruising in infants. A numberof SCR panel members and management review authors were ableto confirm details of the training provided, in particular training for41 Berkshire Child Protection Procedures (section 5)135health professionals in late 2010. There is no doubt that thesemessages had been strongly underlined.4.8.4The review of provision by family support services indicates thatthe children’s centre child protection policy was inadequate insome respects, for example not indicating what arrangementsshould be made when the designated professional was absent.However these were not aspects of the procedures that impacteddirectly on this case. It is more likely that in relation to thisservice, members of staff had received insufficient training tocarry out their responsibilities. This is discussed further in thesection on training and organisational issues. The managementreviewoffamilysupportservicesaskstheSCRtoconsiderproviding more detailed guidance on thresholds for referral to thelocal authority. The view of the SCR is that this exists in thecurrentmulti-agencyproceduresandthatfurtherdetailandreinforcement needs to come through training and managementadvice within the service. Access to multi-agency training wouldbring greater clarity about the roles and responsibilities of otherprofessionals and referral arrangements.4.8.5The case history underlines that however sound procedures aretheydonotremovetheneedforindividualstoexerciseprofessional judgement. Referringtotheexistingprocedures:what for example is an ‘adequate’ explanation for a bruise? Themost important issues are (1) the way in which that judgement isexercised and (2) the context within which judgement needs to beexercised - an important component of which is the access toadvice and additional information that informs the judgement. Inrelation to EY it was the manner in which professional judgementwas exercised which gives cause for concern rather than thewording of the procedures. The case history demonstrates that ona number of occasions professionals were too willing to accept themother’saccountsofhowbruiseshadbeencausedwithoutremaining sufficiently sceptical and without taking further adviceor seeking further information. In one instance a health visitor was136working in a setting which did not make it easy to do this. Whilstsome revision or extension of the procedures might be helpful it istheir implementation by staff in day to day practice which needs tobe the main focus of learning and activity as a result of this SCR.Professional initiative4.8.6Sometimes additional action is required which goes beyond whatis written in procedures and cannot be anticipated in detail bywritten procedures. There is no procedure to say that a 7 monthold who has lived in foster care since birth but is now being placedin the care of the mother should have a new birth visit and a fullfamily health assessment akin to the one that a child wouldnormally receive at 15 days. However it should have been withinthe professional experience and knowledge of the health visitorinvolved to recognise this. Procedures cannot be written to alertprofessionalstoeveryconceivableunusualorunexpectedcircumstance.The need for additional procedures and guidance4.8.7All of the individual management reviews recommend the need foradditional multi-agency procedures to be produced dealing withdenied or concealed pregnancy. This will assist local professionalsby underlining the importance of denied and concealed pregnancyand by setting out minimum steps that are required or need to beconsidered. In particular the procedures should underline theimportance of closer working in such cases between professionalsinvolvedinchildren’sservicesandperinatalmentalhealthservices. The SCR endorses these recommendations and suggeststhat the work to produce brief procedures on this should beundertaken on a multi-agency basis.4.8.8The health management reviews indicate that there would bevalueindevelopingamoredetailed‘pathway’forthemanagement of bruising. The SCR endorses this and wishes tounderline that this will be of value so long as it addresses thepsychological barriers that may exist which make it more difficult137for GPs and others to recognise abuse and make referrals as wellas the managerial and administrative aspects of the problem.4.8.9There are wider concerns highlighted by the case history whichrelate to the difficulty that many professionals had in consideringthe possibility of child abuse as an explanation for bruising and theease with which they arrived at and accepted benign explanationsfor injuries to a child without being more sceptical and withoutconsulting colleagues. These wider concerns need to be addressedthrough the continuing supervision and training that takes place inindividual agencies and the LSCB and they cannot be addressedthrough specific procedures. The briefings and training undertakenin relation to this SCR need to underline the continual need forscepticism,cautionandconsultationbeforearrivingatfirmjudgements.Theywillunderlinetheneedforcontinuingprofessionalopennesstopresentationsthatdonotfittheestablished picture of a ‘high risk’ case.1384.9The skills, knowledge and experience of the staff dealingwith the familyEstablish whether staff and managers dealing with the familyhad the requisite skills, knowledge and experience to respondto the circumstances presented by the family.Staff levels of experience and skill, the training and support givento staff4.9.1Each of the individual management reviews comments in detail onthe skills, knowledge and experience of the staff dealing with thecase. The main issues arising from these evaluations are set out inthe following paragraph.Social work staff4.9.2The social care management review states that ‘social workersandsocialcaremanagers…wereknowledgeableandhadundertakenappropriatetrainingaboutpotentialindicatorsofabuse and neglect’. It goes on to state that the allocated socialworker who was involved in the case from May 2010 onwards wasnewly qualified. It says that she received ‘additional training anddevelopment opportunities … through a Newly Qualified SocialWorker training programme’. The management review details thecontent of this programme which seems to be very relevant,though it is not stated how much of this the worker concerned hadcompleted.42 It is stated that in addition an arrangement wasmade whereby she was ‘supported in developing her knowledgeconcerning adoption through close liaison with experienced staffinvolved through the Fostering Adoption and Respite Service’ andit is understood that the relevant staff were easily accessible tooffer advice.4.9.3Inprinciplethiswouldappeartobeanidealarrangementreflecting the lack of experience of the allocated social worker. In42 Completion of CWDC Induction workbook, training on roles/responsibilities within thedepartmental structure, planning interventions, chronology, remaining child focussed/hearingthe voice of the child, risk assessment and analysis, recording skills, Section 47investigations, report writing and analysis, challenging skills, managing difficult behaviour,presentation skills, and assessment framework. The worker concerned had not completed anumber of key modules including recording skills (!), presentation skills, s47 investigations,and assessment framework, suggesting that she was allocated this case because it wasconsidered straightforward139practice the evidence of drift in the implementation of plans, thefailuretochallengethemotheroverherdelayandtheunderestimation of the indicators of possible concern (all describedin detail in section 4.3 above) strongly suggest that at her stage ofprofessional development this individual worker did not have theskill and knowledge necessary to undertake the work with EY andhis family. Perhaps the clearest symptom of this was the tendencyto hold back from actively engaging in the case, for example bynot visiting the mother and EY together during the period beforethe rehabilitation, relying only on the comments of the foster carerand not engaging directly with the grandparents to assess theirrole much more fully.4.9.4From the information that is available it is not clear how far thiswas due to her lack of experience or whether it is more significantthat everyone involved in the case in the social care serviceadopted the basic attitude previously identified that it would be apositive outcome if EY were to be cared for by his mother and thatthere were no potential risks or complications in allowing this tohappen. This points to the failure of her supervisor and othermuch more experienced colleagues to identify potential difficultiesand to challenge the superficial assessments that were produced.Supervision and management involvement is discussed further insection 4.10.Children’s centre staff and managers4.9.5The management review of family support services addresses indetail the question of the skills, knowledge and training of the twomembers of staff involved.4.9.6The centre coordinator had been working in adult education andfamily learning prior to taking up her posts. This involved ‘co-ordinating, designing and delivering training for adults to improvetheir basic skills’. Nationally and locally this is not unusual inchildren’scentreservicesbecausepromotingthelearningofparents, improving their ability to gain employment and helping140themlearnhowtosupporttheirchildren’slearninganddevelopmenthavebeenimportantpolicyobjectives.Themanagement review recognises that in children’s centres that donot provide nursery or child care ‘the primary relationships … arewith parents rather than children’. It is suggested that althoughtraining was provided in early years development the lack of aprofessional background specifically within children’s services mayhave impaired the capacity of the staff to safeguard EY. Forexample, this was the first possible child protection matter thatthe centre co-ordinator had referred to social care in her career.Thiswouldbeunusualforsomeonewithmanagementresponsibility in a children’s setting. When she made the referralthe manager assumed that she was taking advice from a qualifiedmember of staff and she was surprised that she was not asked forEY’s name. However she did not have the confidence to challengethe approach taken or to ask to speak to someone more senior. 434.9.7These are very specific examples that relate to the referral ofconcerns to social services. However it seems very likely that thecoordinator’s lack of experience in managing a setting attended bychildren contributed to a wider lack of focus on the needs ofindividual children. Examples include: the repeated failure to insistthat the mother provided registration details of EY; the reliance onrecordingepisodesofbruisingindateorderas‘incidents’alongside incidents about other children and parents, making itdifficult to focus on the sequence of events for an individual child;and the lack of training of staff over safeguarding. The centrecoordinator has subsequently acknowledged not feeling confidentin her role as the designated person for safeguarding. A managerfrom a background providing services to children is much morelikely to have regarded safeguarding training as an absolutepriority.43 The local authority had also wrongly believed that the role of the Access Officer was widelyunderstood. This is discussed in section 4.111414.9.8This is not to suggest that a manager from an adult learningbackground could not fulfil the responsibilities of a children’scentre coordinator in a child centred manner. It indicates thatother things being equal he or she would need additional training,support and monitoring to be able to do this. The individualmanagement review recognises that more account needs to betaken of this in relation to the recruitment and training of centrecoordinators in future. Because of its location the coordinator inthis centre was also disadvantaged by being professionally isolatedfrom others carrying out the same role who may have been ableto offer useful peer support.4.9.9The children’s centre worker had training in early years teachingand had previously worked in a role with families and children withadditional needs. However for a number of reasons she had notattended the level one safeguarding training required for her post.This was in part due to a misunderstanding as to which agencywas responsible for providing it but it is also stated that the centrecoordinator did not give this sufficient priority because the centreworker’spredecessoralsoreceivednospecificsafeguardingtraining.Thecentrecoordinatoralsofailedtoensurethatinformationaboutbasicchildprotectionresponsibilitieswasincluded in the centre worker’s induction training so she had notbeen made aware of basic documents on safeguarding or theLSCB’s policies or how to access them.4.9.10The family support service as a whole did not have sufficiently wellorganised arrangements for ensuring the take up of training Thecentre worker’s lack of training had not been identified in theregular audit of staff training because staff lists were not up todate.Health professionals4.9.11Theindividualmanagementreviewsstatethatthehealthprofessionals involved had the requisite skills, experience andtraining. The BECHS management review confirms that ‘eachmember of staff involved with family was up to date with their142safeguarding training’. The GP who examined EY two monthsbefore his death was regarded as being highly knowledgeable inrelation to child health and all of the other GPs involved hadattended relevant training in the recent past.4.9.12If key health professionals had relevant skills, knowledge andtrainingtheninsofarasthereareshortcomingsintheirperformance attention must be paid to the wider organisationalcontext within which they were working to establish whether thereare factors which may have made it more difficult for them toapply this knowledge and skill in practice. The arrangements forGP record transfer and the reticence of the GP to identify childabuse have been discussed in section 4.6 above. Section 4.11whichdealswithorganisationalandmanagementissueswilldiscuss the likely impact of the long standing under capacity of thehealth visiting service and the potential impact on the work ofhealth visitors of working in some child health clinics.1434.10Managements and supervisionWere senior managers or other organisations and professionalsinvolved at points in the case where they should have been?Was there sufficient management accountability for decisionmaking?Agencies and services in which there was no management orsupervisory input4.10.1GPs do not receive supervision, though they are able to consult anamed GP or a paediatrician colleague for advice about thesafeguarding of children. None of the GPs involved in this casehistory did so. It would have been relevant for the GP to havesought advice when he identified the bruises on EY in January2011.4.10.2Midwives operate as autonomous professional practitioners and donot receive supervisioninthe sense that most professionalsoperating within child protection services would understand it. 44 Ifthey have concerns about safeguarding, midwives should consultthe named midwife, but understandably this was not viewed asnecessary in this case. In relation to both children appropriatereferrals were made to the local authority. However the conductand recording of midwifery assessments fell short of the standardsrequired.4.10.3Health visitors are required to attend supervision over casescausing child protection or welfare concerns at least every fourmonths (or when specific problems occur on cases). This case wasnever considered complex or concerning enough to be discussed insupervision.Social care supervision4.10.4Records have been provided which show that EY was discussed intensupervisionsessionsbetweenthesocialworkerandhermanager during the period late May 2010 (when the case wasallocated) and late December 2010 (when the case was closed).44 They are required to meet a mentor annually for the purpose of professional developmentand registration144The sessions were usually held three weekly but there were twogaps of approximately six weeks because of the annual leavearrangements of the social worker and her manager (these werefrom 2 August – 10 September and from 24 September – 3November).Theextendedgapsareinappropriateforaninexperienced worker.4.10.5The individual management review states that the content ofsupervision (as recorded) focused exclusively on the practicaltasks that needed to be undertaken. It notes that little attentionwas paid to exploring any potential risks or complexities in thecaseandthatthesupervisordidnotchallengethepositiveassessments made by the social worker. Both the social workerand her manager appear to have shared the same set of positiveassumptions about the potential for the mother to take on thecare of EY.4.10.6In addition the review of the chronology and the sequence ofdecisions and actions by the social worker in section 3 of thisreportsuggestsstronglythatthesupervisionwasalsonoteffective in ensuring that practical tasks were undertaken withinthe timescales agreed and required by the case. The evidencestrongly suggests that the social worker struggled to understandthe tasks that needed to be carried out. It is not clear if sheunderstood the legal advice that she had been given. It alsosuggests that she lacked the confidence to engage members ofthe family in the positive and constructive way that was necessaryor to challenge the mother’s delay in consulting her family. Theevidenceavailablestronglysuggeststhattheinputofhersupervisor failed to recognise and address these problems. Noevidence has been provided to indicate that the performance ofthe supervisor involved is satisfactory across the range of hisother tasks so it is not clear if this was an isolated episode.Family support service supervision and management1454.10.7Theevaluationwhichfollowsdrawsonthefindingsoftheindividual management review. This offers a very detailed andthoughtfulaccountofthearrangementsforsupervisionthatexisted in the family support service. In particular it has sought tounderstand the nature of the supervision provided within thechildren’s centre and between the centre coordinator and hermanager and the impact that this may have had on the capacity ofthe centre coordinator to pursue the concerns about bruising onEY.4.10.8The arrangements for supervision of the children’s centre workerare shaped by the nature of the service. The centre had one fulltime worker and one co-ordinator (working the equivalent of 4days per week). It is clear that the concerns about EY wereregularly discussed between the two members of staff either inweekly ‘team meetings’ or as they arose. Actions were agreed, atfirst for the worker to take in discussion with the mother and laterfor the centre coordinator to take forward to discussion with hersupervisor. The incidents of bruising to EY would have beenmentioned as part of a wide ranging discussion about all of thecentre’s activities and arrangements. So far as can be establishedthecentrecoordinatorhadinformationaboutallrelevantdevelopmentsandtookresponsibilityfordealingwiththem.However there were shortcomings in the actions that she took(which are identified in sections 3 and 4.3 of this report) and inthe action of her supervisor and her own line manager.4.10.9The Children Centres Programme Manager and the Children’sCentre Coordinator had experience of managing universal servicesor parent focused services rather than services which held caseresponsibility for individual vulnerable children. The managementdiscussions about EY reflect this experience. The Children’s CentreProgramme Manager was made aware of the concerns about EY inearly February (when a pattern of injuries had emerged). She andthe coordinator discussed the action that the centre coordinatorshould take twice during February 2010. Shortcomings in the146notes of her response make it impossible to know exactly whatactions were agreed. The Programme Manager was sufficientlyconcerned to follow up her instructions a few days later, but againshe made no detailed notes of the discussion and so it is not clearwhatfurtheractionswereagreed.Themanagementreviewrecognises that this was unsatisfactory and that in future seniormanagers in the service need to be trained to provide supervisiononindividualcaseswhichismoreakintothesafeguardingsupervision that is provided in health or social care4.10.10During the period when EY was being discussed action was beingtaken in the family support service to address the perceived underperformance of the centre coordinator. This had begun in August2010. As a result of this she was given notice in early March that aformalreviewofhercapabilityasamanagerwouldbeundertaken. On 9 March 2010 the centre coordinator resigned,giving two months’ notice. The individual management reviewnotes that the relationship between the centre coordinator and hermanager deteriorated as a result of the monitoring that was beingundertaken. It is suggested that this may have contributed to herfailure to have a further discussion about the injuries to EY after17 February. After the two discussions were held dealing with EYin early February there were no further discussions about EYbetweenthecentrecoordinatorandhermanagerafter17February. At a one to one meeting with the coordinator in earlyMarch the service manager did not take further steps to find outwhat had happened in relation to EY. This meeting focused almostexclusively on the overall management of the children’s centreservice and the transitional arrangements that needed to be madefollowing the coordinator’s resignation.4.10.11Althoughthecircumstancesdescribedareveryspecific,thisanalysis is valuable because it demonstrates that it is importantfor managers who are dealing with poor performance and widermanagement issues not to lose sight of concerns relating toindividual children’s cases while dealing with wider matters.1474.10.12Themanagementreviewmakesanumberofspecificrecommendationsinrelationtomanagementandsupervisionwhich the SCR endorses.Involvement of senior managers and professionals4.10.13The Programme Manager referred to in the preceding paragraphswas the only person more senior than a first line manager to knowabout the case. The case was not recognised as being one thatcarried any significant degree of risk and it should have beenadequatelymanagedthroughthenormalsupervisoryandmanagerial arrangements in agencies.Other action that may be required under agency management andhuman resources procedures4.10.14It is not the purpose of the SCR to evaluate the competency andconduct of individual staff members and professionals in the casehistory or to make recommendations in relation to this. However itis consistent with the functions of the LSCB to seek assurance thatagencies have taken appropriate action if they believe that there iscause for concern over the competency or conduct of individualswho have been involved. As part of the process of finalising theSCR the LSCB has therefore sought assurance from the employingagencies and commissioning bodies involved that they have takenanyactionthattheyconsidertoberelevantinrelationtoprofessional conduct, disciplinary or competency procedures inrelationtoindividualstaffandmanagersandindependentpractitioners who were involved in the case history.1484.11Organisational matters - the impact of resources, lack ofcapacity and other organisational issuesWere there organisational difficulties being experienced withinor between agencies? Were these due to lack of capacity in oneor more organisations?Was there an adequate number of staff in post? Did anyresourcing issues such as vacant posts or staff sickness havean impact on the case?Introduction4.11.1This section addresses four wider organisational matters that theSCR believes had an impact on the services provided to EY and hisfamily:the lack of resources in the health visiting service relative todemand for servicesthe arrangements for child health clinicsaspects of the development of children centre policyaspects of the organisational arrangements and capacity insocial care.These are reviewed in turn.Capacity in the health visiting service4.11.2The individual management review prepared by BECHS gives aclear account of the resource constraints affecting health visitingprovision. In January 2011 the average caseload of children underthe age of five per full time equivalent (FTE) health visitor post inthe service responsible for making provision for EY and OY was669. This figure is said to be typical of the service throughout theperiod under review by the SCR. This is 67% higher than theagreed government target for health visitor caseloads which is forcaseloads of 400 children per FTE health visitor. This was cited byLord Laming in his review of child protection services and wasadoptedbygovernmentfromstudiescarriedoutbytheCommunity Practitioners’ and Health Visitors’ Association. It istherefore to be treated not as an ‘ideal’ but a level consistent withgood professional standards of work. It is clearly a challengingtarget.1494.11.3Although there are regional and local variations the statistics forEastBerkshiremirrorthenationalpicture.Asallpostsarecurrently filled in the service this indicates that establishmentfigures have been set too low and caseload expectations too high.The management review reports that work is currently under wayin East Berkshire to revise the establishment and caseload figures.The service has a target to recruit an additional 36 whole timeequivalent health visitors which is designed to reduce caseloadnumbers to approximately 350 children under five years of age(per FTE). It is noted in the management review that at a nationallevel efforts to increase health visitor numbers have not met withsuccess.4.11.4It is very likely that in combination with other factors the capacityof the health visiting service had an impact on the quality ofprovision made in this case. Sections 3 and 4.3 above outline theshortcomings in service provision by health visiting staff. Thesecentreonthepoorassessmentsofneedandrisk,poorcommunicationofinformationandthefailuretorespondappropriately to potential indicators of risk. There can be no doubtat all that while other individual and case specific factors alsoappliedtheexcessiveworkloadofhealthvisitorswillhaveadversely affected practice. The management review recognisesthis stating that:‘should the health visiting teams (have) had caseload numberscloser to national recommendations, this would have allowed moretime for planned visits to the family, more time for reflection onthe case, more time for planning and more time for effectivecommunication between the teams’.4.11.5During its discussions the SCR panel has also recognised that highcaseloads can have other negative effects on the way in the healthvisitors are working with families and managing their work. Thechronology and management review highlights how many of themost significant communications in the case history were onlyrecorded by health visitors ‘in the health visitor’s work diary’150because many calls are received on mobile phones, children hadno records or because health visitors did not have the opportunitytorecordeventsinthechild’srecords.45Ifhealthvisitorshabituallyrecordimportantinformationinthiswayitwillsignificantlyincreasethelikelihoodofitnotbeingproperlyrecorded,accessedbycolleaguesandsharedwithothersappropriately.4.11.6The management review of health visiting provision explains thatchildren and families receive a health visiting service drawing onthe skills of different members of the health visiting team andattending child health clinics that may be staffed by any one of anumber of health visitors. This approach is commonplace and hasmuch to commend it. However the potential for a number ofdifferentpractitionerstobeinvolvedwithafamilyfurtherunderlines the need for comprehensive recording that is accessibleto all team members. The use of work diaries to record importantinformation is of greater concern given the team approach toservice delivery. The SCR will recommend that the trust reviewsits expectations of the recording practice of health visitors andgives clear instructions to health visitors as to how they use workdiaries for recording, taking full account of the practice of skillmixed team working.4.11.7It is striking that the health visitors involved in the case did notbelieve that their caseloads had negatively impacted on them. Themanagement review reports that:Each health visitor stated that they were in a position to offerextra input to the family and they were also in a position toprovide this extra input within their caseload …. This is why theydid not feel that capacity impacted on their evaluation of theservice they delivered to the family. (The mother) did not wish tohave extra services from the health visiting team; which is herprerogative. They would feel capacity is an issue if they have45 Key events include: the home visit made to the mother prior to EY moving to live with hismother; the referral of bruising by the GP and the clinic contact with EY the day before hishospital admission.151assessed a family as requiring extra input, but were not in aposition due to staffing levels to offer input to a family. (emphasisin original)This should give rise to heightened concern because the staffinvolved have not recognised that basic standards of assessmentand information sharing were not met. The lack of provision isattributed to the mother’s choice whereas in fact this has nobearingonthepoorqualityandlackofbreadthoftheassessments carried out, the failures to share information or thefailure to recognise indicators of risk. The individual managementreview indicates that action is under way to recruit additionalhealth visitors. It gives no indication of timescales, success or lackof it so far or future milestones. The management review makesno recommendation in relation to health visitor recruitment. Thismay be because the trust is satisfied with the progress that isbeing made. The issue of health visitor recruitment and standardsof practice is of great significance for safeguarding services. In thecircumstances the LSCB needs to be satisfied that it understandswhattheimpactoftheshortfallofhealthvisitorsisonsafeguarding services, the steps that the managing trust is takingto mitigate risk and the progress being made in recruitment. Arecommendation is made in relation to this.The trade off between accessibility and safety of services – childhealth clinics4.11.8EY was seen at a child health clinic the day before he wasadmitted to hospital with the injuries that caused his death. Theright course of action would have been for the health visitor torefer the child to local authority social care services because of thebruising that she observed. In seeking to understand why anexperienced and knowledgeable practitioner did not do this theSCR has considered the context in which this consultation tookplace.4.11.9The clinic setting is described in the management review asfollows:152Every health visitor will take it in turns to work at a clinic on a rotabasis. Health visitors may not have had any previous contact withparents attending clinics as parents are able to drop into any clinicacross the area; they may or may not be familiar with the familyhistory. With large numbers of families accessing some clinics, thecontact time with the health visiting staff may be reduced to 3-5minutes for face to face contact time. The health visitor may notbe privy to the family’s history or be familiar with otherprofessionals’ concerns because they only have access to thePHCR for information where limited information about thecircumstances of a family is recorded.’4.11.10Suchclinics(anumberofwhicharelocatedincommunitybuildingsratherthanhealthcentres)havebeendevelopedbecause they are an efficient way of using scarce health visitortime and because they are readily accessible to families. Theapproach has much to commend it but there is also a danger thatit may negatively impact on the service provided to vulnerablechildren. It is not that such services are not safe, but there arefeatures of the desire to make them as accessible as possible thatmayhavemadethemlesssafe.Thetradeoffbetweenaccessibility or efficiency and the safety of some aspects of theserviceiswellestablishedintheliteratureonaccidentinvestigation and it would be naïve to think that it might notequally apply in some measure to this form of health provision. 464.11.11In the circumstances the health trust should investigate howhealth visitors and other staff working in accessible outreachservices can be helped to offer a safer service to vulnerablechildrenandbeabletorecogniseunusualandconcerningpresentations. Aspects of the design and operation of the clinics,including access toinformation aboutfamilies and access tocolleagues should be considered and the staff who are involved inrunningthemshouldbecentrallyinvolvedindiscussions.46 David Woods et al, Behind Human Error, Ashgate (2010) second edition; Sidney Dekker,The Field Guide To Understanding Human Error, Ashgate (2006)153Discussions about the clinics should be linked to discussions aboutthe tools that health staff use at them such as the PCHR.4.11.12In addition staff in other agencies working with vulnerable childrenneed to understand better how these clinics operate. For examplethe practice of parents attending a clinic, weighing their own babyandcompletingthePCHR(withouthavingcontactwithaprofessional) might be the norm for health professionals but is notwell understood by many other professionals. Other professionalssuch as social workers could very easily assume that a child whosePCHR showed that he had been to a child health clinic had beenexamined by a professional. This might influence their decisionsand actions. It is essential that when service innovations inservices take place other professionals are kept up to date, even ifthe service involved does not consider them to be controversial.4.11.13Similar concerns apply to the role of the Access Officer in thesocial care referral and assessment service. Even though thisarrangement is reported to be a long standing one neither thechildren’s centre worker nor a number of SCR panel members andauthors of management reviews were aware of the roles andresponsibilities of the Access Officer in the referral and assessmentservice. The SCR makes recommendations in relation to both ofthese issues.The impact of the scope and pace of children’s centre developmenton the safety of services for vulnerable children4.11.14The section of this report on the skills and training of staff andmanagers has highlighted some shortcomings in the managementand oversight of the children’s centre attended by EY and hismother. The management review of family support services hasidentified that the very rapid scale and pace of children’s centredevelopment made the service more prone to these weaknesses.4.11.15The individual management review identifies that the scope andresponsibilities of the manager responsible for children’s centreswere substantial:154‘In addition to overseeing the entire programme (10 children’scentres), this role also directly line manages the four RBWMmanaged centres and until January 2011 was responsible for thecapital build programme for new Phase 3 centres. The failure tospecifically check and monitor policies and procedures within anRBWM managed centre would indicate that there was insufficientdifferentiation between the roles of directly line managing somecentres and performance managing others. The intense demandsof completing the capital build programme [for Children’s Centres– KI] during 2009-11 placed a very high level of demand on the(manager) that made it difficult to thoroughly manage thosecentres that were already open.4.11.16Thesafeguardingofvulnerablechildrenattendingchildren’scentres and the training of staff and designated professionals wasstated by government to be a priority for the centres. Howevergiven the scope and pace of the development that has taken placethere was always a potential for conflict between the objective ofrapidly developing highly accessible services and maintaining atight focus on the needs of individual vulnerable children. In thiscontext it is easier to understand that in one children’s centre thesafeguarding of a child was compromised because staff lackedsome of the requisite skills and training and the performancemanagement of this centre had not identified those weaknesses.4.11.17This is a significant issue because large numbers of children attendchildren’s centres and their focus is increasingly on vulnerablechildren.Thepotentialtensionbetweendevelopingeasilyaccessible services and safeguarding the most vulnerable childrenneeds to be addressed. The management review makes a series ofrelevant recommendations on the steps needed to ensure thatsafeguarding practice improves in children’s centres and the LSCBwill monitor progress in the implementation of these closely.155Capacity in the social work teams involved with the family4.11.18The management review of local authority social care provisionindicates that the referral and assessment team was experiencingproblems of capacity in early 2009 leading to decision not to notifyother agencies about the closure of the case after the initialassessment of OY. The SCR is satisfied through the informationprovided by Ofsted unannounced inspections of social care (whichfocus largely on these duty arrangements) that these problems ofcapacity no longer apply. Both published inspection feedbackletters identify improvements in the service since early 2009 andneither identifies priority actions that need to be taken by theauthority. 4747 http://www.ofsted.gov.uk/local-authorities/windsor-and-maidenhead1564.12DiversityWas practice sensitive to the racial, cultural, linguistic andreligious identity and any issues of disability of the child andfamily, and were they explored and recorded?4.12.1The potential significance of ethnicity, religion, disability in relationto the case history has been considered carefully in all of theindividual management reviews. EY’s mother and father and thechildren were recorded by all agencies as being of White UK origin.There was no record of any disability or any other informationpointing to possible social exclusion. With the exception of thechildren’s centre, professionals recorded no information about theeconomicstatusofthefamily,thoughhomevisitsbyallprofessionalsconfirmedthatthemotherandfatherwereeconomically comfortable.4.12.2GP records contain basic information about the ethnicity of themotherandthechildren.TheBECHSandHeatherwoodandWexhamParkHospitalsNHSFoundationTrustmanagementreviews comment on the lack of detailed background informationabout the family in the agencies’ records. This should be treatedas indicative of the lack of information about the family and theverylimitedassessmentsthatwerecarriedout,ratherthanrevealing anything specific about the assessment of diversity.4.12.3Thesocialcarereportdemonstratesthatinrelationtothepotential adoption of EY the parents were consulted as to theirviews about the sort of family that they wanted EY to be placed in.They reveal that the parents did not firmly hold or activelypractice any religious beliefs and broadly speaking wanted EY tobe in a family that bore some resemblance to the mother’s family.4.12.4The mother and children had most contact with staff at thechildren’s centre. Interviews with staff confirmed that ‘the familywere not observed to be in any financial distress. The childrenwereobservedas“nicelydressedandwithageappropriateclothes”andthemotherwaswellpresentedandpaidcloseattentiontoherappearance.Themothershowedstaff157photographs from her skiing holiday taken in February 2011’. Oneof the parenting workers described the mother as a ‘young,attractive, chatty girl’ who ‘perhaps did not need the Children’sCentre as much as others and was not necessarily looking for helpbut more of a social life’. The father and mother were both inemployment at the time of the birth of OY. It is not recorded inany agency record but it has been confirmed since the death of EYthat the maternal grandparents have a successful business.4.12.5This relative economic wellbeing in comparison to many familieswho need targeted support services or have a looked after child islikely to have been the most significant aspect of the family’scircumstances, so far as their interaction with professionals isconcerned. The review of family support services includes thespeculative, but perfectly plausible, comment that: ‘this financiallystable well presented image was a contributory factor in thechildren’scentre’sunderestimationoftheriskfactorsandvulnerability of the family and made it less likely that staff wouldbe suspicious of the information given’.4.12.6It is very possible that the same sort of factors may haveinfluenced the assessment of the social care staff and the positiveviews of the foster carer about the prospects for the successfulplacement of EY with his mother.4.12.7The social background of the family was another factor thatmarked this case out as being unusual because as has been notedabove none of the risk factors most commonly associated withchild death and serious child abuse were present.1584.13What do we learn from the case?Are there significant lessons for the way in which organisationswork individually and collectively to safeguard children?Key lessons for safeguarding practice4.13.1There are significant lessons for the way in which organisationswork to safeguard and promote the welfare of children. Thefollowing areas have been highlighted in this report and theindividual management reviews:staff in all agencies need to recognise the significance ofconcealed and denied pregnancy – including in unusual casessuch as this where the usual factors associated with concealedpregnancy (learning difficulty, drug misuse and mental illness)are absent. It is highly unusual for a mother to have twoconcealed pregnancies.the circumstances surrounding any concealed or deniedpregnancy need to be investigated in detail, including thepsychological and psychiatric status of the parentsthe new birth health assessment in relation to OY was verylimited and failed to take account of wider family factors thatmight have impacted on healththe initial social care assessments of OY were of limited value.The complexity of EY’s circumstances merited a coreassessment. Although there was no procedure to require this,professional judgement should have identified the case as acomplex one which merited a fuller assessment.involvement of the father and members of the extended familywas very limited in this case. Better engagement would haveadded to the assessment of risk and needprofessionals should not underestimate the risks associatedwith the re-unification of a child with parents after aconsiderable period of separation (or as in this case when aparent has never had responsibility for the child). Thedevelopmental needs of the individual child, the meaning forthe parents of the individual child and the child’s history of159attachment need to be evaluated in detail even when there isno obvious indication of risk.professionals in three different settings – the GP practice, thechildren’s centre and a child health clinic – did not comply withthe child protection procedures and the training that they hadreceived and did not report suspicious injuries to social care.Professionals need to have the skill and confidence to take theaction required to protect children when faced with confidentand convincing parents who are denying the harm done tochildrenthere was a lack of curiosity about scratches on the face of aninfant which should have been recognised as an unusual andpotentially concerning presentationif professionals are not sure that a referral to the localauthority is required then they must consider alternatives suchas referral for a paediatric opinion or taking advice from anamed professional or another more experienced colleague.the current system for the transfer of GP records is not fit forpurpose as it relates to the needs of vulnerable children. Itmay place some children at risk and the delays that arecommonplace mean that the service offered by GPs may beseriously impaired. Current arrangements make GPsprofessionally vulnerablethe coordination of health care for children who are dischargedfrom being looked after needs to be better coordinated and therole of the LAC health team should be reviewed to take thisinto account. All of the health professionals who will beinvolved with a child and its family need to be informed aboutthe relevant history and know which other professionals areinvolved with the childsome aspects of professional practice were made more difficultby the context in which professionals were required to workwith vulnerable children. When services – such as child healthclinics and children’s centres - are developed with a view to160maximising the accessibility of services to families, agenciesneed to ensure that staff and managers are trained andsupported so that they can continue to meet the needs ofvulnerable children who attend themnewly qualified social work staff dealing with children’s casesrequire a high level of supervision tailored to their individuallevel of competence, skill and knowledge.1615ConclusionsThis is a summative section that should comment on whetheragencies – individually or collectively - could have predicted thatEY was at risk of significant harm and whether his death couldhave been prevented. Is important to base this judgement onwhat was known (or should have been known) at the time ratherthan with the benefit of hindsight.Missed opportunities to identify the risk to EY and protect him5.1.1The professionals involved underestimated the complexity of thefamily circumstances because they did not understand the level ofconcernthatwasassociatedwiththemother’sdenialorconcealment of her two pregnancies.5.1.2When considering the rehabilitation of EY to his mother the localauthority made overly positive assumptions and paid insufficientattention to the negative features of the case history, such as thelong periods when EY’s mother did not visit him and had littleinterest in him.5.1.3There were no grounds to prevent EY returning to the care of hismother but the complexity of the background and the evidencethat the mother had little positive interest in EY indicated the needfor careful monitoring of his health and development and the carethat he was provided after his placement with his mother. Thereshould have been a coordinated child in need plan linked to asimilar plan for his health needs.5.1.4Four weeks after he moved to live with his mother professionalsnoted scratches on EY’s face. Four weeks after this, bruises werenoted on his face and head. EY’s mother usually stated that thesehadbeencausedbyhisolderbrotherorbyfalls.Someprofessionalsfoundtheexplanationsconvincingbutthesepresentations were highly suspicious. EY’s age and circumstancesmarked him out as being extremely vulnerable. The professionalsinvolved should have responded differently and they should havebeen reported to the local authority so that child protectionenquiries could be undertaken. At the very least professionals162should have taken advice from a member of staff or a professionaladvisor with expertise in child protection or referred EY for apaediatric assessment. There were two occasions on which healthprofessionalsmissedopportunitiestoprotectEYandseveraloccasions when he attended a children’s centre and both the staffand other mothers identified suspicious bruises.5.1.5When the children’s centre sought advice from the local authoritythe centre coordinator spoke to an unqualified member of staffwithout realising this. She was unhappy with the advice given, butdid not challenge it. The systems in place in the local authority forscreening calls were not clear to other professionals.5.1.6The post-mortem findings show that EY’s death was caused by avery serious head injury. He had numerous bruises on his face,head, chest, back and legs when he was brought to hospital veryseriously injured. EY had also suffered a number of fractures thatpredate his death by at least two weeks. It is not possible to datethese injuries more precisely so some or all of them may be olderthan this. However taking only the two week period before hesuffered the injuries that caused his death the agency records listthe following episodes in which he was examined or bruising wasnoted or discussed:2 March 2011 – two bruises and scratches observed on EY’sface at children’s centre14 March 2011 - EY was seen by a GP with a cold and cough.No detailed examination of his body would have taken placebut he was noted to be ‘alert, interacting and comfortable’ andotherwise well15 March 2011 – crèche workers at the children’s centrereported bruises to EY’s forehead and cheek. A crèche workerchecked his legs, back and chest and found no other bruises16 March 2011 - the mother and both children attended thechildren’s centre. Both children seemed poorly and EY waslethargic. It is not clear whether the bruises were observed163again. They may not have been recorded because they hadbeen recorded the day before.17 March 2011 the mother took EY and his brother to a childhealth clinic. The health visitor (HV7) examined him briefly andnoted two bruises on his cheek and forehead.5.1.7None of these incidents was reported to the local authority. If thathad happened or EY had been referred for a paediatric assessmentthe bruises would have been investigated. Given EY’s age andvulnerability it is very likely that a full child protection medicalexamination would have been undertaken. In the circumstancesthis would very likely have included a skeletal survey (an x-ray ofthe whole body). This would in turn have very likely identified theolder fracture injuries and this is likely to have led to action beingtaken to protect EY.5.1.8The conclusions of the SCR are that 1) over the long term therisks to EY were underestimated 2) when he moved to live with hismother he should have been closely monitored because of theconcerns about the circumstances of his birth and his mother’sfailure to visit him for long periods when he had been looked after3)inthetwoweeksbeforehisdeathprofessionalsmissedopportunities to intervene which, if they had been taken, are verylikely to have led to the detection of serious injuries and wouldprobably have prevented his death.1646RecommendationsOverview Report1.The LSCB should oversee the production of the proposed ‘pathway’ for themanagement by health professionals of bruising so as to ensure that it isconsistent with sound multi-agency child protection practice.2.BHFT should establish the quality of new birth assessments in a sample ofcases giving particular emphasis to the wider family, social andenvironmental issues that are highlighted in the national and localguidance.3.The LSCB should use ensure that agencies improve their engagement withfathers and other male carers in all aspects of child protection work.4.The LSCB should produce multi-agency guidance on the assessment andmanagement of need and risk where there has been a denied or concealedpregnancy.5.Health commissioners and provider trusts should review the current designand use of the PCHR.6.The local authority should ensure that all relevant staff are made familiarwith relevant research on reunification and are able to apply it.7.Health commissioners and provider trusts should ensure that professionalswho may be involved in the reunification of vulnerable children are awareof the complexity of reunification of looked after children so as tocontribute effectively to discussion and decision making.8.RBWM, BECHS and NHS should review the role of the looked after childrenhealth team to ensure that suitable health arrangements are made forchildren who are discharged from care as well as those who become or arecurrently looked after.9.a) The LSCB should make known the specific concerns about the impact ofthe slow transfer and summarising of GP records in this case to theDepartment of Health and ask it to take action to improve the system at anational level.b) The current standard for the transfer and summary of GP medicalrecords should be reviewed and a lower target time set should be set.c)NHS Berkshire should set challenging targets for electronic transfer ofpatient notes between GP practices in Berkshire. Progress should bereported regularly to senior managers in the NHS and as appropriate tothe LSCBd) Training and briefing sessions arising from this SCR should emphasisethe impact of this issue on children and the vulnerability of GPs who donot take steps to improve their systems for transferring andsummarising children’s records.10.BECHS should give clear guidance to health visitors on the use of workdiaries to record information about service users and contacts with otherprofessionals.11.BECHS should provide a full report of the current capacity of the healthvisiting service to the LSCB identifying implications for safeguarding andindicating the steps being taken to recruit health visitors and to mitigatethe impact of staff shortages.16512.BECHS should publicise the arrangements for its child health clinics toother professionals working with vulnerable children, including the practiceof self weighing.13.RBWM should publicise the role of Access Officer in the social care referraland assessment service to all other professionals working with vulnerablechildren.14.BECHS should review the current arrangements for child health clinics inthe light of the findings of the SCR.Health Overview Report - NHS Berkshire15.Providers of child protection training to staff in the health services acrossBerkshire must provide assurance to the Local Safeguarding ChildrenBoards and to NHS Berkshire that strategies are developed to evaluateand assess the impact of child protection training.16.BHFT must review the clinical supervision policy specific to child protectionto include the requirement for discussion about children born followingconcealment of a pregnancy and also children returned to their birthfamilies.17.Midwifery services should consider the implementation of clinicalsupervision specific to child protection for midwives.18.Training is commissioned to support health visitors to undertake fullyinformed risk assessments which follow with appropriate actions andidentified expected outcomes for children.19.Quality performance indicators to include a range of measures such asaudits of standards and outcomes for children must be developed by thePCT for all contracted health services, including GP services, to assure thePCT, as the current commissioners of health services, that robustmechanisms are in place to support health professionals in theidentification of families with vulnerable children and risks to the childrenare rigorously managed.20.The LAC Team in BHFT undertakes the self assessment tool offered byNICE Public Health Guidance 28 (2010) to benchmark the current healthservices for looked after children alongside the services offered byChildren’s Social Care.Berkshire Healthcare NHS Foundation Trust21.All key practitioners directly and indirectly involved in the IndividualManagement Review are debriefed and informed of the review findings.22.BHFT procedures will mirror updated LSCB pre-birth procedures andinclude specific information and action to take in the event of a23.All health visiting teams will be briefed about action take in the event ofobserved bruising on an infant.24.A pathway will be developed for specific action to take in the event of anobserved injury on a baby, infant or child.25.Health visiting teams will be briefed on current research and the potentialimpact concealed pregnancies may have on the welfare of children at theAnnual Safeguarding Forum November 2011.16626.Families in which a child has moved home following foster placement willbe targeted for extra intervention, including monitoring the child’s healthand development.27.Recommendations from this review will be incorporated within practiceguidance for health visitors and disseminated to health visiting teams.28.There will be a review of ‘flagging’ systems used within the Personal ChildHealth Record and a review of professional input at ‘self-weighing’ clinics.29.A pathway will be developed for the transfer of records between healthvisiting teams.30.The revised health visiting documentation will include recommendationsfrom the individual management reviewHeatherwood & Wexham Park Hospitals NHS Foundation Trust31.HWPHFT should review its policy and procedure to incorporatemanagement of concealed pregnancy.32.HWPHFT should review its current procedures on the information pathwaybetween maternity services and community practitioners to ensure it is fitfor purpose. This should include senior managers and practitioners acrossthe service.33.HWPHFT’s Safeguarding children training should emphases the importanceof information sharing with other agencies e.g. GPs, Health Visitors, LACNurse, Social Care together with good practice examples.34.HWPHFT’s record keeping standard should ensure that information ofinteraction between child, parent (s) and other family members; isincluded in the patient record.35.HWPHFT’s should review its process for disseminating information to otheragencies.36.HWPHFT should use a standard checklist form that should be completedfollowing postnatal discharge of clients; and implement a sign off proformachecklist for completion following postnatal discharge of clients.37.HWPHFT should amend the record keeping standard to ensure thatreferrals to the local authority and other agencies are noted in the patientrecord.Primary Care38.GPs should organise a formal mental health assessment of any womanwho conceals a pregnancy, unless referral to mental health services hasalready been made.39.The Designated and Named Professionals should review clinical guidelinesfor bruising in infancy, and distribute any revision to all primary carepractices.40.All primary care practices should put in place processes to ensure all newpatients’ records have been received into the practice within three monthsof registration with the practices.16741.Berkshire Shared Services should improve uptake of electronic transfer ofrecords with Berkshire through GP2GP transfer.42.Primary care practices should be encouraged to use a generic emailaccount to enable them to share concerns about children and families withhealth visitors.Children’s Social Care Services, Royal Borough of Windsor &Maidenhead43.Social Care will compile and disseminate local good practice guidance forthe staff, including the provision of training on concealed pregnancy andbirth.44.Social Care Services and partner agencies involved with children who arein-patients in health setting should agree a protocol to ensure thatappropriate services are invited/involved in discharge planningarrangements.45.Social care should ensure that all relevant agencies involved with childrenwho are discharged from the care of the Local Authority should be invitedto attend/actively involved in discharge planning arrangements.46.Social Care to ensure, as per regulations and guidance, that all childrenwho are Looked After by the Local Authority should have a comprehensiveCore Assessment.47.Social Care to ensure that internal referral systems in PARIS IntegratedChildren’s System are fully understood by managers, and implemented ina timely fashion.48.Social Care teams should ensure that formal letters, as per regulationsand guidance, are sent to key agencies informing them when social careinvolvement is ending.49.Social Care teams should ensure that, as per regulations and guidance, allchildren with Looked After status should be considered as a child in needwhen discharged from care for at least a three month period.50.Social Care and partner agencies will agree a step-up/step-down protocolconcerning the use of the CAF.51.Social Care Referral and Duty Team to establish written guidance for roleof Access Officer, particularly in relation to contact/ referral arrangements.52.Social Care to ensure that partner agencies are aware at the point ofcontact that the Access Officer in Referral and Duty Team is not a qualifiedsocial worker.53.Social Care to ensure that all aspects of learning regarding legal adviceand contact with extended family members, for children who may beadopted, is incorporated into local policy and practice.54.Social Care to ensure that case file and supervision recording policy andpractice is reviewed to ensure that case file recording is comprehensiveand contemporaneous.55.Protocol between social care and local CAFCASS service concerningnotifications for children relinquished for adoption to be established andimplemented.168Family Support Service, Royal Borough of Windsor & Maidenhead56.FSS standards of practice are developed clarifying which injuries in infantsshould trigger a referral to social care.57.Children’s centres review their record keeping template and processes forincidents/concerns.58.Clarification is provided for children’s centres on what to do if a member ofthe public raises safeguarding concerns about a child.59.The Parenting Team review their referral processes for early interventionparenting groups.60.Mechanisms to ensure greater oversight of children’s centres’ safeguardingpolicies are developed.61.The FSS Safeguarding Policy and Procedures is fully implemented acrossthe whole service.62.Recruitment and professional support for Children Centre Coordinators inRBWM managed children’s centres are reviewed.63.Training is provided for FSS managers on the role of supervision insafeguarding.64.Procedures for accessing Level 1 Safeguarding training are clarified andaudit processes strengthened.65.A standardised FSS induction process is implemented and monitored.169ADDITIONAL RECOMMENDATIONS MADE BY THE OVERVIEW REPORT AUTHORAND THE SERIOUS CASE REVIEW PANELWhy is a recommendationrequired?Recommendationmade toIntended impact –local or nationalRecommendation1.The response of professionals tobruising of an infant wasinadequate and led to failures toprotect EYLSCBBerkshireThe LSCB should oversee the productionof the proposed ‘pathway’ for themanagement by health professionals ofbruising so as to ensure that it isconsistent with sound multi-agency childprotection practice.2.The quality of the health visitornew birth assessment was poorin this case. Assessments of thehealth needs of infants in thecontext of wider familyfunctioning are a criticalopportunity to identify needs andrisks to children.BHFTEast BerkshireBHFT should establish the quality of newbirth assessments in a sample of casesgiving particular emphasis to the widerfamily, social and environmental issuesthat are highlighted in the national andlocal guidance.3.The father was not engaged fullyin the work by staff in anyagency. None of the professionalswho received information fromhim showed sufficient curiosityabout the needs of his childrenand the wider familycircumstancesLSCBWindsor andMaidenhead – allagenciesThe LSCB should use ensure that agenciesimprove their engagement with fathersand other male carers in all aspects ofchild protection work.4.The significance of two concealedpregnancies was underestimated.A number of agencies believethat their staff need moreguidanceLSCBWindsor andMaidenhead – allagenciesThe LSCB should produce multi-agencyguidance on the assessment andmanagement of need and risk where therehas been a denied or concealedpregnancy.170Why is a recommendationrequired?Recommendationmade toIntended impact –local or nationalRecommendation5.The design of the PCHR impairedthe easy access to importantinformation about the child’shistory.Doctors are believed not to makefull use of the PCHRAll health agenciesEast BerkshireHealth commissioners and provider trustsshould review the current design and useof the PCHR.6.The risks associated with the‘reunification’ of EY wereunderestimated by the localauthority and staff did not applyrelevant knowledge of this issueRBWMWindsor andMaidenheadThe local authority should ensure that allrelevant staff are made familiar withrelevant research on reunification and areable to apply it.7.There was no multi-agencyassessment of the risks of‘reunification’Healthcommissioners andprovider trustsBerkshireHealth commissioners and provider trustsshould ensure that professionals who maybe involved in the reunification ofvulnerable children are aware of thecomplexity of reunification of looked afterchildren so as to contribute effectively todiscussion and decision making.8.The LAC health team played noeffective role in the discharge ofEY to the care of his mother as itwas not part of the brief of theteam to do so.RBWM and BECHSWindsor andMaidenheadRBWM, BECHS and NHS should review therole of the looked after children healthteam to ensure that suitable healtharrangements are made for children whoare discharged from care as well as thosewho become or are currently looked after.9.The system for the transfer andsummary of GP records impairedthe practice in this case and isnot fit for purpose in relation tothe needs of vulnerable childrenDepartment ofHealthNational9 a) The LSCB should make known thespecific concerns about the impact of theslowtransferandsummarisingofGPrecords in this case to the Department ofHealthandaskittotakeactiontoimprove the system at a national levelNHS BerkshireBerkshire9 b) The current standard for the transferandsummaryofGPmedicalrecords171Why is a recommendationrequired?Recommendationmade toIntended impact –local or nationalRecommendationshould be reviewed and a lower targettime set should be set.NHS BerkshireBerkshire9 c) NHS Berkshire should set challengingtargets for electronic transfer of patientnotes between GP practices in Berkshire.Progress should be reported regularly toseniormanagersintheNHSandasappropriate to the LSCBLSCBWindsor andMaidenhead9 d) Training and briefing sessions arisingfromthisSCRshouldemphasisetheimpact of this issue on children and thevulnerability of GPs who do not take stepsto improve their systems for transferringand summarising children’s records.10.Many important contacts withBECHS staff were only orprimarily recorded in their ‘workdiaries’.BECHSEast BerkshireBECHS should give clear guidance tohealth visitors on the use of work diariesto record information about service usersand contacts with other professionals11.The issue of health visitorrecruitment and standards ofpractice is of great significancefor safeguarding services. In thecircumstances the LSCB needs tobe satisfied that it understandswhat the impact of the shortfallof health visitors is onsafeguarding services, the stepsthat the managing trust is takingto mitigate risk and the progressbeing made in recruitment.BECHSEast BerkshireBECHS should provide a full report of thecurrent capacity of the health visitingservice to the LSCB identifyingimplications for safeguarding andindicating the steps being taken to recruithealth visitors and to mitigate the impactof staff shortages12.The current arrangements forcommunity based child healthclinics (including self weighing)BECHSEast BerkshireBECHS should publicise the arrangementsforitschildhealthclinicstootherprofessionalsworkingwithvulnerable172Why is a recommendationrequired?Recommendationmade toIntended impact –local or nationalRecommendationneed to be understood by otherprofessionals working withvulnerable childrenchildren,includingthepracticeofselfweighing.13.The role of Access Officer in thesocial care referral andassessment service was poorlyunderstood.RBWMWindsor andMaidenheadRBWM should publicise the role of AccessOfficerinthesocialcarereferralandassessmentservicetoallotherprofessionalsworkingwithvulnerablechildren.14.The circumstances in which staffwere working in the health clinicin which EY and his family wereseen shortly before he wasseriously injured were notconducive to the identificationand assessment of risk tovulnerable children, particularlywhen taken in combination withthe current design and use of thePCHR.BECHSBerkshireBECHSshouldreviewthecurrentarrangements for child health clinics in thelight of the findings of the SCR.173Appendix ITerms of reference of SCRThe full terms of reference of the SCR are set out in a separate document. The focusof the SCR is as followsThe review will address all of the areas required by Working Together to SafeguardChildren – 2010. In addition it will focus on the following:1. Identify any historical information (prior to 1 July 2008) on the familymembers that may have impacted on the parenting capacity of the mother,GY, and father, PO;2. Establish the quality of assessment of circumstance relating to either andboth children and their family;3. Identify factors that helped or hindered the engagement with the family;4. Establish how well agencies identified and responded to children’s injuriesand other indicators of harm;5. Analyse the extent of, and professional understanding of, the support fromthe extended family;6. Establish what advice was given and what services were offered to theparents concerning adoption issues;7. Establish what risk factors in the family were known to agencies during theperiod under review;8. Establish whether staff and managers dealing with the family had therequisite skills, knowledge and experience to respond to the circumstancespresented by the family;9. Establish whether sufficient attention was given to issues relating thereunification of EY and his mother following the period when he was infoster care.The review will consider in detail relevant events from 1 July 2008, the perceivedstart of the pregnancy of the elder child and 18 March 2011 prior to theinvolvement of emergency service.The review will consider the circumstances of both children.174Appendix IISCR PANEL MEMBERSHIPAgencyDesignationDonald McPhail, ChairChair of LSCBNHS Berkshire EastDesignated PaediatricianRoyal Borough of Windsor andMaidenhead CouncilHead of Services to Children andYoung PeopleRoyal Borough of Windsor andMaidenhead CouncilHead of Safeguarding andSpecialist ServicesThames Valley PoliceDetective Chief InspectorThames Valley Probation TrustSenior Probation OfficerBHFT (Community Health Services)Assistant Director, Children’sServicesATTENDEES AT SOME OR ALL PANEL MEETINGSProfessional advisor to the panelLSCB Business ManagerDesignated Nurse Child Protection, NHSBerkshire.Health Overview Report AuthorAdministrationLSCB Secretary175Appendix IIIList of documents provided for the SCRIndividual Management ReviewsBerkshire East Community Health Services 49 (which provided thehealth visiting service)General Practice (covering the services provided by three GPpractices)Heatherwood and Wexham Park Hospitals NHS Foundation TrustRoyal Borough of Windsor and Maidenhead CounciloSafeguarding Services 48 (which provides local authoritychildren’s social care services)oServices for Families (which provides and commissionsChildren’s Centre services and other family services)Background reports on agency involvementSouth Central Ambulance ServiceCombined Legal Services (hosted by Reading Borough Council)48 This service is referred to as ‘children’s social care’ in the body of the report49 Berkshire East Community Health Services (BECHS) merged with Berkshire HealthcareTrust (BHFT) during the course of this review. References to BECHS and BHFT should betreated as synonymous in all documents related to this review.176Appendix IVAgencyEvaluation of the contribution made by the individual management reviews (IMR)to the findings of the SCR1.Berkshire EastCommunity HealthServicesThe IMR was prepared by the Named Nurse Team Lead Child Protection for the trust. Shewas not involved in the case and had no line management responsibility for the servicesprovided for the family. She has considerable experience as a child protection specialist. Thereport was authorised by the Managing Director Berkshire Healthcare NHS Foundation Trust- Community East.The IMR provides a very detailed account of the involvement of health visitors and thelooked after children health team. It makes a thorough appraisal of the strengths andweaknesses of the input of the services concerned. This IMR has enabled the SCR tounderstand the settings within which health visiting teams are working and the impact thatthis may have had on their work. The IMR also deals openly with the difficulties posed by thelarge caseloads of health visitorsThe recommendations of the IMR follow from the learning. The SCR overview report hasmade additional recommendations which go beyond those contained in the IMR because itwas able to locate the impact of shortcomings in the services provided by health visitors andthe LAC team within the wider context of the case history.The IMR makes clear how information was obtained from staff and records. The IMR statesthat ‘each health visitor had managerial presence at the interviews’. It is not entirely clearwhat this means, however the SCR author is concerned that this may not be the best way toenable professionals to participate fully and freely in process whose aim it to learn lessons. Itis suggested that the trust should review this process in the event that future IMRs arerequired.2.General PracticeThe IMR was prepared by the Named Doctor Child Protection Berkshire East PCT-Bracknelllocality. The author is also an experienced GP partner. The report is authorised by theMedical Director Berkshire PCTs Cluster. The author was not involved in the case and had noline management responsibility for the services provided for the family.The IMR provides a very detailed account of the contacts that a number of GPs had with the177AgencyEvaluation of the contribution made by the individual management reviews (IMR)to the findings of the SCRchildren and their parents. In particular there is a detailed account of the contact that theyounger child had with his GP in which bruises were identified. This has enabled the SCR tounderstand the circumstances in which this happened and the judgement that the GP made.It is clearly recognised that the findings of this report and those of the health overviewreport and the SCR overview report are in parts at odds with one another. The overviewreports are clear that this presentation should have been referred to the local authority or atleast for an urgent paediatric assessment. The IMR focuses on the perspective and normalworking practice of GPs and seeks to understand why it was that the GP acted as he did. Itrecognises that GPs are much more comfortable making referrals to medical colleagues thanto social care about bruised children. This is not what the procedures say should happen,however recognising this is absolutely vital learning for the LSCB. The IMR and the overviewreports all make recommendations, complementing one another, which address this issue.The different perspectives contained in the IMR and the overview reports complement oneanother and enable the SCR as a whole to understand the pressures that some healthprofessionals feel when considering the need to refer children to social care and how this canbe addressed in day to day working. This leads to recommendations in all of the reports forwork on a ‘bruising pathway’.The GP IMR also recognises that delays in transferring and summarising records had animportant impact on the case history. It is extremely helpful that this issue as beenhighlighted. In relation to this the recommendations of the SCR overview report go beyondthose made in the IMR, recognising the national context of this problem and the need tomake challenging recommendations to the NHS locally and nationally. This is understandablebecause it is only when an overview of this issue is available from the case history as awhole that its significance in the outcome of the case is apparent.3.Heatherwood andWexham ParkHospitals NHSFoundation TrustThe IMR was prepared by the Lead Named Nurse for Safeguarding Children for the Trust.The Lead Named Nurse had no direct or indirect involvement to the case or line managementresponsibility for the staff involved, and is thus independent from the case. The IMR isauthorised by the Director of Nursing.The IMR provides an account of the brief contact that the trust had with the children andparents. It is hampered by the fact that on in relation to the younger child contact was only178AgencyEvaluation of the contribution made by the individual management reviews (IMR)to the findings of the SCRvery brief and no postnatal records could be found.Unusually there were two concealed pregnancies which meant that the mother had noantenatal care. This would normally be the period in which midwives establish informationabout risk factors. The IMR identifies that staff identified the basic level of concern arisingfrom the concealment of pregnancies and made appropriate referrals to the local authority inrelation to both children. Beyond this however midwives played very little role in activelyassessing the circumstances in any depth, for example the reasons for the denial orconcealment of pregnancy. There were shortcomings in the information shared with otherhealth professionals.These findings are reflected in wide ranging recommendations made by the IMR aboutrecording and the entire information pathway between antenatal services and communityhealth services.4.Royal Borough ofWindsor andMaidenhead CouncilServices for FamiliesThe IMR was prepared by the Family Support Manager. The author had had no contact withthe family and no direct involvement in this case during the timeframe covered by thisreview. However she manages a large service area within the local authority which includesthe Children’s Centre programme and the Parenting Team. She has also had someinvolvement in human resources procedures in relation to staff who feature in this review. Assuch the author is not independent of the line management of the case, though she is in asenior position with a degree of distance from the events under review.The SCR Panel and the independent author were aware of this once the first draft of thereport had been prepared and aware of the potential for there to be a conflict of interests.However the SCR panel and the independent overview report author are of the view that thereport is a frank and insightful one which has not been compromised by the position of theauthor in the local authority management structure. In the view of the panel and theindependent SCR author the report fulfils the requirements of Working Together because itlooks ‘openly and critically at individual and organisational practice and at the context withinwhich people were working to see whether the case indicates that improvements could andshould be made and, if so, to identify how those changes can be brought about’ (paragraph8.34). The report has been closely scrutinised both within the SCR process and within thelocal authority to ensure that it meets the requirements of objectivity.179AgencyEvaluation of the contribution made by the individual management reviews (IMR)to the findings of the SCRThe findings of the review have been of great value to the SCR. The review has describedand analysed practice and service provision at a detailed and ‘micro’ level carefullyreconstructing through interviews and records the events under consideration. This is aconsiderable strength because it has enabled the SCR to understand how – in the day to dayworking of staff in the children’s centre – opportunities to refer the child were missed.However it also offers strategic oversight of the way in which the children’s centre servicehas been developed and scope of responsibility of middle managers in the service and theculture of management in the service. There are some particularly valuable insights such asfor example how the focus on performance management led to individual cases not beingdealt with properly in supervision. The report proposes detailed solutions to the problemsidentified in the recommendations that are made. It is likely that the detailed workingknowledge brought to bear on the analysis has outweighed any disadvantages that arisefrom being part of the service that is being scrutinised.5.Royal Borough ofWindsor andMaidenhead CouncilSafeguarding ServicesThe IMR was prepared by the Safeguarding Service Manager who is responsible for QualityAssurance, Development, and Planning. The author was not involved in the case and had noline management responsibility for the services provided for the family. The review wasauthorised by the Head of Safeguarding and Specialist Services.The IMR provides an account of the involvement of the local authority safeguarding servicewith both of the children and their parents. It identifies the key decisions and actions of thesocial care staff involved and the underlying rationale for them. Through interviews with staffand review of records the IMR identifies the key belief of local authority staff. This was that itwould be a good outcome to the case if the younger child were to be returned to the care ofhis mother. The IMR identifies how local authority staff did not recognise the manyconcerning factors in the case history pointing to the mother’s lack of interest in her youngerchild. It demonstrates clearly the need for a child in need plan to support and monitor thechild when he was placed in the care of his mother.180Appendix VPolicy and research referencesResearch and resources referred toBrandon M, Belderson P, Warren C, Howe D, Gardner R, Dodsworth J, andBlack J (2007) Analysing child deaths and serious cases through abuse andneglect: what can we learn? A biennial analysis of serious case reviews 2003-2005. DfESBrandon et al, (2009), Understanding Serious Case Reviews and their Impacta Biennial Analysis of Serious Case Reviews 2005-07 DCSFCox, J. L., Holden, J. M., & Sagovsky, R. (1987). Detection of postnataldepression: Development of the 10 item Edinburgh Postnatal DepressionScale. British Journal of Psychiatry, 150, 782-786.Sidney Dekker, The Field Guide To Understanding Human Error, Ashgate(2006)Department of Health (2010) Healthy Child Programme- Pregnancy and theFirst Five Years of Life.http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_118525.pdfFarmer, E., Sturgess, W., and O’Neill, T (2008) ‘Reunification of looked-afterchildren with their parents: Patterns, Interventions and Outcomes”, ResearchBrief for DCSF, October 2008. (University of Bristol)Friedman, Henegan and Rosenthal, (2007) ‘Characteristics of women whodeny or conceal pregnancy’ Psychosomatics, 48.2 March – April 2007NICE (2010) Promoting the Quality of Life of Looked after children and youngpeople, NICE / SCIE public health guidance No 28P Reder, S Duncan and M Gray, (1993) Beyond Blame – Child AbuseTragedies Revisited, Routledge.Unannounced inspection reports on RBWM http://www.ofsted.gov.uk/local-authorities/windsor-and-maidenheadDavid Woods et al, Behind Human Error, Ashgate (2010) second edition;Procedures and process governing the conduct of the Serious CaseReviewHM Government, Working Together to Safeguard Children – 2010.Berkshire Child Protection Procedureshttp://berks.proceduresonline.com/chapters/p_ser_case_rev.html181Appendix VIEdinburgh Depression Scale(or Edinburgh Postnatal Depression Scale)DATE COMPLETED_____________As you have recently had a baby, we would like to know how you are feeling.Please CIRCLE the number next to the answer which comes closest to how youhave felt IN THE PAST 7 DAYS, not just how you feel today.IN THE PAST 7 DAYS1. I have been able to laugh and see thefunny side of things.0 As much as I always could.1 Not quite so much now.2 Definitely not so much now.3 Not at all.2. I have looked forward with enjoyment tothings.0 As much as I ever did.1 Rather less than I used to.2 Definitely less than I used to.3 Hardly at all.3. I have blamed myself unnecessarily whenthings went wrong.3 Yes, most of the time.2 Yes, some of the time.1 Not very often.0 No, never.4. I have been anxious or worried for no goodreason.0 No not at all.1 Hardly ever.2 Yes, sometimes.3 Yes, very often.5. I have felt scared or panicky for no verygood reason.3 Yes, quite a lot.2 Yes, sometimes.1 No, Not much.0 No, not at all.182IN THE PAST 7 DAYS6. Things have been getting on top of me.3 Yes, most of the time I haven'tbeen able to cope at all.2 Yes, sometimes I haven't beencoping as well as usual.1 No, most of the time I havecoped quite well.0 No, I have been coping as wellas ever.7. I have been so unhappy that I have haddifficulty sleeping.3 Yes, most of the time.2 Yes, sometimes.1 Not very often.0 No, not at all.8. I have felt sad or miserable.3 Yes, most of the time.2 Yes, quite often.1 Not very often.0 No, not at all.9. I have been so unhappy that I have beencrying.3 Yes, most of the time.2 Yes, quite often.1 Only occasionally.0 No, never.10. The thought of harming myself hasoccurred to me.3 Yes, quite often.2 Sometimes.1 Hardly ever.0 Never.183Scoring and Other InformationResponse categories are scored 0, 1, 2, and 3 according to increased severity of thesymptom.Items 3, 5-10 are reverse scored (i.e., 3, 2, 1, and 0). The total score is calculated byadding together the scores for each of the ten items. Users may reproduce the scalewithout further permission providing they respect copyright (which remains with the BritishJournal of Psychiatry) quoting the names of the authors, the title and the source of thepaper in all reproduced copies.The Edinburgh Postnatal Depression Scale (EPDS) has been developed to assist primarycare health professionals to detect mothers suffering from postnatal depression; adistressing disorder more prolonged than the "blues" (which occur in the first week afterdelivery) but less severe than puerperal psychosis.Previous studies have shown that postnatal depression affects at least 10% of women andthat many depressed mothers remain untreated. These mothers may cope with their babyand with household tasks, but their enjoyment of life is seriously affected and it is possiblethat there are long term effects on the family.The EPDS was developed at health centres in Livingston and Edinburgh. It consists of tenshort statements. The mother underlines which of the four possible responses is closest tohow she has been feeling during the past week. Most mothers complete the scale withoutdifficulty in less than 5 minutes.The validation study showed that mothers who scored above a threshold 12/13 were likelyto be suffering from a depressive illness of varying severity. Nevertheless the EPDS scoreshould not override clinical judgement. A careful clinical assessment should be carried outto confirm the diagnosis. The scale indicates how the mother has felt during the previousweek, and in doubtful cases it may be usefully repeated after 2 weeks. The scale will notdetect mothers with anxiety neuroses, phobias or personality disorders.Instructions for users1. The mother is asked to underline the response which comes closest to how she hasbeen feeling in the previous 7 days.2. All ten items must be completed.3. Care should be taken to avoid the possibility of the mother discussing her answers withothers.4. The mother should complete the scale herself, unless she has limited English or hasdifficulty with reading.5. The EPDS may be used at 6-8 weeks to screen postnatal women. The child healthclinic, postnatal check-up or a home visit may provide suitable opportunities for itscompletion.Cox, J. L., Holden, J. M., & Sagovsky, R. (1987). Detection of postnatal depression:Development of the 10-item Edinburgh Postnatal Depression Scale. British Journal ofPsychiatry, 150, 782-786.184Appendix VIIHeight and weight chart from Personal Child Health Record of EY19 November – EY moved to live with motherAll previous weights on 75th centile30 November 2010 Child health clinic 8.9KgAge 32 weeks 75th centile19 January 2011 GP developmental check 9.0 KgAge 38 weeks mid point 50th – 75th centile17 March 2011 Child health clinic 9.0KgAge 47 weeks mid point 25th – 50th centileIt is important to note that this is a substantially enlarged version of part ofthe original document185Appendix VIIIBerkshire combined safeguarding proceduresSection 4.6 on ‘bruising’ - current at January 2011Children can have accidental bruising, but the following must be considered as highlysuspicious of a non accidental injury unless there is an adequate explanation provided andexperienced medical opinion sought:Any bruising or other soft tissue injury to a pre-crawling or pre-walking infant or nonmobile disabled childBruising in or around the mouth, particularly in small babies which may indicate forcefeeding2 simultaneous bruised eyes, without bruising to the forehead, (rarely accidental,though a single bruised eye can be accidental or abusive)Repeated or multiple bruising on the head or on sites unlikely to be injuredaccidentally e.g. the backThe outline of an object used e.g. belt marks, hand prints or a hair brush (a pinchcauses small double bruises, a punch or kick causes an irregular bruise with a palercentre, gripping causes ovals from fingertips or lines between fingers)Linear pink marks, haemorrhages or pale scars may be caused by ligature, especiallyat wrists, ankles, neck, male genitaliaBruising or tears around, or behind, the earlobe/s indicating injury by pulling or twistingor slappingBruising around the faceBroken teeth and mouth injuries (a torn frenulum - the flap of tissue in the midlineunder the upper lip - is highly suspicious in non-mobile children, but frequently occursaccidentally in mobile children)Grasp marks on small childrenBruising on the arms, buttocks and thighs may be an indicator of sexual abuse