Death of a 4-month-old baby in Summer 2013. Baby V was admitted to hospital after suffering a cardiac arrest at home and died the next day. Hospital staff were told that Baby V had choked on food; tests later revealed a rib fracture, which occurred somewhere between 10 days and 3 months prior to the incident, a linear skull fracture and brain damage due to lack of oxygen. Father was found responsible for causing the injuries and convicted. Family were known to universal services only. Mother had reported concerns to professionals that father was not bonding with Baby V and that Baby V was pinching itself, leaving scratches and bruising to its face. Identifies four key findings: insufficient professional awareness and understanding of how to respond to bruising in non-mobile infants; need for greater clarity of the level of child protection training required by professionals within different agencies and how this is monitored and compliance measured; need for respectful scepticism; and need for improved communication between GPs and community care. Makes various recommendations in relation to the findings.
      
 Title:  Serious case review: on the services provided for Baby V. LSCB: Hampshire Safeguarding Children Board Author: Alan Bedford 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.                                          1       SERIOUS CASE REVIEW  On the services provided for Baby V   IN STRICT CONFIDENCE  October 2013   updated July 2014                                                                   Independent Author: Alan Bedford                    2  Para  Page  SUMMARY 3    1 INTRODUCTION 5 1.1 Rationale for Serious Case Reviews (SCRs)  1.5 Terms of Reference   1.7 Summary of Circumstances Leading to the SCR 6 1.8 Anonymity  1.9 Family Details  1.10  Methodology  1.14 Independent Reviewer 7 1.15 Family Involvement  1.16 Introduction to the Review below     2 THE FACTS 8 2.1 Background  2.10 Opportunities 9    3 ANALYSIS and APPRAISAL 11 3.1 Introduction  3.2 Areas of Opportunity  3.3 Analysis by Agency 17 3.4 North Hampshire Urgent Care (NHUC)  3.5 General Practice 18 3.6 GP Communication out of hours 20 3.7 Southern Health NHS FT (SH) –Health Visiting  3.8 Solent NHS Trust 22 3.9 South East Coast Ambulance Service NHS FT (SECA)  3.10 South Central Ambulance Service NHS FT (SCAS) 23 3.11 Hampshire Police  3.12 Frimley Park Hospital NHS FT (FPH) 24 3.13 University Hospital Southampton NHS FT (UHS) 25 3.14 Removal of Life Support and Safeguarding Processes 26 3.15  Family Views     4 KEY FINDINGS 27 4.4 ‘Bruising in Children who are Not Independently Mobile Protocol’  4.5 Training 28 4.6  Scepticism and Challenge  4.7 Primary/Community Care Communications     5 CONCLUSION 30    6 COLLATED RECOMMENDATIONS 31     APPENDICES  App 1 Agency updates on Actions in Response to the SCR 33 App 2 Significant Events 41 App 3 Index of Acronyms 42                                                                         3           1 SUMMARY   i. As Serious Case Reviews (SCRs) are now published, this summary is not designed as a stand-alone as in the previous SCR “Executive Summaries”  but is a way of outlining the key facts, findings and recommendations from  the Review that may help the reader make good use of the more detailed report that follows.  ii. The Review is around the services provided to the family of a baby, called ‘V’ in this report, only a few months old, at the time of death. V was found to have a skull fracture, facial and body bruising, and a healed rib fracture. Unlike many SCRs, there were no indications from the background of either parent, or V’s older sibling, that V would be at any risk of violence. However, there were some indications during V’s lifetime that might have been explored further at the time.  iii. The family was not known to social services, and all dealings by the GPs (which were frequent), health visitors and midwives with the parents or the older child were not deemed to be out of the ordinary. Police and the GP were aware of some instability in the lives of the maternal grandparents (who provided the mother with much support), but there was no recorded involvement of children during these periods. The Review looks at whether knowledge of the instability should have been shared with health staff who worked with the children.  iv.  V was born by emergency caesarean section which the mother found very distressing but midwifery, in the mother’s opinion, helped her work through this.  v. The mother found V more difficult than her first child, and reported to family and 3, possibly 4, professionals that V got angry and the cheeks were pulled, causing scratches and bruises. She also told at least two that V was not bonding with the father. No professional who either heard about or saw bruises followed the agreed Hampshire protocol on what to do when there are bruises on a non-mobile baby, which is to alert social services and for there to be a paediatric examination.  The Review found that neither the nursery nurse (who was told of the bruising) nor the out of hours GP (who saw it) were aware of the protocol, nor were they trained sufficiently to be clear about what they should have done.  vi. The school heard about the bruising from mother at around the same time she was sharing with the GP the lack of bonding with father, and around the time the mother says she told a midwife or health visitor about the bonding, pinching and bruising. Had either of those who heard about the bruising in such a young baby told social services there may have been a pooling of information which would have brought those threads together.  vii. The day before the baby was admitted to hospital with what proved to be the fatal injuries, V was taken to an out of hours GP surgery very poorly. Two bruises on each cheek were immediately noticed and the pinching explanation was given. Other than asking the family GP Practice to monitor for further bruising no action was taken, which was in breach of a clear local protocol of which the GP was unaware. The GP also had no past experience of referring injuries to social services. As it was a bank holiday Sunday the message only got to the GP two days later when the surgery reopened, by which time V was on life support. The delay made no difference in this case, but might do in other cases. There is a recommendation about looking at safeguarding communications out of hours. The out of                 4  hours GP provider has acknowledged that at the time there was an assumption that GPs they employed would be sufficiently trained and experienced, and have now introduced mandatory evidence of safeguarding training.  viii. This Review identifies a number of areas which help understand individual staff actions by looking at the organisational context within which they work. The protocol about bruising in non-mobile babies, and updates, are not clear and not always easy to find so, even if aware of it, professionals might not always be clear to whom it applies and exactly how to follow it. There are recommendations about the review of, and implementation of, the protocol. Some staff are not receiving training to equip them for dealing with bruising in young babies, and there are recommendations about the Hampshire Safeguarding Children Board (HSCB) and member agencies having arrangements to monitor compliance with required training.  ix. Even putting to one side whether training was adequate, the opportunities for further consideration of what was happening in this family suggest that there may be some reticence to be sceptical about explanations, and to challenge. The HSCB will need to consider how widespread this is beyond this case, and there is a recommendation about agencies modelling a culture of proper challenge through the way they supervise staff.  x. There are also some illustrations of communications between GPs, and between GPs and community staff, which did not affect this case but which might benefit from further review.  xi.   The overall conclusion is that there were no historical warning signs that could have alerted staff, and  contacts with services were mainly unexceptional.  There were one or two opportunities which might have led to a helpful pooling of information that might have led to concern, and one opportunity which almost certainly would have led to intervention which would have protected the baby. All these instances need to be seen in the context of how individuals were prepared for their work.                                      5  1       INTRODUCTION  1.1   Rationale for Serious Case Reviews   1.2   Regulation 5 of the Local Safeguarding Children Board Regulations 2006 requires Local Safeguarding Children Boards (LSCBs) to undertake reviews of serious cases in accordance with procedures as set out in ‘Working Together to Safeguard Children’ (HM Government, March 2013), referred to here as WT2013.   1.3   When a child dies, and abuse or neglect is known or suspected to be a factor in the death, the LSCB should conduct a Serious Case Review (SCR) into the involvement that organisations and professionals had with that child and their family. WT2013 says SCRs should:   provide a sound analysis of what happened in the case, and why, and what needs to happen in order to reduce the risk of recurrence  (recommend) actions which  result in lasting improvements to services which safeguard and promote the welfare of children and help protect them from harm; and  (have) transparency about the issues arising from individual cases and the actions which organisations are taking in response to them, including sharing the final reports of SCRs with the public.  1.4 The Hampshire Safeguarding Children Board (HSCB) Chair decided in June 2013 to hold an SCR because the child in this case had died and abuse was suspected. This report and its recommendations were accepted in full by the HSCB on 14 October 2013, but the publication (of a slightly updated report) was delayed until September 2014 so as not to prejudice the criminal trial. There was one conviction, with the father found to be responsible for the injuries.  1.5 Terms of Reference (TOR): The LSCB set the following terms:    Identify and analyse key events/opportunities for assessments and decision making. Were any child care or safeguarding concerns recognised and responded to appropriately?  Identify and evaluate decisions, assessments and plans made and services offered by agencies in relation to members of the household. To what extent were the children’s needs, views and wishes taken into account?   Examine and analyse the level and effectiveness of exchange of information and communication between agencies and across areas. Identify any gaps which may have impacted upon assessment, service provision or outcomes.   Was the work in this case consistent with each agency’s and the LSCB’s policy and procedures for safeguarding and promoting the welfare of children and with wider professional standards?  Were there any organisational difficulties being experienced within or between agencies? Were these due to lack of capacity within the agency? Did any resourcing issues such as vacant posts or staff on sick leave have an impact on the case?  Highlight ways in which practice can be improved and make recommendations as appropriate.                  6  The time frame was from the mother’s first pregnancy to the death of V: late 2008 to early summer 2013  1.6 The author’s style is not to write overview reports using the headings in the TOR, but to get over the story and analysis in a way that suits the case, whilst ensuring the TOR questions are covered.  1.7 Summary of Circumstances Leading to the SCR:  Child V, who was not yet five months old, was admitted mid-morning to the local general hospital by ambulance after respiratory arrest at home. The presenting story was that V had choked on food. The baby was very seriously ill and close to death so was moved after two hours to a specialist hospital with a paediatric intensive care unit. V was artificially ventilated but treatment was withdrawn the following day and they died. Tests showed that V had suffered a rib fracture ten days to three months old, a linear skull fracture, and brain damage due to lack of oxygen and significant trauma.   1.8 Anonymity:  The details relating to the family and individuals are anonymised where possible. Specific dates, and dates of birth, are omitted to aid anonymity. Agency names are included, other than the School and GP Practice involved as that would make identification of family members much easier.  1.9 Family Details:  All are white British. Only relatives with whom the mother lived at some point within the timeframe are listed:  Mother   The mother of baby V Father    The father of W and V W           Their first child  V            Their second baby and the subject of this SCR Maternal grandmother (MGM) Maternal grandfather   (MGF)      The mother lived with her parents at the time of the first birth until W was several months old. She then lived alone with W until the father joined them in early 2012.  1.10 Methodology: Since the publication of WT2013, LSCBs have had flexibility on which method they use to undertake an SCR, as long as the method fulfils the principles set out in that guidance. This enables the method to suit the nature and complexity of a Review.  For this case, where there was limited agency involvement and most contact was with the NHS, the LSCB decided to engage a single reviewer to undertake the necessary inquiries without the full agency reports required under the previous methodology. A reviewer (see 1.14) was chosen with considerable safeguarding and NHS experience.  1.11 Agencies were asked to produce a chronology and a very brief summary of agency involvement, and thereafter the reviewer reviewed files and interviewed staff as seemed necessary from the emerging evidence. Any one interviewed had a copy of the interview notes to check accuracy and understanding. There was no SCR Panel for this SCR, but the standing SCR Subcommittee was kept appraised of progress and discussed the final draft. There was a small Reference Group of staff from involved agencies which the reviewer could use for advice or as a sounding board, and they offered feedback on an early draft and facilitated further inquiries.                   7  1.12 Agencies were asked at a senior level in August and September 2013 to check the draft for accuracy, and to submit a note on progress stemming from the developing learning in this case. See Appendix 1 which is updated to July 2014.  1.13 The following agencies participated in the SCR:  Agency Acronym Hampshire Safeguarding Children Board HSCB Frimley Park Hospital NHS Foundation Trust  FPH Hampshire Police Police Southern Health NHS Foundation Trust  SH Solent NHS Trust SOL University Hospital Southampton NHS Foundation Trust UHS South East Coast Ambulance Service NHS Foundation Trust SECA South Central Ambulance Service NHS Foundation Trust SCA North Hampshire Urgent Care NHUC Hampshire County Council   HCC Nursery School  Nursery North East Hampshire CCG  CCG Family GP Practice  Out of hours GP’s GP Practice   1.14 Independent Reviewer: Alan Bedford was selected by the HSCB to undertake this Review. He has a background in child protection social work with the NSPCC, where he was also national training manager. Following this he spent 18 years in the NHS, the majority of the time as a CEO in Trusts and Health Authorities. He now works independently as Alan Bedford Consulting on a range of issues from infection control, to emergency health care, to safeguarding. From 2009-11 he was Director of Safeguarding Improvement for NHS London, leading a London wide peer review programme, and from 2009-13 was chair of the Brighton and Hove Safeguarding Children Board. He has conducted a number of SCRs, is accredited as a SCIE Systems Reviewer and completed the 2010 and 2013 national training for SCR authors.  1.15 Family Involvement:  Both parents, and the maternal grandparents were invited to meet the reviewer, as they have a right for their views to be heard. The paternal grandfather declined as his concerns were outside the terms of reference. The father did not respond. The mother agreed, but only with the presence of her own mother. The HSCB Chair and Business Manager met the mother and her mother to feedback   the Review’s findings. The father and maternal grandfather did not accept an invitation for a similar discussion.  1.16 Introduction to the Review below: Compared to many SCRs the volume of agency involvement in this case was relatively small and the family was not known to Hampshire County Council’s Children’s Social Care. The review does not describe in day by day detail the ‘normal’ events but summarises them, and focusses on issues of concern or from which something can be learned. The review describes the facts, and then analyses   them with any necessary appraisal of agency actions. There is then an assessment of why events occurred as they did, followed by an overall conclusion. There are recommendations from this review for the HSCB and member agencies.                 8  2 THE FACTS  2.1 Background: This section describes what happened in the case, and includes events or knowledge that was or may have been relevant to looking at whether what happened might have been prevented, and to looking at the quality of services to the family. In order to aid anonymity, specific dates are not given, with the age of the baby at any given point being the main way of tracking developments. This section does not contain any judgement about agency performance.  2.2 As most events contained in the chronologies produced by agencies are ‘normal’ or not of concern, what is given here is firstly a summary of the known facts of the case, and then a summary of missed opportunities.  2.3 When the mother became pregnant with W, the midwifery services and then health visiting services had no cause for concern. The mother was living with her own parents and the mother felt this was a supportive environment. Ante natal contacts were normal and unexceptional, as was the birth and post natal visits by midwives and health visitors. .  2.4 The family had frequent contact with the GP surgery in the nearly four years between W’s birth and V’s death. Excluding tests and immunisations, the MGM had over 25 contacts, mother over 40, W around 15, with V only 2. The practice considered the level of contact to be unexceptional given the presenting problems, and not unusual amongst the Practice population. The Practice had no concerns that warranted passing information to midwives, health visitors and certainly not children’s social care. The mother was depressed for a brief period after W’s birth, but again the Practice GPs were clear that this was a fairly typical presentation and not one which would have led to any onward transmission of information.  2.5 With the second pregnancy (V) there was again nothing exceptional in antenatal care, but after admission to hospital in late 2012 for routine induction of the baby, a baby heart problem was identified and there was an emergency caesarean section which the mother found distressing, and led to debriefing discussions in hospital and then at home with the midwife. There were three midwife home visits, and none led to any concern. No risk factors were identified, although the routine domestic violence question was not asked as the father was present. There were three health visitor visits up to V being around 6 weeks, and apart from mother’s worry about the baby’s colic there were no concerns and nothing to suggest any risk to the baby.  2.6 V was taken to see a GP twice (other than for jabs). Firstly at two months, when mother was worried V was not bonding with father. She told the Review that V would only settle with her or the grandmother and no one else. Secondly, ten days before the final admission to hospital the mother raised concerns about V pulling at both cheeks. She says there was a facial bruise, but the GP Practice says they never saw any bruise.  2.7 Neither midwifery nor health visiting services were aware that in W’s second year, the mother’s mother, V’s maternal grandmother (MGM), had been involved in incidents of domestic abuse, and had related convictions for assault and criminal damage, connected to a drink problem. Two months later the MGM was arrested and her daughter, V’s mother, was slightly hurt. The MGM was cautioned for assault. This                 9  was after the mother and W had moved into their own accommodation. There had also been overdoses.  The GP practice was aware of the MGM being an alcoholic, either recovering or relapsing, and also treated her for depression. When V was a month old the GP recorded that the drinking was uncontrolled again. (Section 3 looks at whether any of this information should have been passed to health colleagues). Police attended the grandparents’ home twice the month before the fatal injuries as a result of a violent domestic dispute between the grandparents after the MGM had been drinking.  Adult Social Services were informed of both attendances. No children were reported as present in any police attendance at the grandparents’ home 2010-13.  2.8 The police had no other information of relevance about the parents.  2.9 The baby was taken to hospital, still not five months old, after the father called 999 saying V was not breathing, and may have choked. CPR advice was given. Ambulances attended, and V was taken to Frimley Park where abuse was not considered (and no history of trauma was given by the family) as frantic efforts to save V were undertaken. After two hours V was sent to Southampton where there is a paediatric intensive care unit (PICU) for more specialist care. The following morning, a healed rib fracture was identified and considerations that the symptoms were secondary to non-accidental injury (NAI) came to the fore. Ophthalmology tests showed retinal haemorrhages and a brain stem test showed clinical death at 1pm that day. During the later test, an examination of V’s head showed three bruises on the left face, a bruise by the clavicle, and another on the chest. Treatment was withdrawn early evening and V died. A CT scan showed a short linear skull fracture and brain haemorrhages. It is now known that there were three skull fractures, brain haemorrhages, three rib fractures, and multiple bruising. It is understood these covered up to four separate episodes.  2.10 Opportunities: There were several areas of opportunity to provide either wider professional thought about the risks, or protective action. Each relates to descriptions or sighting of marks on V explained by the parents as being self-inflicted. These are analysed in section three.  2.11 Nursery School:  When V was three months old the mother (without V) visited W’s nursery school for an open session and spoke to W’s nursery nurse. She told the nursery nurse that she was worried that she could not take V to be weighed as she was embarrassed by scratches and bruises. The mother said that the baby kept ‘hurting itself’. The nursery nurse says a report was written that V was scratching and pulling, leaving scratches and bruises to face arms and legs. (The mother told the Review that there were never bruises on arms or legs). She added that unlike W, V cried all the time. The nursery nurse advised her to take V to the GP. Later that day the mother did attend the GP surgery for V’s immunisations (by a nurse as usual), but no GP was seen.  2.12 Midwifery/Health Visitor: The mother indicated to the school and later to the SCR that ‘the health visitor’ already knew about the baby pulling at its self and had also advised her to see the GP. No health visitor who had seen the baby has recalled any discussion about the baby pulling/pinching itself, and it is possible that the call was to midwifery as mother said she called Frimley Park Hospital. Despite a full search no record or memory of such a call has been identified by the NHS. However the Police                 10  have found a record of a long call from mother to health visitors the month before speaking to the nursery nurse, so this may well have been the call mother described. The mother told the Review that the person she spoke to advised her that questions would be asked if the baby was taken to clinic, and they also discussed the use of mittens to prevent the baby hurting itself.  2.13 Relatives: At an unspecified time a relative, who had at one time child-minded W, said she had heard from other relatives that that V ‘had a temper’ and would scratch and leave marks. The relative had not seen the marks described.  2.14 GP: Four days before the admission to hospital with the fatal injuries V was taken to the GP with a mild viral infection, a blocked nose, and slightly off food. Also, ‘pulling at cheeks’ which the GP witnessed. The GP was unaware of what the mother had told the school described in 2.10 above. The GP said that at least the chest and face would have been examined and nothing suspicious was noticed. The mother told the Review that she pointed out a bruise on the baby’s chin to the GP.  2.15 Out of Hours GP:  The last professional contact that was a missed opportunity was the day before V’s admission with the fatal injuries. At around 1pm the mother called 111 from the MGM’s home, with the presenting complaint being a cough and refusing food. She was advised she needed to see a GP in 12 hours, and as it was a Sunday she was called an hour later by the out of hours GP. Hearing of the cough and refusing food the parents were asked to attend the out of hours GP centre at Frimley Park Hospital run by North Hampshire Urgent Care (NHUC- a not for profit organisation commissioned by the NHS). The parents took V to Frimley Park Hospital straight away.  2.16 The out of hours GP immediately noticed two small round bruises (four in all) on either cheek, and asked for an explanation. The parents told the GP that V had been pinching cheeks in anger. Whilst the GP was suspicious, no referral was made, and the notes asked for the GP to be faxed as well as getting the automatic notification so the family’s Practice would be aware of the request to ‘watch for further bruising’. The mother was concerned V was losing weight, and the GP advised that V be taken to the health visitor for weighing. Medication was prescribed. As the examination took place on a bank holiday Sunday, neither fax nor normal electronic transmission of the event were received until the Tuesday as the GP surgery was closed, and V was already in hospital on life support.                               11  3 ANALYSIS AND APPRAISAL  3.1 Introduction: This section aims to assess how well agencies worked around this family by analysing their contact with the family. This involves looking at individual work in the systemic context within which they work so it becomes more understandable. The section first looks at the two areas of opportunity, then at learning by agency which included obtained in the review but which may not have had an impact on this particular case, but might on future cases. Section 4 identifies any overarching themes. Recommendations by the author from this review are in bold, and listed together in Section six.  3.2 Areas of Opportunity: The aim is to look in more detail at these areas, look at what happened, or should have happened, and explore why.   3.2.1 The mother says that when V was around two months she called ‘a health visitor’ at ‘Frimley Park’ (FPH) and told them about the pinching and marks, and lack of bonding with father. Midwives, not health visitors are based at Frimley Park. A call to midwifery has not emerged from a list of contacts submitted by FPH and a search has not identified any record. There is though a phone log of a call to health visitors by mother at the right time, so the call was probably made to them although, if it was, nothing was recorded. If the account is true, then it would have been inappropriate not to record this in the notes. The mother says she was warned that questions would be asked if the baby was seen and the use of mittens was discussed. Also, and again assuming marks/bruises were mentioned (and especially in the context of discussing a bonding problem), the call should have led to some sort of action. This could have included passing the information to the GP who may have had other relevant information, and the health visitor on whose books was V.  At about this time the mother told the GP about V not developing an attachment with the father.   3.2.2 Bruising Protocol: In Hampshire at the time of the baby’s death there was an  April 2010 protocol called ‘Bruising in Children who are Not Independently Mobile’ which is produced and agreed by the four separate Safeguarding Children Boards in Hampshire (“4LSCB”- Hampshire, Southampton, IOW and Portsmouth). The purpose of the Protocol itself can be summed by this extract “A bruise must never be interpreted in isolation and must always be assessed in the context of medical and social history, developmental stage and explanation given. A full clinical examination and relevant investigations must be undertaken”. It also emphasises the non-discretionary nature of the policy. It requires, regardless of explanation, a referral to the Council Children’s Services for any bruising on a non-mobile baby and that social workers should then arrange a paediatric examination.  3.2.3 That version was marked ‘for review 2011’ and is under review now although this had not been completed by the approval of this SCR in October 2013. It applies to all front-line clinical staff, and does not say it applies to non-clinical staff.  Note: Since the completion of this SCR a reviewed and single version of the protocol has been produced.  3.2.4 However, there were two guidance updates. Both refer to the ‘3B Protocol’ which from deduction refers to the logo at the top of the guidance which says “Baby, Bruising, Be Aware’. However the Protocol to which the update guidance refers makes no reference to 3B so this must have been confusing. The first one, dated                 12  May 2010, which could be found in the 4LSCB Procedures on line, but not in the HSCB Procedures, says it is for ‘health and social care professionals’ and results from concerns that full protocol might lead to over referral. However, the only judgement allowed is to decide if it is a bruise, if so the protocol must be followed. In my opinion, it confuses the guidance as it allows children’s services and a paediatrician not to have an examination, whilst the full protocol requires a paediatric examination and the guidance to two distinct professional groups is not clear to whom any particular section relates.  3.2.5 The second update is in the HSCB Procedures but not the 4LSCB Procedures.  This is headed “Guidance for Partner Organisations’ and dated July 2010. It asks all members of the 4 LSCBs to train it staff to be aware of the Protocol and use it. In my opinion this muddies the waters further. This is because the main protocol requires any health professional seeing bruising in a non-mobile baby to refer to social services who then arrange a paediatric examination. This update Guidance asks partner organisations, which means in this context, everyone other than health not to refer to social services (Children’s Services), but to refer to a health professional      (anyone from a GP to A&E to a midwife). That health professional, if they follow the main Protocol would have to refer to Children’s Services, which appears to add an unnecessary step.  3.2.6 This is because a health professional has no discretion under the main Protocol but to refer to Children’s Services – which the partner organisation could have done direct. (Yet another document- the ‘Protocol Summary’ says clearly that such bruising ‘…..should result in an immediate referral to Children’s Services and an urgent paediatric opinion’).  3.2.7 The danger of having a range of documents, each with a slightly different take on what has to be done, increases the likelihood that professionals do not refer and that they might make a judgement that referral is not needed. Such individual decision would be contrary to what the Protocol Summary clearly states ‘It is the responsibility of Children’s Services and the local acute or community paediatrician to decide whether bruising is consistent with an innocent cause or not’ and by implication no one else’s decision.  Note: Since the completion of this SCR a reviewed and single version of the protocol has been produced.  3.2.8 As said above, the purpose of the Protocol itself can be summed by this extract “A bruise must never be interpreted in isolation and must always be assessed in the context of medical and social history, developmental stage and explanation given. A full clinical examination and relevant investigations must be undertaken”. It also emphasises the non-discretionary nature of the policy. It requires, regardless of explanation, a referral to the Council Children’s Services for any bruising on a non-mobile baby and that social workers should then arrange a paediatric examination.   3.2.9 In the case of the call to ‘the health visitor’, the baby was not seen, and there would have been no clarity about the nature of any marking. When nothing is actually seen the duty under the non-mobile bruising protocol to refer to Children’s Services is not specifically covered in the protocol, but the significance of such bruising in the protocol should have triggered some action. As indicated in 3.3, such a conversation with a mother would need to be discussed with someone else: firstly as it is describing marks in a non-mobile baby, and secondly the reference to non-bonding.                 13  There was no proof that any marks were caused as the mother explained, and professionals need to have a degree of scepticism in a baby’s interests. A health visitor, for example, has similar colleagues who could be consulted such as team leader or the named nurse. It is accepted that the facts are not verified, so the recommendation is general.  It is recommended that health visiting (and midwifery) services review message taking processes, and make it clear that calls must be recorded and procedures followed, even if the family is not currently being seen.  3.2.10 As at this point there were no concerns about the family, and as is described later, an out of hours GP who saw such bruises did not refer on. It would be wrong to assume that had the midwife discussed the call with anyone it would necessarily have led to any action that would have prevented the later injuries. The chances of identifying a growing problem would though have been much higher with wider discussion.  3.2.11 The second professional to hear about the story of the baby hurting itself was a nursery nurse caring for W when V was three months old. Again the baby was not seen. The nursery nurse believes the mother described scratches/bruises to face, arms and legs so the episode is appraised on that basis, although the mother said she only mentioned face.   3.2.12 The School has a ‘Child Protection Policy, Procedure and Safeguarding Guidance dated September 2012 which requires all staff to ‘follow the procedures set out by the LSCB…….’. This would not be easy as the internet links to the 4LSCB procedures or the national guidance on ‘What to do if you are worried a child is being abused’ do not work as they are outdated. For example the government sites concerned are no longer there.  3.2.13 The Guidance requires staff ‘to be aware of and alert to the signs of abuse’.  In this particular case, the nursery nurse did not hear what was said as being about ‘abuse’ but simply about the behaviour of a baby that was leading to marks. The nursery nurse considered the ‘bruises’ to be part and parcel of the pinching and scratching.  Having also heard that a ‘health visitor’ knew about it and had recommended taking V to the GP, it was thought the matter was in hand. The Child Protection Policy requires a discussion with the Head (who is also the safeguarding lead) and a full record kept if abuse is suspected, but as the worker took the story at face value these actions were not triggered under the policy.  3.2.14 It was only after V’s death that the nursery nurse recalled and recorded the conversation. The worker was at a disadvantage, not recalling having received any safeguarding training in six years at the school. There was no awareness of the non-mobile bruising policy, and said that with older children (there are no babies at the nursery school) practice was for staff to form a view on whether any marks were worrying before recording and passing the information on.  3.2.15 The head teacher accepted that the case had identified a weakness in training arrangements. The  nursery school is one of a few still maintained by the council and as such, she felt, can get left out. The head said that while there had been a recent inset day on safeguarding (at the head’s request) by the Council for the staff of the primary school it had not covered the nursery school. Having said that senior school                 14  staff did provide updates/briefings on safeguarding for nursery staff. Whilst the Council can provide training it is the responsibility of School Governors to ensure that safeguarding arrangements are satisfactory and staff appropriately trained. This would include at induction and annual updates.  3.2.16 HCC reminds schools annually that they must do an annual audit of safeguarding arrangements, and ask for a copy of the results to be sent to the Council. The school did complete audits in 2011 and 2012 and in the latter requested help from the Council for inset day training. They were referred to the Workforce Development Department. In the 2012 annual safeguarding report the box that says ‘staff receive up to date high quality appropriate training, guidance support and supervision to undertake effective safeguarding of pupils’ was ticked. V was not a pupil but the lack of training for nursery staff was acknowledged to the Review.  3.2.17 The conclusion of this review is that the nursery nurse was unprepared for the situation faced and in the absence of training it is somewhat understandable that mother’s story was believed with no personal conclusion that it was suspicious. However, a note of the conversation should have been made at the time and shared with a senior colleague because what was heard was an unusual presentation. There can be no guarantee that had the matter been referred on that there would have been a different outcome. The baby may not have had marks at that time, and the explanation may have been believed (although this is unlikely if there had indeed been bruises on face, arms and legs).   3.2.18 It is recommended that the governors of the school ensure that nursery staff are fully trained in safeguarding as per school policy, and that the board of governors receive regular assurance reports on compliance. It is also recommended that HCC work with both its maintained school nurseries to support governors to provide appropriate safeguarding training. (This needs to include guidance about babies even if no babies are at the nursery).  3.2.19 The examination by an out of hours GP the day before V’s final admission to hospital is of some concern, but again the individual performance needs to be considered in the context within which the GP worked. The facts of the examination that day are described in 2.14-15. The GP is a salaried GP (ie not a partner) in a neighbouring county, Surrey, doing an average of 5 sessions weekly. The GP had done additional sessions for North Hampshire Urgent Care (NHUC) at its out of hours clinic at FPH for 16 months before the examination in question. It is an independent organisation, and not part of FPH although providing service there.   3.2.20 The GP was faced with a decision which was outside that doctor’s experience. Although qualifying over 20 years ago, the GP had no experience of physical abuse, and had never referred a case of suspected physical abuse to social workers. Although self-regarding as not being trained in safeguarding, the GP had been to a Level 2 session in mid-2013 led by the GP who took the lead for safeguarding in the Practice. This covered general principles and understanding of abuse, but did not cover the Surrey non-mobile baby bruising policy as the GP presenting the session was unaware of it. This being the case, the out of hours GP would not have had such guidance in mind when working for NHUC nor known that the family’s county Hampshire had a similar policy. Although attending the training session, the GP was unaware of the formal role of ‘Lead GP’ for safeguarding at the Practice. The GP                 15  wonders if the whole training session was attended as a meeting at that time can rarely be attended at the start. In any case the training provided did not include the non-mobile bruising policy  3.2.21 GPs have a personal responsibility to remain up to date on safeguarding. A 2009 letter from the chair of the Royal College of GP’s Council and the chair of its GP Committee says “As noted above, all GPs have a duty to remain up-to-date. This is set out in the GMC’s Good Medical Practice. As a GP’s work is likely to include child protection, you must maintain your skills and competence in this area in line with GMC guidance. There are various ways that this can be achieved – for example, by attendance at courses, by distance learning, practice team meetings, etc”. (GP’s of course, by definition, have a huge range of topics on which they must remain up to date and proficient, so there are always judgements to be made by individual GPs or their employers as to the weight they can give each).  3.2.22 Whilst there is much training material available, there is no nationally agreed training in the contract GPs would have with NHS England. In Surrey, GPs are encouraged by the Named GP to have at least level 2 training, then moving to the more detailed level 3 training. Level 3 training courses are being provided by the CCG safeguarding advisers, and there is high demand for places. However, no NHS authority can currently insist through their contract that GPs are trained to a specific level, but providers such as NHUC can set such standards as a condition of employment.  3.2.23 Having said that, the combined medical Royal Colleges (including the Royal College of GPs) do have “Safeguarding Children and Young people: roles and competences for health care staff INTERCOLLEGIATE DOCUMENT September 2010” which says the following “It is now recognised that the complexity of relationships with child and young people patients and their parents and carers in the primary care context (see RCGP Curriculum section 8) requires level 3 competences. For the purposes of being up to date and revalidated, GPs should have all the competences in level 2 and be working towards level 3”.  3.2.24 Working that day at the Out of Hours service at FPH, the GP was not aware of the specific non-mobile bruising policy in Surrey, (or that Hants had a similar policy), so was unaware of the requirement to refer such bruising to Children’s Services. The doctor was however rightly suspicious and properly asked questions about the four facial bruises seen. However, the baby was not examined unclothed for further marks, nor was any drawing made of the bruises. NHUC did not provide body maps on which to do this, but has now committed to make them available.   3.2.25 The doctor had had no briefing from NHUC on how to deal with any safeguarding issue, and NHUC presumed that GPs arriving to work for them were properly trained. As a result of an external audit, and confirmed by this review, the risks in such an assumption are clear and NHUC is now to ask GPs to provide evidence of training. There was no reference to safeguarding in doctors’ induction to NHUC and no reference to it in the handbook provided which gave guidance on a range of clinical conditions. Nor was there any briefing from NHUC on what might be different about policies in neighbouring counties from where patients might arrive.  3.2.26 The actions in hand by NHUC to remedy these weaknesses are described in 3.5 below and in Appendix 1. The SCR recommendations for NHUC are in that section.                 16   3.2.27 The GP openly accepts that in hindsight there should have been an onward referral but at the time, although suspicious, was not sure enough to do that. The doctor also ‘didn’t want to do the wrong thing’ by which was meant that, in hindsight, probably worrying too much about the parents eg being unfair to them. This is the sort of thought process which, whilst a natural human reaction, would have been helped by good training. The GP has acknowledged personal distress in now realising the oversights.  3.2.28 The GP was concerned enough to note that there should be monitoring by the GP for further bruising, and to ask for the electronic note to be faxed ahead of the normal later electronic transmission. Apart from this being a bank holiday and there being no GP to receive the fax for some time, there are other issues about out of hours to GP communication which will be looked at under ‘General Practice’ below.  3.2.29 The GP had two options.  The Protocol, of which the doctor was unaware, says there should be a referral to Children’s Services who would then have arranged a medical examination. Not knowing of the Protocol, it would not have been difficult to use the adjacent A&E to obtain a paediatric opinion. This opinion, whether requested by the GP or Children’s Services, might have accepted the parental explanation, but on the other hand a skeletal x-ray would have seen the healing rib fracture and the baby would have been protected. This Review took the advice of an independent Consultant Paediatrician who has worked on SCRs, is a Designated Doctor, and chairs a regional designated doctors and nurse group. Asked ‘Can babies of 3 weeks to 5 months bruise (ie a real bruise not a red mark) their face by pinching and the answer was an emphatic ‘no’.   3.2.30 No inquiries were made of other agencies at the time, and to be fair had there been, given it was a bank holiday Sunday, it was unlikely this would have led to any information that would have helped the GP. Also, there was nothing in agency records which would have strengthened the GP’s concern.  3.2.31 The extreme rareness of bruising on non-mobile babies (the chances are set out in the Protocol), the fact they were somewhat symmetrical, and that they were small and round as in finger-tip bruising, all mean that there should have been action beyond just letting the family GP know in a few days’ time that such bruises had been seen. Compared to other illustrations above where bruises were heard about but not seen, this is a clear instance of where a referral should have been made to Children’s Services, and this may well have prevented the fatal injuries that are believed to have occurred in the next 18 hours.   3.2.32 The Review sought the views of a manager of the County Council Social Services Out of Hours Service (unfamiliar with this case) on what reaction there would have been had such a case been referred. The response was immediately that such bruising would be of considerable concern given the age of the baby, that a paediatric examination would have been sought, and depending on the diagnosis, any necessary protective action taken. The non-mobile baby bruising protocol was regarded seriously. The Review was assured that the level of response from social work would have been no less because of the bank holiday. Assuming this is an accurate description of the likely social work response, then the non-referral was indeed a critical moment.                 17   3.3 Analysis by agency: This section looks at both issues which may have made a difference in the case, but also at other learning that might have an impact on other cases in the future so is included here as it is a learning exercise. There are also sections on issues which overlap agencies. Note: There are updates on progress from each agency in Appendix 1 as at August 2013, refreshed at July 2014 where necessary.  3.4 North Hampshire Urgent Care (NHUC)  3.4.1 NHUC has a ‘Child, Young Person and Vulnerable Adult Guidelines’, and a ‘Safeguarding Children and Vulnerable Adults Policy’. The latter says the CEO has ultimate responsibility for the effective discharge of safeguarding, and that the Medical Director with responsibility for safeguarding is responsible for ensuring the highest standards are achieved. It says their procedures must be in line with and support the Surrey, Berkshire and Hampshire LSCBs’ procedures to which there are online links. It goes on to say that NHUC will ensure that all staff are trained appropriately and are competent to be alert to potential indicators of abuse or neglect in children and vulnerable adults and know how to act on their concerns consummate to their role, this should be in line with the intercollegiate document 2011 – “Safeguarding Children and Young people: roles and competences for health care staff – September 2010”. It requires each staff member to sign a declaration that they have read both policy and procedures. There is no such document for the GP concerned, nor evidence of induction including safeguarding.  3.4.2 NHUC’s contract with the NHS requires it to provide training if the GPs have insufficient training in their other work. NHUC has acknowledged that both the 2012 external review of their governance by Urgent Health UK, and this SCR had identified that too many assumptions were made that the GPs they hired, who mostly would have worked in their own practices too, arrived well prepared on safeguarding. This may stem from GPs being independent contractors and largely responsible for ensuring they meet appropriate training standards. For example, there was an assumption that GPs would know about the protocol on ‘Bruising in Children who are Not Independently Mobile’ from their own practice files. This was exposed in this case as the policy was unknown to the Practice where the GP mainly worked.  3.4.3 NHUC, and the GP concerned, accept that a referral should have been made. NHUC both from their external audit and the sad learning from this case have realised the need to tighten up considerably, and have communicated to the review a strong commitment to do so. The two NHS Clinical Commissioning Groups which commission Out Of Hours Services will be working together to ensure that there are consistent commissioning expectations around safeguarding and appropriate monitoring of compliance.  3.4.4 NHUC have now decided that by the end of September 2013 all clinical staff will have to demonstrate that they have completed level 3 safeguarding training. This was an action for September 2012 after the external audit. NHUC have also identified that staff they took on who may have worked for them before were missing induction. This is to be remedied by checking annually that all doctors are up to date. NHUC will be preparing a new hard copy folder of procedures for ease of access. They will be cascading the non-mobile bruising policy to all its staff wherever they                 18  work. Their records are almost wholly electronic, but body maps will be made available. Instead of there just being a GP safeguarding lead for all NHUC there will now also be a safeguarding lead for the centre at Frimley Park Hospital.  3.4.5 The actions from the 2012 audit were behind plan, and whilst this cannot excuse any delays, NHUC explained that the NHS contract for the service ended in March 2011 and there have only been short term extensions since, and tendering processes slipping. Whilst now awarded the contract, there was a long period of uncertainty about the future which may have impacted on developmental activity.   3.4.6 The external audit was repeated in July 2013 and on safeguarding the rag rating moved from red to amber, as despite some improvements, the audit identified some on-going weaknesses in arrangements- although there are plans in place to address each issue noted.  3.4.7 The case was discussed by the Reviewer with Hampshire County Council Out of Hours Service to test out what might have been the reaction should the GP had made the referral under the Bruising Protocol. The response was that there would have been immediate suspicion about the explanation, and an assumption that it needed full paediatric examination.  The Review was told that there would have been a good knowledge that bruising to non-mobile babies is very rare, and a working assumption that a baby could not harm itself like that. A paediatric examination would have been advised, and monitored both to see it happened and so that any appropriate protective action was taken after the diagnosis.  3.4.8 A similar discussion took place with a Consultant Paediatrician at FPH to assess what would have been the likely outcome of a referral to them for a safeguarding examination. On that Sunday the baby would have been seen by a paediatric registrar if no consultant was there, and the examination discussed with the consultant on call. Relevant x-ray and other tests would have been available, and although they may not have had the most expert interpretation until after the weekend, the baby would have been kept in hospital until all results were back.  3.4.9 It seems likely then that the non-referral of the four cheek bruises shortly before the fatal injuries was a very significant matter, but as said above has to be seen in the organisational context within which the individual doctor worked.  3.4.10 There are a number of recommendations in relation to NHUC: It is recommended that the CCGs who contract with NHUC work together to ensure there are consistent organisation wide expectations of NHUC in their contracts, and there is a joint approach to performance management. It is recommended that the CCGs monitor closely the rapid achievement of the actions set out in the  plan following the external audit and any actions from this SCR.  3.4.11 It is recommended that NHUC ensure that all staff working for them are aware of and have easy access to safeguarding guidance, both internal and county wide. Also that any training in house or induction covers not only the principles of safeguarding but practical consideration of what GPs on call need to do in specific scenarios.                   19  3.5 General Practice:  The family’s Practice is a large multi GP practice serving a relatively poor population which tends to make high use of their services. The Practice was very cooperative with the review and engaged constructively in what might be learned from this case.  The Practice has a lead GP for safeguarding and whole practice training was provided in 2012 via the Medical Defence Union. Further training by the Named GP for safeguarding is to be arranged. Daily informal meetings of all staff allow for an exchange of information about cases of concern. There is an internal messaging system so staff can be alerted to risks e.g. a violent patient. The GPs were aware of the Bruising in Non-Mobile Babies Protocol, and said such bruises were so rare such an occurrence would be taken seriously. The nurse practitioner who saw the baby was also aware of the Protocol and said that should bruises have ever been seen, it would have been discussed with the duty GP for the day.  3.5.1 There were a number of issues which are worthy of further consideration. One, about which the GPs are themselves concerned, is about continuity of care when patients both use the Practice often and insist on seeing the first available GP rather than ‘their’ GP. This can be illustrated by this case, as excluding appointments for tests and jabs members of this family saw numerous GPs across the period of this review. The mother saw 14 GPs in over 40 attendances, the grandmother saw 12 GPs in over 25 attendances, and W saw 8 GPs in 15 attendances. The chances of getting a good sense of accumulating issues in one patient, never mind putting together information about a family must be reduced significantly by such a spread of GPs involved.  3.5.2 There is a flagging system at reception that tries to get specific patients to a specific GP, but as the Practice had no special concerns about the family this did not apply. The risk here is that concerns could be missed as small factors are not pieced together, reducing further the chance of say linking a parental issue with child well-being. Even in hindsight the Practice cannot see that a concern to the level of say a referral to Children’s Services, or even a discussion with say health visitors or midwives was warranted. This Review is not saying that anything was missed by the Practice- but is saying that there is an inherent risk in the lack of care being provided by a smaller number of staff.  The Practice has tried to find a way of improving this, but would appreciate advice. It is recommended that the CCG in conjunction with the local area team of the NHS Commissioning Board work with the Practice to explore how continuity of care can be improved by patients seeing a lesser number of different GPs.  3.5.3 A second, and case related, issue is whether there was a need for GPs caring for the maternal grandmother to share any information about her illness with either the notes of one or both children, or with community staff like midwives or health visitors. It should be emphasised that the issue being discussed was not any direct risk, but whether there might be an impact on the mother’s degree of stress, especially when she was for a while a single parent. It is important to look at this without hindsight, and to assess it as it was at the time.   3.5.4 There is no record of GPs dealing with any alcohol/aggression/family dispute related matter with the grandmother from W’s pregnancy until after mother and W had moved out to live on their own, so there was no obvious need to consider a child related link. Other than one drink related conviction it seems that the Practice was                 20  unaware of other convictions/cautions so was probably unaware of the extent of the problems, although aware of overdoses. The mother told the Review that her own mother’s problems did not affect her, and both she and the grandmother thought that information about the alcohol problem should not have been shared with other people. The mother never disclosed it to any professional.  3.5.5 It is clear from the GP records that the Practice was aware of the grandmother being in a state of recurrent relapses through V’s pregnancy, and after birth. For example when the baby was less than one month old a counselling service wrote to the Practice that the grandmother ‘feels (the alcohol dependency is) greatly influencing her moods and relationships with her family’. It is easy in hindsight to say that a quiet word with the midwife or health visitor would have enabled them to check that mother was not too distressed by all this- but at the time the GP to whom the letter was addressed had only seen one of the children once, and mother (for non- child related issues) on only  4 of her 40 plus attendances, so would be most unlikely to have made any mental link. In any case, no one would have suspected that, whatever the stress, V would have been at risk.  3.5.6 The GPs no longer have a role during normal antenatal care, so do not refer to maternity as in the past with details of the case including any risks. Midwives, who have access to the Practice records, identify any risks from their own scrutiny. In this case the midwife would not have known to look at any other family records, and was thus unaware of any wider family stresses.  3.5.7 In discussion with the GPs, their view and that of the reviewer coincided. This is that there were no obvious risk factors to children in what was known, and even if it had all been pieced together the information would still have been some way below the threshold for referral to Children’s Services.  3.5.8 When V was two months old mother told a GP about the pulling at cheeks and not bonding with father- but this was assessed as nothing out of the ordinary. The GP who saw V a few days before death said there were no bruises, although the mother says she pointed out one facial bruise when discussing the pinching.  This difference of memory cannot be clarified further, so the Review can only   recommend that should a GP see any bruise on a non-mobile baby, regardless of the explanation, it should be recorded, drawn, and referred under the Protocol.  3.5.9 In considering what information can be easily shared with colleagues, the Practice felt strongly that their access to health visitors and opportunities for informal exchange was much reduced. In March 2013 the Practice wrote to Southern Health NHS FT (SH)   expressing concern about lack of meetings with health visitors, when their presence at practice meetings would be valued. “We currently feel we have no health visitor support at the Practice and given the high number of at risk children and problem families we have we do not feel this is acceptable……. (and they hoped) to … get some system in place for a regular meeting so that doctors are able to discuss any concerns they may have.”  There was a discussion and the Practice reported a little improvement. This family is most unlikely to have been discussed in this way, but GP- health visiting links in other cases might be more important.  3.5.10 The Review also had discussion with the Practice from which the out of hours GP came.  The Practice’s Lead GP for safeguarding, who did provide a session last year                 21  for the clinical staff on safeguarding, was not familiar with Surrey’s non-mobile bruising policy and so it was not incorporated into the training provided. Although happy and willing to give the in house training with the material provided, the lead did not feel particularly well prepared as a trainer, and this will be fed back to the local LSCB’s Named GP. (The current practice in Surrey is for training to be CCG led and not by practice leads). It is recommended that the HSCB shares this report with the Surrey LSCB.   3.6 GP communications out of hours: This will be a national issue, but from a safeguarding point of view it is interesting that  there is no way that a family GP can be contacted out of hours to see if there is any information which might help an out of hours doctor on say a safeguarding decision, as responsibility is wholly transferred to the out of hours provider.(There is a system, which the Review was told was not fully used across Hampshire called Hampshire Health Record which is designed to show other GPs headline issues from cases). In this case the out of hours GP asked for the child’s GP to get a fax and not just the electronically transferred attendance record. This might draw more attention, but can only be received when a practice is open. In addition, neither NHUC nor the GP Practice keep records of faxes so this Review could not see what the fax contained.  3.6.1   There is also the issue of follow up. NHUC would not have known if the GP had seen the message about monitoring future bruising two days later. Sometimes, a professional needs to know if a recommended action happened e.g. a parent did indeed take a child to see another professional, but it is not clear that with sessional staff whether such follow ups occur. It would be worth out of hours’ providers and safeguarding advisers to explore with some case illustrations how such providers can manage child protection cases in long out of hours periods. It is recommended that the responsible NHS bodies in Hampshire review with out of hours providers processes for communicating with GPs and seeking additional information about possible child protection issues  3.7 Southern Health NHS FT (SH) – Health Visiting: There is no evidence that the health visiting service missed any observed warning factors that might have predicted future harm to the baby. Records of assessments do not show anything of concern (although with V the standard question about domestic violence was not asked as both parents were seen together). Contacts were routine, in the expected number and were unexceptional. Health visitors were unaware of any potential stress arising from the maternal grandmother’s recurrent drink problems.   3.7.1 Although it is most unlikely that it would have made any difference, there was no antenatal visit by a health visitor with V as required for all mothers (and their families) under the Trust’s 2011 guidelines. It is designed to cover liaison with the midwife/GP and a safeguarding assessment. Exceptions to this universal policy are to be raised with line managers. I was advised by SH that in 2012-13 the target set by commissioners of their service was 50%, and SH have now set an 80% internal target. The health visiting clinic concerned was under staffing pressures in 2012-13 and was not doing antenatal assessments.  3.7.2   Health visitors visited V on three occasions. There were no concerns passed on by the midwives so a visit was made just after the fourteen day target (bank holidays intervened). Other than the baby already being on ‘hungry baby milk’ which the health visitor would have discouraged for a first baby – there was nothing memorable                 22  about the visit. The same nurse went again two days later to do the hearing check. Again, no concerns, nor any other plan than routine care. The final visit was at seven weeks for the ‘six week check’ by a student health visitor (unexceptional as no known concerns). The baby had gained weight but had some colic which the nurse said should be discussed with the GP. The next contact was to be at eight months.  3.7.3  The health visitors told the Review their caseloads were around 800 each which would be well above recommended levels, but they all agreed , as does this Review, that had they been less pressured the level of contact with the baby would have been the same.  3.5.9 described the GP concern about the frequency of health visiting contact with the Practice, which they think is only partially resolved, although SH said a recent audit had not identified current concerns.  3.7.4   If the phone call by mother about bruising was made to a health visitor then it should have been recorded, and if it described bruising to a non-mobile baby should have led to at least discussion with a colleague, and further action. SH say that if a call had been made an email to the team’s generic email would have been sent, where either the family or duty health visitor would see it. If any action, it is recorded on the electronic record. However prior to March 2014 there was no system to record emails that had been dealt with, so it is possible no action was taken and the email now gone.  The recommendation is at 3.5.8 above. SH has informed the review that it will audit the post March message taking process in all its health visiting teams to assure robustness  3.7.5  The mother said that three visits only from the health visitors was enough, and she was pleased there were not more as she found their inability to give a time for their calls a bind.  3.8 Solent NHS Trust: This Trust’s only involvement was in providing alcohol services for the maternal grandmother from early in V’s pregnancy, from which she was discharged (after a phone call the previous month) when V was five weeks old after ‘successful completion of a recovery programme’. (Interestingly this was eleven days after the grandmother reported uncontrolled drinking again to the GP, which was followed two days later by a letter to the GP from another counselling service saying she was being discharged also for good progress). The records show no mention of grandchildren or the impending birth of V.  3.8.1 There is no suggestion that not doing this at the time had any impact at all on the case, but the Trust is considering extending its standard query about children of its adult patients to include whether the patient has any regular child care duties. This might prove helpful in other cases.  3.9 South East Coast Ambulance Service NHS FT (SECA): This was the ambulance service which took V to hospital with the fatal injuries. There had been no prior call outs to either V or W, but there had been four calls to the maternal grandmother and at none of these calls was there any reference to there being a child on the scene, and the calls were not in the period when W was living with his grandmother.  3.9.1 The Review has studied a report of the ambulance attendance to V, and it was prompt and well attended. There was nothing to make the crew think of non-accidental injury and their priority was resuscitation. From call to arrival at the pre-alerted hospital it took 23 minutes. SECA says that police should be routinely notified                 23  of life threatening events to children before arrival at hospital, but were not in this case- although it would have made no difference, and staff will be reminded of this expectation.  3.10 South Central Ambulance Service NHS FT (SCAS): This service does not cover the area in terms of ambulance attendance, but had three contacts with the family in the year leading up to V’s death, as the provider of the recently created 111 call service. The first was for W when V was two months old, for a routine illness. The advice was to speak to the GP Practice within an hour (which was not followed). The second was about V when nearly four months old after constant screaming, an abdominal rash and a temperature. The ‘chief complaint’ was noted as a choking episode (not described or timed) in the previous 24 hours. The SCAS advice was to go to A&E in an hour, and this was done. V was admitted overnight with an infection.  3.10.1 The final contact was the day before V’s admission with the fatal injuries, with the presenting issue being a cough and off food, and the advice was to contact a GP within 12 hours. As it was a bank holiday and hence out of hours- in this case NHUC at FPH The call handlers would have known neither child was subject to a child protection plan as this would have been flagged on screen.  3.10.2 The records kept by the 111 service are not what a layman would recognise as a medical record, but a series of questions – computer generated-  where the symptom is logged as present or not, and a series of outcomes against possible developments with the illness. Non clinical call handlers adhere rigidly to the computer generated process. It is not possible to see from the record what was volunteered by the caller, and what was a response to a question. Whilst it is likely this works well for most routine cases, one could imagine it would be hard to pick up from the record any subtlety about a possible abuse case. In the case of V, especially when choking was said by the father to be what led to the collapse on the final day, it would have been more helpful in hindsight to know more about the ‘choking’ episode a month before her death. There does not seem to be room for free text in the 111 records.  3.10.3 The record also says the patient was advised to speak to GP in 12 hours and if out of hours to call the out of hours GP. In fact, the mother was already speaking to the number she would have had to ring to call the out of hours doctor, so what happens is that the 111 service get the out of hours GP to call the patient, which is what would have occurred in this case. It is recommended that SCAS consider whether any amendments could be made to the way 111 calls are recorded to provide clearer descriptions of what is being conveyed in calls that may relate to safeguarding.  3.11 Hampshire Police: The police had no involvement with either child. When they attended the maternal grandparents’ home for incidents, this was when the mother was living away from her parents. The police notified adult social services of the two attendances made on the same day ten days before V’s final admission: one about a violent dispute between the grandparents, and the other as the grandmother had taken excess alcohol and pills. Had there been any known child issues  at that address (there were not) then they could have been linked with this police notification. The forms routinely completed at domestic abuse attendances are always assessed centrally and any child related issues followed up, so there does                 24  seem to be a proper system in place- even if not relevant to this case. There were no issues from the police involvement from the identification of injuries.  3.12 Frimley Park Hospital NHS FT (FPH):  This NHS Trust was involved in three ways: as the provider of maternity and community midwifery services, as the provider of A&E, and as the provider of paediatric services.  3.12.1 Maternity/Midwifery: The booking checklist used to identify any possible problems was completed for both pregnancies, and there were no concerns even in hindsight. They were aware of mother’s chronic gynaecological problems. As mentioned in 3.5.6 above, at least at the family’s practice, GPs are not involved in referring a mother to maternity, and the discovery of background risk factors is left to the community midwives to make their own inquiries- which they can through the patient’s GP records. There must be a risk that issues relating to the family or to the mother can be missed if not then self-reported. This can be seen in this case, because even if there is no evidence that the grandmother’s illness affected the mother, had it been having more impact the midwives would not have known.  3.12.2 At the birth, the risk to the baby was spotted and immediately acted upon with an emergency caesarean. The mother naturally found this very distressing and thought that hospital staff could have been more sensitive to her after the operation. She also found the attitude to her about the fact she smoked ‘unpleasant’. She was discharged home at 8.30pm which is quite late given a new baby and the stress mother had been through. Mother could see no reason for the delay other than the wait for a clinician to approve the discharge, and thought she and baby were ready hours earlier. The community midwife’s later de-briefing with mother about the emergency birth was appreciated by the mother.  3.12.3 There were three midwifery visits in all to the home, a normal number which does not seem unreasonable in the circumstances, and a contact number was left should there have been any issue before the health visitor started.  3.12.4 Paragraph 3.2.1 describes the call made to health visitors or midwifery about the pulling/scratching/bruising. The Reviewer has seen in another SCR how a similar call to another midwifery service which required action could not be traced, and whether or not a call was made in the V case. It would be useful for FPH to review the  guidance and process around the recording of calls- especially when the case is no longer active, making it clear that all calls should be noted, and that anything of concern should follow procedures whether it is an open case or not. The recommendation on this is in 3.2.9 (Note: it is likely the call was made to health visiting)  3.12.5 A&E/Paediatrics:  A FPH Consultant Paediatrician reviewed with the Reviewer the notes of V’s admission via A&E a month before V died, to see if there was any indication of missing, for example, signs of abuse given that the rib fracture may have occurred by then. The Review accepts the conclusion that there were no such signs. Even had checks been made with other agencies, nothing would have emerged to raise concerns. There was one scenario which might just have spotted the rib. The consultant said that V’s temperature seemed too high for the assumed cause of illness and this might have led to a chest x-ray which might have seen a healing rib fracture- if indeed it was there by them.(One rib was fractured up to two                 25  months before the final injuries).  Even if such an x-ray had been taken, it would have been examined for infection not trauma and the rib might not have been noticed. The review concluded that this theoretical opportunity to notice an injury was too speculative to be a learning point. -  3.12.6 When V was taken to hospital following the fatal injuries, V was at FPH for  only two hours as the clinicians realised that the most specialist of help elsewhere was needed if there was to be any chance of survival. In those two hours abuse was not suspected, and the clinical mind-set was totally focussed on saving the baby’s life. Given that the baby had facial bruises the day before, and more were seen the next day (plus two body bruises) it is likely that V had bruises when at FPH.  None were recorded. V would have had a mask on at all times and considerable amounts of tape too holding mask and tubes in place. Had bruises been seen it would have made little difference to what the clinicians were doing, but University Hospital Southampton (UHS) would have received V knowing that abuse was a possibility, and the diagnosis of abuse may have been slightly earlier.   3.12.7 It is quite understandable that the whole focus was in reviving V. However, the Reviewer is aware of other SCRs elsewhere where the local hospital has not identified considerable injury because the focus was on the presumed problem, say a catastrophic infection. It is recommended that FPH look at its procedures in relation to such seriously ill babies where the cause is not clear so that, for example, there is always at least a clinical examination looking for signs of trauma, unless to do so would harm treatment.  3.12.8 Finally, as described above, FPH would have had appropriate systems in place should V have been referred there by the out of hours doctor the day before her injuries.  3.13 University Hospital Southampton NHS FT (UHS): Part of the UHS response to the arrival of V for care in their PICU was a notification from the Trust child protection team- which is done routinely for an out of hospital child cardiac arrest. A history was not taken from the father as one had been taken at FPH when no history of trauma was given. Like FPH, the bruises on V were not noticed during the frantic effort at recovery, but a chest x-ray taken for the  infection showed a possible fractured rib which triggered immediate further tests and appropriate safeguarding procedures. The head bruises were seen during tests for brain stem death. A formal history was then taken from the parents.   The same recommendation as made to FPH in 3.12.7 about checking for bruises when there is no clear cause of serious illness is made for UHS. The UHS PICU Director has written to all PICU consultants and senior nurses about looking for and recording bruises ‘particularly in circumstances where there is no clear diagnosis’.  3.13.1 A strategy meeting was called to share multi agency information and prepare a plan. In the evening V’s treatment was withdrawn and in the presence of the parents V passed away.  3.13.2 The mother did feel that the announcement by the clinician that V had finally gone was perfunctory and insensitive, and the mother wanted visible sign of sympathy. I suspect this may have occurred as the hospital staff would have wanted to interfere as little as possible with the parents’ last moments with their baby.                 26   3.13.3 UHS asked the Review to raise the issue of the Child Death Overview Procedure ( a statutory review process required after any unexpected child death) being commenced before V had actually died, and that they found the suggestion that the safeguarding strategy meeting also be designated as the stage one Child Death Overview Panel meeting inappropriate.   3.14 Removal of life support and safeguarding processes: The mother raised an interesting ethical issue about the timing of safeguarding processes and the removal of life support. She was aware Children’s Services wanted to interview them, and she asked if it could be done before the support for V was removed. This was because she wanted clarity in her own mind if trauma might have been involved before saying goodbye. She said the response she received was that the social worker wanted them to say their goodbyes to V first, and this is what in the end happened. Like the doctor in 3.14 above, it may well have been that the social work stance was thought to be a sensitive one but perceived differently by the family. In the subsequent discussions with the social worker, the mother said that a relative there “counted the worker threatening numerous times to remove W into care” which she found insensitive in the circumstances. (It is clear that W would have needed to be protected in a safe place).  3.15 Family Views:  The SCR sought the views of parents, and maternal grandparents. The father has not responded. The grandfather declined when he realised his concerns were outside the timeframe of the Review, but the mother (with V’s grandmother in attendance) did meet the reviewer. Given how difficult it must have been for the mother to speak to the Review given the sad loss of V, and decisions not yet being taken about any culpability if any, she was able to make a number of comments worthy of agency consideration in here  and at other points in the report.   3.15.1 Her views have been given in relation to a number of issues above which are not repeated here. At the time of the meeting the mother did not accept that trauma had taken place so there could only be a limited discussion about how services did help or might have helped. Her general view was that she was well supported by her family, did not require more public service than she received.  3.15.2 As no professional to whom she mentioned marks on V made an onward referral, the mother was asked what her reaction might have been had they done so. She thought she would have been very annoyed as she knew how the bruises were caused. On the out of hours visit the day before the final hospital admission she would have accepted an onward referral to hospital paediatrics if it was to look more into V’s illness, but not if it was related to the marks.  3.15.3 She raised two incidents of what she said were false assurances about V’s situation in her last 24 hours. At FPH she said a nurse assured her V would be fine, when the mother said the nurse must have known this was not the case. At UHS she said a doctor assured the parents that the baby’s condition could not have been prevented and they were not to blame. The Review has not sought confirmation of this, but it does illustrate how parents might interpret (probably well intentioned) attempts to be positive.                    27  4 KEY FINDINGS  4.1 This section identifies four overarching issues which have emerged from the Review. Given that the Review was case specific it is not easy to determine whether any issue occurs frequently, or how broadly it may occur across the County.  The HSCB and its partner agencies will need to form their own views about this when determining their actions following the Review.    4.2 The section looks at the context within which professionals worked, as it is only in understanding why decisions were made or not made that improvements can be made. Working around child protection is not easy, nor are judgements at the time as straightforward as they might appear in hindsight. Making a decision as to whether to take something further involves knowing when to do that, knowing how to deal with any uncertainty about that decision, knowing what to do, overcoming any innate tendency to believe what one is told, bravery to challenge when to do so might create a backlash that makes future contact more difficult, and the innate hope that things are not as bad as they might seem. To get this right requires good training and supervision, a management culture that values challenge, and systems which have clear processes and which are reviewed.  4.3 The previous section on analysis and appraisal showed how some of these conditions for good practice were not sufficiently in place.  4.4 ‘Bruising in Children who are Not Independently Mobile Protocol’:  The lack of clarity in the existing policy statements was analysed in paragraphs above  This is critical guidance, with the clear intention that all bruises to non-mobile babies should be subject to further scrutiny and more than one professional involved in decisions. As written this is not discretionary. The finding from this review is that there are some staff who are unaware of its existence, and therefore do not know the key principles within it, and who are therefore vulnerable to error which might leave a baby unprotected. It needs to be understood by all who work with  families, as information may come about a baby even if the case focus is an older child.  4.4.1 The HSCB and its members must study the awareness and understanding of the protocol to ensure that there are not gaps. In another review elsewhere the reviewer identified four groups of staff; those who knew about the protocol and followed it, those who knew about it and didn’t follow it; those who knew about but thought it did not apply to them, and those who were unaware of it. In this case the nursery nurse and out of hours GP were in the latter category.  4.4.2 The message from this Review is that unless there is a rigorous approach to universal application of the protocol the chances of mistakes are high.  4.4.3 This Review made an early draft of the section on the Protocol available to the HSCB group reviewing it.  Both the revision and its roll out to all staff who work with children needs to ensure, following the categorisation on 4.4.1, that staff are aware of it, know it applies to them, and that the guidance is followed. This will require audit.  4.4.4 It is recommended that the HSCB ensure that the Non Mobile Bruising Protocol is reviewed in light of this SCR, that its use is a core part of local training, and that compliance is monitored.                 28   4.5 Training: This case illustrates the risks of organisations not being clear about training expectations, or what is in place. The nursery nurse says no formal training on safeguarding had been provided at the school. NHUC did not know how well its staff were equipped to handle child protection issues. The out of hours GP had had little training or experience of child protection. This had a clear connection with decisions not to refer on as per guidance (which was not actually known about).  4.5.1 It is recommended that the HSCB and its member agencies should review their arrangements for being clear about what level of training is required, its frequency, and compliance. Also agency Boards or equivalent should receive assurance about compliance levels with safeguarding training requirements, and, the HSCB can then review the overall position in its annual report.   4.5.2 It is important that training looks at practical examples and not just principles, and also is grounded in local procedures. The out of hours GP had had some training but this did not include the local  bruising protocol which was unknown to the Practice. The fact that despite being suspicious the baby was not examined unclothed suggest that any training was not that detailed. The nursery nurse, even if trained, might not have known of the bruising protocol as the nursery did not work with babies.  4.6 Scepticism and Challenge: Even if one puts to one side any lack of preparedness from training, staff working with families need to have a respectful scepticism about what they hear, and not automatically accept self –report. Staff from at least two different professions- education and medicine – who saw or heard about bruising were insufficiently sceptical or challenging to talk to others about it or refer elsewhere. This may have also have applied to a heath visitor when ( says the mother) told about a lack of bonding and bruises in a 2 month old baby.  4.6.1 Sometimes this can relate to training weakness so the professional may not realise there is indeed something to be worried about, but often it is to do with either the dynamic of the relationship with the family (eg the out of hours GP recalls being worried about the impact on the parents), or the degree to which organisational culture supports challenge (eg supervision which is challenging provides a model for work with families). There are two types of ‘challenge’. One is a summons to a fight, the other is a request for more information. Sometimes professionals shy away from   the latter in case it comes over as the former.  4.6.2 This is a difficult concept to turn into a tangible recommendation, but the value of taking a sceptical stance in the interests of child safety, the appropriateness of challenge as a search for necessary information, and the need for managers, supervisors and boards including the HSCB to model this approach, needs to be something borne in mind in training and organisational arrangements. It is recommended that HSCB and its member agencies consider how they can model good challenge in the way that will help staff have the confidence to rigorously inquire into potential abuse  4.7 Primary/Community Care Communications:  The way in which GPs, health visitors and midwives communicate with each other, did not have a significant impact on this case, but issues were seen that merit further thought in the interests of future                 29  cases, and those agencies which carry responsibilities in this area may want to use these points to review current arrangements. The issues are summarised below.  4.7.1   Out of hours- GP communications:  There does seem to be a gap in the ability to gain GP information out of hours, extended over long weekends, which might be very important in weighing up risks. It also impacts on the follow through of any actions agreed during out of hours. There is also the related issue of the speed by which GPs will actually see any messages that out of hours deem important.   4.7.2 GPs and Midwives: In this case the Practice was positive about the ability to communicate with midwives as they hold clinics on site.  One issue that needs thought is midwives only finding out information about pregnant women they care for if they make their own researches, rather than having an informed briefing/referral from the GP- and how this might miss family connections.  4.7.3 GPs and Health Visitors: The view of the family Practice in this case that there was insufficient contact with health visitors, is not uncommon nationally as health visitors have been more centrally rather than GP based to make the best use of staff in any particular area. The Reviewers experience of leading peer reviews of health visiting and GP services (not in Hampshire) showed that contact worked best where there is a written agreed policy of how health visitors link with Practices and information is shared, which is then audited to ensure it is happening.  4.7.4 It is recommended that, in each of these three illustrations about communication, organisations should look at their own processes, with the HSCB holding the overview, to assess whether improvements can be made.  4.7.5 SH informed the review that there is a written GP Communication Guidance (updated in March 2013) with a list of link health visitors made available to GP Practices. SH says it is for the link health visitor to negotiate a minimum level of monthly contacts with each Practice which can be n person or through message books etc. This would work better if there was a clearer expectation and not left to front line negotiation. For the Practice concerned SH say the new link health visitor has planned meetings arranged. In light of the review SH will re audit GP-health visitor links across the Trust.                          30  5 CONCLUSION  5.1    Other than the time when a doctor saw several facial bruises shortly before the baby’s death there were no occasions where one could conclude that a critical opportunity was definitely lost. This is because others heard about but did not see any marks on V, and one could only speculate about what might have been seen and how it would have been interpreted if investigated further. However, it is possible that had staff who heard about bruising followed the guidance in the bruising protocol that information would have been pooled, and at least a decision taken on whether more could be done. 5.2   On that one occasion when the baby was presented to a doctor with facial bruising, it is reasonably certain that had there been an onward referral, the baby would have been admitted and not at home to have received the final injuries   5.3   The Review has identified that  the two staff, definitely  known to have either heard about  or seen bruising,  were not aware of  the non-mobile bruising policy , and neither were sufficiently sceptical  about what could cause bruises  in such a young baby- which was probably also knowledge/training related.  Neither had prior experience which would have helped them.  In the case of the out of hours GP, the employer was unaware of any training or experience deficits. In the case of the school, the nursery school seems to have been overlooked in formal training programmes. 5.4   The largest number of recommendations are about the HSCB ensuring that the proper infrastructure, especially around training or procedures, is both in place, and monitored to ensure there is good compliance. Also, on reviewing the bruising policy. There are also recommendations for specific agencies. The HSCB and agencies need to examine their own arrangements so they are aware of the extent to which any issues raised in this SCR is prevalent beyond this case.                             31  6 COLLATED SCR  RECOMMENDATIONS  The recommendations are divided into organisational responsibility, but all agencies should look at each to be sure no key action is missed. The origin of each recommendation is in parentheses. There are some updates from agencies in progress in Appendix 1. It is recommended that: Frimley Park Hospital and Southern Health NHS FTs  1. Health visiting services (and midwifery) review message taking processes, and make it clear that calls must be recorded and procedures followed, even if the family is not currently being seen. (3.2.9) Frimley Park Hospital and University Hospitals Southampton NHS FTs 2. FPH and UHS look at their procedures in relation to such seriously ill babies where the cause is not clear so that, for example, there is always at least a clinical examination looking for signs of trauma, unless to do so would harm treatment. (3.12.7 and 3.13)  General Practice  3. Should a GP see any bruise on a non-mobile baby, regardless of the explanation, it should be recorded, drawn, and referred under the Protocol. (3.5.8)   Clinical Commissioning Groups (CCGs)  4. CCGs which contract with NHUC work together to ensure there are consistent organisation wide expectations of NHUC in their contracts, and there is a joint approach to performance management. (3.4.10)  5. The CCGs monitor closely the rapid achievement of the actions set out in NHUC’s plan following the external audit and any actions from this SCR. (3.4.10)           CCGs and NHS England  6. The responsible NHS bodies in Hampshire review with out of hour’s providers processes for communicating with GPs and seeking additional information about possible child protection issues. (3.6.1)  7. The CCG in conjunction with the local area team of the NHS Commissioning Board work with the GP Practice to explore how continuity of care can be improved by patients seeing a lesser number of different GPs. (3.5.2)  North Hampshire Urgent Care  8. NHUC ensure that all staff working for them are aware of and have easy access to safeguarding guidance, both internal and county wide. (3.4.11)                 32   9. Also that any NHUC training in house or induction covers not only the principles of safeguarding  but practical consideration of what GPs on call need to do in specific scenarios. (3.4.11)  South Central Ambulance NHS FT  10. SCAS considers whether any amendments could be made to the way 111 calls are recorded to provide clearer descriptions of what is being conveyed in calls that may relate to safeguarding. (3.10.3)            School Governors  11. The governors of the school ensure that nursery staff are fully trained in safeguarding as per school policy, and that the board of governors receive regular assurance reports on compliance. (3.2.18)            Hampshire County Council  12. HCC work with its maintained school nurseries to support governors to provide appropriate safeguarding training. (This needs to include guidance about babies even if no babies are at the nursery). (3.2.18)           Hampshire Safeguarding Children Board (HSCB) /member agencies 13. The HSCB ensure that the Non Mobile Bruising Protocol is reviewed in light of this SCR, and that its use is a core part of local training, and that compliance is monitored. (4.4.4)   14. In each of the three illustrations about primary/community care communications,  organisations should look at their own processes, with the HSCB holding the overview, to assess whether improvements can be made. (4.7.4)   15. That the HSCB and its member agencies should review their arrangements for being clear about what level of training is required, its frequency, and compliance. (4.5.1)  16. Also agency Boards or equivalent should receive assurance about compliance levels with safeguarding training requirements, and, the HSCB can  then review the overall position in its annual report. (4.5.1)  17. It is recommended that HSCB and its member agencies consider how they can model good challenge in the way that will help staff have the confidence to rigorously inquire into potential abuse. (4.6.2)   18. HSCB shares this report with the Surrey LSCB. ( 3.5.10)                    33  APPENDIX 1 Agency Updates on Actions in Response to the SCR (originally submitted as at October 2013, and updated where necessary at July 2014  These submissions below are self-reported by the agencies which were asked to inform the Board of actions taken already and significant plans.  The School:     The School has shown the Review an updated version of its action plan following the SCR. At the annual health and safety update INSET session in September 2013 the child protection input covered the usual policy and practice, but included information for all staff about the significance of issues of vulnerability that come to school attention about siblings, raising of any injuries, bruises etc and referring sibling issues to health professionals and social service as appropriate. Records will be kept of any concerns raised about siblings of children attending the school/nursery, and reported to CPLO. The policy about non mobile bruising was brought to staff attention. The school organised child protection training for all Nursery staff and the early years SEN outreach team through an organisation recommended by HCC in September 2013. The Nursery Teacher undertook training in the management of child protection through the Guildford Diocese in September 2013. The Head Teacher undertook the HCC three yearly refresher training for school child protection liaison officers (CPLOs) in January 2014. The school governors undertook the annual safeguarding audit. An action plan was completed and this is monitored termly. This was shared with Ofsted in November 2013 during an inspection.  Solent NHS Trust:   As a result of the SCR V, Solent NHS Trust instigated a review of the HOMER (Substance Misuse Service) assessment paperwork. Since the end of October 2013, the paperwork for HOMER now includes a question for all clients presenting at HOMER services, asking whether they have regular caring responsibilities and/ or contact with children.   South Central Ambulance Service NHS FT:   They had nothing to add.  Hampshire Safeguarding Children Board:  The existing working group for the four LSCBs reviewing the protocol on bruising in children who are not independently mobile were informed of the draft findings of the SCR at the earliest opportunity and subsequently produced a single document in December 2013.  Raising awareness of the protocol has been a core part of HSCB training, especially in the eight  sessions on learning from case reviews that took place from October                 34  2013 to March 2014. The revised protocol was launched at the HSCB Joint Working Conference on the 27 February 2014 which was attended by 100 practitioners. In January 2014 HSCB undertook a survey in order to gain an overview of practitioners’ awareness and application of the protocol. Of the 279 respondents, 64% said they had an awareness of the protocol. The survey was repeated in  June 2014 following the launch of the protocol in February 2014. Of the 197 respondents, 88% said they had an awareness of the protocol. On the communications issues raised, the HSCB required the lead NHS CCG for safeguarding to report back to the HSCB January 2014 Board an overview on these issues, together with actions taken and planned. The outcome of this piece of work is outlined in the response from Hampshire CCGs below. On the recommendation that the HSCB and its agencies review arrangements for being clear about requirements for/level of safeguarding training, a revised training policy was published in January 2014. HSCB has required partner agencies to report on training compliance levels through the 2014 Section 11 Audits and the single agency training audit for 2014. The overall position on safeguarding training across the workforce will be reported in the 2014/15 Annual Report. On the modelling of ‘good challenge’, the theme is included in the HSCB workshops on lessons from case reviews. The HSCB learning and improvement framework and quality assurance frameworks both promote rigorous inquiry and challenge.  Following from another SCR (Child S and R) partner agencies are already committed to reporting to the HSCB on the robustness of their internal supervision arrangements to ensure fixed thinking is identified and challenged. The report has been shared with the Surrey SCB.  Hampshire County Council:  Action has focussed around respective responsibilities for safeguarding between HCC and Schools, and in particular those 11 with nurseries. A letter has been sent to these schools saying, “The responsibility for staff training and support, including safeguarding training, rests with the governing body of the school, although from a day to day management perspective, this may be delegated to the Head teacher……..but, for the purpose of clarity, it may be helpful to reinforce that this responsibility relates to the whole school staff, including staff working in nursery classes.”   The letter went on to describe the potential sources of training, including a subscription scheme for training provided by HCC. It also provides a web link to the LSCB policies on bruising and emphasising that the bruising might be seen or (as in this review) reported. Following the review of the bruising protocol a web link to the updated version was sent to all schools via the schools communications. At the November 2013 meeting between officers of HCC’s Services for Young Children and the 11 schools with nursery units, there was an item reinforcing the messages from the letter and to provide any further clarification necessary.                 35  ‘Clarification about schools’ responsibility will be strengthened, following the publication of Keeping Children Safe in Education document, April 2014, at the briefing for schools on 11th November.’  Southern Health NHS Foundation Trust:  It had become evident that, whilst messages were taken, it was impossible to demonstrate later whether a message had been taken and actioned or more importantly demonstrate that a call had not been received. The Trust reviewed the message taking process across the Health Visiting Service in Hampshire and developed a standardised approach for use across the Children’s division including Health Visiting and School Nursing. This standardised approach means that when staff move around within the Trust they will always be able to follow the same process. The messages are recorded straight on to the child’s record so that the process is auditable and the information available at a later date if required. In addition the Trust has provided a specialist training package to all staff directly working with non-ambulant infants following the launch of the updated HSCB Bruising protocol. The Bruising Protocol is included in training for all Trust staff not just Children’s Division. The Trust has also developed a Single Point of Contact to provide advice and support Trust wide when staff have concerns regarding the welfare of the child. The Single Point of Contact is staffed by an experienced member of the Safeguarding Children Team which supports the exculpation of concerns particularly around challenge when other agencies do not respond as expected or there is dissent around decision making. The Surrey GP Practice:  The doctors in the practice have all been circulated with the bruising policy on non-mobile children, with a reinforcing letter. The practice child protection policy (based on the RCGP model policy) and list of local safeguarding contacts has been available on practice computers for the last couple of years. To this has now been added a list of appropriate codes for recording concerns about children/family members and a body map for recording any bruising. An update course on child protection issues run by the MDU was run at the practice in September 2013. The Family’s General Practice:  No submission, but have accepted the accuracy of the Report. See the CCGs/Wessex Area Team response below. South East Coast Ambulance Service NHS FT: The Service reports that “….We have published a Child Death Procedure for all operational staff that was subsequently supported by a further instruction to our Emergency Operational Centre staff, entitled 'Community based death in under 18's”. Both of these provide direction on who in our Trust should contact the receiving hospital and/or police in the event of unexpected or expected cardiac or respiratory arrests in under 18's. These two documents were combined as the 'Procedure for Managing Death or Life Threatening Incidents in under 18’s' and issued in April                 36  2014. Our procedures themselves are not changing, we are simply making sure there is only one document for guidance, that details staff responsibilities in an even more comprehensive format than the previous documentation”.  Frimley Park Hospital NHS FT:  In relation to the SCR recommendation about the management of phone calls: As part of the review and at the request of the legal team a full review of telephone calls during the given time-frame received into the organisation was carried out with no evidence of a call being received by midwifery. There are telephone record sheets in triage and a communication record book in Central Delivery Sheet and on the Postnatal Wards to document calls received for advice from parents regardless if the family is under the care of the midwifery service. On the 31st January a dedicated telephone advice line manned by a qualified midwife was implemented in the community midwives office. A recent audit of this has shown that recording advice and information is robust and can be easily traced. The Trust telephone system has changed recently and the Cisco system does not allow the tracing of telephone calls into individual department as before, this is apparently due to incomplete software, this was identified in a recent Serious Untoward Incident.  Frimley Park Hospital is reviewing the feasibility of purchasing additional software.    Secondly, the SCR asked FPH (and UHS) to look at their procedures in relation to such seriously ill babies where the cause is not clear so that, for example, there is always at least a clinical examination looking for signs of trauma unless to do so would harm treatment.   The following was already in place. All paediatric middle grade and consultant staff are APLS (Advanced Paediatric Life Support) trained and are aware that non accidental injury can present with altered consciousness or the clinical picture not correlating with the history given by the care giver.  APLS guidelines suggest as part of ‘exposure’ in the secondary survey of the critically ill child, a search for bruising be included following stabilisation of the child. (V was in the department for about two hours and active resuscitation and stabilisation of this child was still being addressed until care was transferred).  The ‘Bruising in non-mobile children’ policy is in the Paediatric Guidelines on the intranet.  We have recently re-presented the policy to the Paediatric Department as we have frequent staff changes. The policy has also been re-iterated in training packages to all staff.   What has changed at Frimley Park Hospital since V presented:  A proforma for the transfer out of the critically ill child has been developed. This now forms part of the transfer letter to the Paediatric Intensive Care Unit that retrieves the ill child. It has been ratified through the clinical governance process.  This ensures that a general physical examination of the child will be carried out to actively look for and document the presence or absence of bruises/evidence of neglect/suspicious behaviour in all ill children transferred out of the Trust.                   37  University Hospitals Southampton NHS Foundation Trust : The UHS Paediatric Intensive Care Unit Director has written to all Paediatric Intensive Care Unit consultants and senior nurses about looking for and recording bruises ‘particularly in circumstances where there is no clear diagnosis’. North Hampshire Urgent Care:   North Hampshire Urgent Care has made the following improvements:   All clinicians working on the rotas have completed Level 3 Safeguarding training (either through E-learning or face to face).    In addition to this they must have training in local arrangements for referrals.  This training will be completed by 30th September 2014.  The NHUC Management Council will receive training on their responsibilities for Safeguarding of Children on 6th August 2014.  The Safeguarding Children Policy has been thoroughly reviewed and updated.  The policy is available to clinicians electronically on the intranet and NHUC website and paper copies are available within the Primary Care Centres.    The flowchart for Safeguarding is available in every consulting room.  Electronic links are being developed to give out of hours’ clinicians access to the list if children on a Child Protection Plan  The clinical system, Adastra, is being configured to send a copy of the consultation notes for any child under five to the health visitor in addition to the patient’s GP  The Bruising in non-mobile babies protocol has been recirculated and knowledge of it will be audited to ensure that it is embedded within the organisation.  Clinical Commissioning Groups (CCGs) Hampshire:  Following on from recommendations 4 and 5 North Hampshire CCG (NHCCG) awarded the out of hours contract to North Hampshire Urgent Care (NHUC) in October 2013. It was updated in February 2014 with a clause that it would be reviewed annually. The next review is in October 2014. Regarding performance reviews, North Hampshire CCG and North East Hampshire and Farnham CCG (NEHF CCG) have a joint Clinical Quality Review Meeting (CQRM) quarterly to monitor the compliance and quality of care provided by NHUC.  The most recent meeting was held on 10 July 2014.  In addition to the CQRMs, a bi-monthly review on the progress of the V action plan will be submitted to the Chief Nurses of North Hants CCG and NE Hants and Farnham CCG by NHUC.   The bi-monthly reviews will also monitor the quality of induction of new staff, the level of training and compliance to legislation, ensuring that all NHUC employed GPs are trained to Level 3 (RCPCH toolkit).  The training must include the Bruising Protocol and domestic abuse awareness.                 38   Regarding staff access to guidance on safeguarding children on their website, NHUC was asked to forward their updated safeguarding children’s policy to the CCGs. The safeguarding children’s policy was forwarded to the CCGs on 18 July 2014. NHUC confirmed that the policy is now accessible to staff on their website via the staff portal.  A significant aspect of the recommendations was to ensure that GPs accessed face to face training that was scenario based. The Wessex Area Team through the Named GP offered training in March 2014 which nurses attended. NHCCG has offered NHUC places on their training schedule for GP’s 2014/2015 where the teaching will be scenario based.  The named GP will continue to work with NHUC to provide professional support.  Following on from recommendation 7 regarding communication between out of hours providers and GPs: NHUC out of hours doctors send a fax to the child’s GP following every contact. GPs can also access further information regarding a child through:   The Health Care Record. This is dependent on all GPs using Read Codes for any risk factors within the nuclear or extended family.  For individuals accessing out of hours services at Hampshire Hospitals NHS Foundation Trust, the GPs should access additional information via the triage system within the Accident and Emergency Department. This would provide them with information regarding contact with Social Care. This will be further explored by the Named GP and Designated Nurse who will also discuss this difficulty with senior members of the children’s services team.  NHUC out of hours doctors could access information directly from the local authority social care department by telephone.  The Bruising Protocol has been updated by Designated Doctors, Named GPs and Designated Nurses across Hampshire and Solent CCG’s and has been sent to all GP practices, including North Hampshire Urgent Care (NHUC).   The SCR also recommended (3) that GPs record and draw any bruises seen on a non-mobile baby, and refer the child using the Bruising Protocol. Part of the recommendations to other agencies highlighted the need for the Surrey County Bruising protocol to be in line with the Hampshire Bruising protocol. The Designated Nurses for each area have been reviewed the respective protocols to ensure that there is no difference in the management of non-mobile babies with bruises. This ensures that all staff (clinical and non-clinical) follow the same procedures. The Hampshire Bruising protocol can be accessed by staff/public on the following web-sites and links:  Wessex Local Medical Committee (LMC) https://www.wessexlmcs.com/safeguardingbruisingprotocols   The Hampshire Safeguarding Children Board                 39  http://www.hampshiresafeguardingchildrenboard.org.uk/resources-policies-guidance.html   The Hampshire five CCGs website which has a clear link to the protocol on the HSCB website       http://www.westhampshireccg.nhs.uk/about-us/safeguarding-children/useful-links-and-training-information  The following will be carried out to ensure reinforcement of the messages and maintain the awareness amongst staff members:   In September 2014 NHCCG will resend the protocol to all out of hours GP providers in North Hampshire which will be six months after the initial HSCB launch.  The Wessex Area Team is sending the protocol to all dental practices, opticians and pharmacists.  On receipt of the results of the HSCB audit for the bruising protocol due to be presented in September 2014, the CCG and Wessex Area Team will take forward any identified gaps, providing the HSCB with clear timescales of completion of actions.  The Designated and Named teams for Hampshire will:  Use this SCR within the scenario based training delivered to primary care.   Wessex Area Team of NHS England:  The Wessex Area Team and the CCG have worked with the GP practice to explore how continuity of care can be improved by patients seeing a lesser number of different GPs. The Wessex Area Team is committed to ensuring high standards for children accessing GP practices. The team has explored how continuity of care can be improved by patients seeing fewer different GPs. The Wessex Area Team emphasises the importance of applying Read Codes to highlight risk factors within a family with regard to safeguarding through its safeguarding training programme. The GP audit conducted by the West Hampshire CCG (on behalf of the five Hampshire CCGs) in October 2013 informs us that some practices aim to ensure complex families are seen by the same GP. This is encouraged by the Wessex Area Team.  Surrey Named GP (for Surrey CCGs/SSCB):  There have been some similar issues in relation to bruising in non-mobile in another recent SCR, and we are currently implementing some recommendations. We have reviewed our procedures, protocol and guidance regarding bruising. The Named GP for safeguarding has now embedded this protocol within the Surrey GPs’ level 3 training. This training is accessible to all Surrey GPs, not just practice safeguarding leads. She is also in the process of circulating the protocol to all the leads, asking them to ensure ALL clinicians are made aware of it.                 40  The Named GP has informed the LSCB of further actions. As a result of a Surrey SCR, all practice leads have been asked to ensure that ALL their practice staff are aware of who their practice lead for safeguarding children is. On continuity of care in large practices, this is an issue across the whole of primary care. Many practices do encourage patients to see the same GP whenever possible. This, however, is increasingly difficult to achieve, particularly with acute presentations, when a patient wants or needs to be seen on the same day. With extended surgery opening hours, and more GPs working less than full time with their practice, this will remain a difficult problem to solve. The key is more in robust record keeping, and appropriate Read coding, so that any concerns are picked up quickly and reliably by any clinician in the practice. Regarding access to the patient's own GP by out of hours services, there is a  prompting system that allows out of hours providers to contact us regarding specific patients, but this is pre-arranged, for example, with a terminally ill patient receiving palliative care at home. It is hard to envisage a scenario where any GP can be contacted day or night regarding individual patients; this is why the OOH service is commissioned in the first place.                                    41    APPENDIX 2   Significant  events  V’s approx. age  Significant  Event   2 months  Mother shares with GP concerns about lack of bonding with father  Mother calls a health visitor or midwife about the lack of bonding, pulling at cheeks and bruising. Probable earliest time rib fracture may have happened 14 weeks  Mother tells nursery worker that V keeps ‘hurting self’ and  there are bruises and scratches- and that the ‘health visitor’ knew. 15 weeks  Admitted overnight with an infection. A week before death  Mother discusses with GP V pulling at cheeks, and says there was a chin bruise- but not noted by the GP. Day before last admission Out of hour GP sees two bruises on each cheek. 20 weeks  Admitted with the fatal injuries. Day after admission   V dies after life support removed.                                 42    Appendix 3   Index of Acronyms  CCG Clinical Commissioning Group CEO  Chief Executive FPH  Frimley Park Hospital NHS FT HSCB Hampshire Safeguarding Children Board LSCB  Local Safeguarding Children Board NAI Non Accidental Injury NHS FT NHS Foundation Trust NHUC North Hampshire Urgent Care PICU Paediatric Intensive Care Unit SCAS South Central Ambulance Service NHS FT SCR Serious Case Review SEC South East Coast Ambulance Services NHS FT SH Southern Health NHS FT SOL Solent NHS Trust UHS University Hospital Southampton NHS FT                Final v H1b 