Injuries to an 8-week-old girl in 2019. Beatrice was taken to a walk-in centre concerning a rash and was found to have unexplained bruising. An ambulance was called and Beatrice was taken to hospital where scans showed 13 fractures to ribs and legs of differing ages. Beatrice's parents did not live together. Father suffered from depression, had anger issues and was diagnosed as having Asperger's Syndrome. Mother had made allegations of sexual abuse against her father, and had a history of self-harm and suicidal ideation. Father had attempted suicide previously and Mother had a history of risk taking. Concerns over both parents not taking prescription medication. Family proceedings and criminal investigation were in progress at the time of writing the review. Ethnicity and nationality not stated. Learning includes: local authorities should liaise around support to care leavers living across boundaries; where there is a history as a care leaver, background information should be sought from the responsible authority; police should take a more holistic view of a person's circumstances and consider information sharing to protect a child, even in cases where the child is not yet born. Recommendations include: agencies working with care leavers must be aware of the right for care leavers for service provision up to the age of 25-years-old; request guidance on information sharing between local authorities where care leavers are not living in the area of the responsible authority; ensure information sharing policies are in place and include all cases, not just those managed under formal child protection procedures.
      
    Sefton Local Safeguarding Children Board (LSCB)    Serious Case Review (Beatrice)  January 2020   Jane Booth Independent Author   2  Contents:        Page  1. Introduction        3        2. The review        3            3. Views of the family       5    4. Background        6  5. Childhood histories and transitions from child to adult services 6  6. Significant information prior to the timeframe of the review 8  7. Significant events/practice episodes during the period  covered by the review       9  8. Analysis and learning       15  9. Good Practice        20    10. Conclusions         21  11. Recommendations       22   3  1. Introduction  1.1 This review arises from concern about injuries to a child to be known as Beatrice was taken by her mother and paternal grandmother to the walk-in centre as they were concerned about a rash.  Beatrice, at this point was eight weeks old, and was found to have unexplained bruising and an ambulance was called to take her to the hospital.    1.2 Over the next few hours more bruising became apparent.  Subsequent examination and scans showed thirteen fractures to ribs and legs of differing ages.  Parents said Beatrice had been unwell for the last couple of days but could offer no explanation for her injuries.  1.3 The parents stated that they did not live together.  Beatrice lived with her mother.  Father was said to live with paternal grandmother but spent much of his time at mother’s home.  Paternal grandmother offered support and was the only other person to have taken part in Beatrice’s care.  1.4 At the time of writing this report, both family proceedings and a criminal investigation were in process.  2 The Review  2.1 Sefton Local Safeguarding Children Board (LSCB) Practice Review Panel (PRP) considered whether the case met the criteria for a Serious Case Review.  In accordance with paragraph (1) (e) of Working Together 20151 a serious case is one where;   a) abuse or neglect of a child is known or suspected; and    b) Either — (i) the child has died; or (ii) the child has been seriously harmed and there is cause for concern as to the way in which the authority, their Board partners or other relevant persons have worked together to safeguard the child.    2.2 The PRP concluded that the criteria for a Serious Case Review had been met and recommended a review be undertaken. Jane Booth was appointed as the independent author to complete the work and a Serious Case Review Panel established to support the work and ensure timely completion.  The independent author has never worked for any of the agencies involved in this case, has considerable experience in the field of social care and has previously authored reviews for other Safeguarding Boards in the North of England.  2.3 The report generally refers to family members using their relationship to the child e.g. paternal grandmother.  Professionals are referred to by the role they fulfilled.   2.4 The PRP set the following terms of reference for the serious case review;                                                             1 Although Working Together 2018 had been issued prior to the commissioning of this review, the review was commissioned prior to the move to new arrangements and therefore under the 2015 requirements. 4   o Establish lessons to be learnt from the case regarding the way in which local professionals and organisations work individually and together to safeguard and promote the welfare of children.   o Identify clearly what those lessons are, both within and between agencies.    The review will consider the following issues: o Transitional arrangements from children’s services to adult services o Understanding the known and unknown vulnerabilities of Mum o Understanding the known and unknown vulnerabilities of Dad o Multi-agency working in assessment, risk management, safety planning and permanence o Connectivity with health services.  2.5 The following agencies contributed to this review:  o National Probation Service o Merseyside Community Rehabilitation Company o Merseyside Police o North West Borough Healthcare NHS Foundation Trust  o Mersey Care NHS Foundation Trust o Southport and Ormskirk Hospital NHS Trust;  o Alder Hey NHS Foundation Trust;  o Liverpool Women's Hospital NHS Foundation Trust o GP surgery o Sefton Children’s Social Care  o Sefton Early Help Service o Sefton IRO Service o One Vision Housing  2.6 Access has also been provided to records held by Children’s Social Care Service from a neighbouring local authority who were responsible for mother’s care as a child. Father lived in another local authority area up to 2012 but attempts to identify records have been unsuccessful and it seems likely there was no social care involvement.   2.7 The timespan considered by the review was set as 01.08.18 to 03.06.19  2.8 The methodology used for the review involved the development of single agency chronologies which were then integrated into a single timeline of agency involvement.  Practitioners, and some managers, who had worked with the family were invited to a practitioners’ learning event where key issues arising from the chronology were considered alongside the terms of reference for the review.     5  3 Views of the Family  3.1 The parents and paternal grandmother were invited to make a contribution to the review.  It was initially agreed that father and paternal grandmother would meet with the reviewer after the completion of the fact finding hearing2 in care proceedings. Mother was initially unsure.  In the event paternal grandmother did meet with the reviewer but father did not, and mother made a contribution via telephone. 3.2 Paternal grandmother has always supported her son and was keen to support both parents with preparation for, and care of the baby.  She knew that mother had support from what she thought was a psychiatric nurse, and knew she had been in care.  She knew that parenting would be likely to present a challenge for both parents.   3.3 Paternal grandmother was contacted during the course of the pre-birth assessment.  She stated this consisted of a 10-minute phone conversation with the social worker.  During the court proceedings she says she heard a lot of background information that she did not know, some of which she believes her son also did not know.  3.4 Paternal grandmother encouraged the parents to engage with any help offered and they were both positive about this. She believed agencies were talking to each other.  Her perspective on the extent to which the Asperger’s Service knew about the relationship and pregnancy is at variance with the information submitted for the review.  Paternal grandmother states that she attended an appointment with father when the relationship was discussed and that on at least one occasion mother also attended when obviously pregnant.   3.5 Paternal grandmother feels she was identified as an important support but kept in the dark.  She did not know the extent of mother’s vulnerabilities, or her risk-taking behaviours.  She feels it is also possible that father did not know, almost certainly, about the risks arising from going to high places.  3.6 Mother states that she was open with professionals from the start about her history and her own anxieties about being a first-time parent. She states she was keen to accept all and any help offered, and even when she knew it would be difficult for her, e.g. the parenting group, she would have tried to take advantage if more support had been offered.  3.7 She says that she was frightened that her history would result in her child being taken into care but wanted to work with Children’s Social Care.  She was anxious about the outcome of the pre-birth assessment and had to ring up to find out the outcome.  She was surprised to be told the case had been closed. 3.8 Mother is angry with agencies and feels let down.  She is aware that there were some issues about multi-agency communication and does not understand why this                                                            2 Fact-finding hearings are used in Care proceedings (where the Local Authority has concerns about children) to decide important issues that are in dispute between the parties or to find out what happened on an occasion. They are generally used to decide on a factual issue, to inform an assessment or welfare report.  6  happened.  She says she attended the Asperger’s Service with father when he was having difficulty dealing with feelings of anger, when she was clearly pregnant and recalls his medication being increased.   3.9 She says she would have welcomed early help and doesn’t know why this was not arranged before the baby was born.  She says some professionals cancelled appointments with her and does not feel she was always listened to when she voiced concerns.  She was however pleased that the support from the Personality Disorder Hub was extended beyond the usual 2-year period.  4 Background  4.1 Father and paternal grandmother were not known to local social care services.  Father was receiving support from the local Asperger’s Team, and had a history of depression and suicidal ideation.  4.2 It was known that mother had been a looked after child in a neighbouring area and was residing in Sefton when still a care leaver.  She was receiving support from mental health services in Sefton as an adult. On leaving care she had lived in supported accommodation prior to obtaining her own tenancy.  She had a history of offending, linked to a mental health episode in 2017 – a single incident of assault on a health professional and police.   4.3 Mother had a significant history of self-harm and suicide ideation, was under the care of a psychiatrist and was being supported by the Personality Disorder Hub, via a two-year intensive programme.  A Care Programme Approach Care Plan was in place.    4.4 A Pre-birth Assessment was undertaken by Children’s Social Care between August and November 2018 and did not identify the need for ongoing support/intervention from the service.    4.5 Mother accessed local community midwifery services in Sefton and opted for a hospital delivery at a hospital across the local boundaries. Midwifery services made appropriate referrals to Children’s Social Care. The hospital produced a care plan in consultation with the specialist mental health midwife and, post-birth, there were routine midwifery visits, visits from the 0-19 (health visiting) service and a referral was made to the Early Help Service.   4.6 Beatrice was presented to the GP on a number of occasions with minor health issues, all were appropriate concerns.  5 Childhood histories and transition from child to adult services  5.1 Mother is a member of a large family.  Maternal grandmother (mother’s own mother) is recorded as having both a visual impairment and a learning disability.  Concerns regarding neglectful care, physical abuse, domestic abuse and the home being” chaotic”, are recorded.  7   5.2 When mother was fourteen years old the school made a referral to their local Children’s Social Care (the family lived in another local authority area at the time) about a possible pregnancy, drinking and allegations that mother was having sex with an adult.  It was established that she was not pregnant.  There is no record of the outcome of the allegation regarding sex with an adult nor any reference to possible sexual exploitation.  5.3 Family relationships were highly conflicted.  Maternal grandfather was alleged to have physically abused and controlled his wife, and to have physically abused the children.  Mother was also recorded as a perpetrator of violence towards her siblings.    5.4 On 1 September 2009, when aged 14 years, mother alleged sexual abuse by her own father (maternal grandfather).  She reports that she was not supported by her own mother (maternal grandmother) and was rejected by the family.  She became a looked after child. As she moved towards adulthood she moved into supported housing and was provided with the support of a leaving care worker.  She continued to receive this support until the age of 21 years.  She had a number of placements but finally settled well in a residential unit where she made friends and had a good relationship with staff.  She continued to receive support from the unit after she left.   5.5 Mother is said to have received support from the Child and Adolescent Mental Health Service (CAMHS) in a neighbouring area.  This was outside the time frame for the review and has not been further explored.  It is not known whether she ceased one service and later represented or whether formal transition arrangements were carried out.  It is clear however that by the time mother was an adult she was known to adult mental health services due to significant self-harm and suicide ideation resulting in presentation at emergency services.  She was diagnosed as having an unstable Emotional Unstable Personality Disorder and has been in receipt of specialist services.  Mother herself has been open with professionals about her childhood so these issues were known to the Personality Disorder Hub.  5.6 Father is one of three children and little is known about his childhood experiences.  He was not known to local Children’s Social Care and attempts to identify any information held in neighbouring authorities has been unsuccessful.  5.7 It is known that he was electively home educated from around the age of 13 years and GP records state he self-reported that he was referred to the Child and Adolescent Mental Health Service but did not attend. The Asperger’s Service have been entirely reliant on self-reporting from father regarding his history  Analysis and learning re transitions 5.8 Mother’s transition to adulthood was supported via a neighbouring authority’s leaving care service up to the age of 21 years and she continued to receive emotional support from staff at her last placement beyond this point, on an informal 8  basis.  Despite her significant mental health problems, she appeared to cope well in practical terms, making her own arrangements to move on from supported housing and managing her finances well.  It is not clear whether extending the care leaver support beyond 21 year was considered but the presenting problems at this time were all associated with her mental health and by the time the leaving care support ceased, she was being supported by adult mental health services.  In the event, Children’s Social Care in Sefton were not informed that another authority were supporting a care leaver in their area.  Learning point 1: In general, it would be good practice for local authorities to liaise around support to care leavers living across boundaries. (In this case it is unlikely that this would have resulted in any additional active support being offered to mother.)  5.9 It has not proved possible to trace records of father’s childhood history.  What is clear is that there is no record of engagement with children’s social care, either in Sefton or in neighbouring areas.  His last involvement in formal education appears to have been in Lancashire in 2005 at which point he became home educated but it has not been possible to trace any records.   5.10 The only specialist service working with father was the Asperger’s Service and they have no information regarding father’s history other than that which he provided himself.  He was referred to them by the GP.  It would appear there were no arrangements or plans developed to ensure smooth transition from child to adult services.  6 Significant information prior to the time period of the review  6.1 During 2015, prior to the period under review, mother had two episodes of compulsory admission to mental health settings.  During 2016-18 she had 26 Accident & Emergency Department (AED) attendances resulting in 13 admissions linked to her mental health and in 2017 she was convicted for an assault on hospital staff and police – linked to a mental health admission.  There is one reference to cannabis use in MASH3 records but drug use was not noted as an issue in recent times.  6.2 During the period immediately prior to the review, father is recorded as having made a suicide attempt after a breakdown of a previous relationship.  GP notes reference drug and alcohol use but no agencies record serious concerns regarding this.  He is recorded as suffering from depression and was diagnosed as having Asperger’s Syndrome in June 2018.  6.3 It is understood by some agencies that the parents met online.  It is not clear whether they actually lived together as father maintained that he was living with his mother (paternal grandmother) whereas mother’s conversation with professionals suggested he was with her much of the time. Whilst services supporting mother                                                            3 MASH refers to the Multi-agency Safeguarding Hub which is the gateway for incoming referrals to Children’s Social Care 9  knew about her relationship with father and that he also had mental health problems, he too disclosed his relationship with the mother to the Asperger’s Service.  6.4 Both parents were known to be unreliable in terms of taking their medication.  7 Significant events/practice episodes during time covered by the review  7.1 In March 2018 mother became pregnant but in April 2018 records indicate that there was a miscarriage and reference to this having been “a molar pregnancy”4.  There is no note of any significant response from agencies or any work done with mother around this.  7.2 In July 2018 father was assessed at the “single point of access”, an entry point for mental health services.  He said he was struggling with anger.  He made no mention of being in a relationship, the impact of the miscarriage, or the possibility of being a parent in the near future.  He said his outbursts could be set off by the smallest thing (giving an example of having run out of milk) and that his anger was generally directed towards his immediate family.  He was referred back to the Asperger’s Service. He was not explicitly asked about caring responsibilities.  7.3 Three weeks later mother attended the early pregnancy assessment unit where a scan confirmed a 6-week pregnancy.  She stated that both she and her partner were feeling positive about the pregnancy.    7.4 Later in August 2018 a student social worker commenced a pre-birth assessment (referral having been made by the local midwifery service).  Although father was known to have Asperger’s Syndrome, there appears to have been no discussion with him about how this manifests, and what impact it might have on parenting nor any contact with the Asperger’s Service.  There is no record of discussion about their relationship or about the recent miscarriage.  The MASH5 enquiry generated on 20 August 2018, when the referral was made, had indicated that mother had been a cannabis user, but this also was not discussed. There does not appear to have been any discussion about the recent miscarriage and its impact on the parents.  7.5 At this time mother’s period of support from the Personality Disorder Hub was due to come to an end due to the natural conclusion of a two-year programme of work.  Mother was expressing concern about this.   7.6 On 28 August 2018, the police responded to a report from a member of the public that mother was on the railway bridge and maybe about to jump.  She had left by the time they arrived, but they located her nearby.   They obtained good information                                                            4 A molar pregnancy is where a foetus doesn't form properly in the womb and a baby doesn't develop.  A lump of abnormal cells grows in the womb instead of a healthy foetus.   10  from contact with mental health services, including the possibility that she was pregnant (not yet confirmed).  Mother herself denied this and denied being suicidal.  A common pattern of behaviour for her has been to go to high places, bridges or car park roofs usually resulting in an emergency service call-out.  She generally has said this was to “let off steam” and not part of a suicide attempt.  She has not generally acknowledged the inherent dangers.   7.7 The police dropped mother off at AED on a voluntary basis so she could access the mental health crisis service.  Information about this event was shared with mental health services for mother but does not appear to have been known to either midwifery or children’s social care.  7.8 Early September 2018 both parents attended the booking appointment at a local hospital.  Both were present for most of the appointment but routine screening for domestic abuse took place without father there.  A referral was made by the midwife to the perinatal mental health at the local hospital.  Mother declined this referral although she was seen at a later date by the perinatal mental health midwife.  Additionally, a second referral was made to Children’s Social Care.   7.9 Comprehensive histories were taken for both parents and they disclosed their mental health histories.  Both were said to be smokers and a smoking cessation referral was made for mother.  The parents stated they did not live together but that father would be spending more time with mother after the birth.  7.10 The Care Coordinator from the Personality Disorder Hub continued to give weekly support and made additional visits jointly with the social worker doing the pre-birth assessment.  The Care Coordinator is recorded as giving considerable support and re-assurance to mother and described the coming baby as a “protective factor” for mother.  Father had disclosed that he had Asperger’s Syndrome, but no detailed information was sought and no supporting services identified or contacted.  The Asperger’s Service remained ignorant of his relationship and the pregnancy.    7.11 As part of the completion of the pre-birth assessment the social worker contacted the psychotherapist at the Personality Disorder Hub.  The psychotherapist stated that mother did not attend very often.  The social worker recorded the psychiatrist as saying “…. the birth of the baby will be a great event for mother as she is a very capable person and will make a good mother with the right support around her”.  There is no record of a risk assessment re parenting having been completed by the Personality Disorder Hub at any point.  Maternity Services at local hospital were not consulted regarding the pre-birth assessment.  7.12 At the end of September 2018 there was a second joint visit by the Care Coordinator from the Personality Disorder Hub and the social worker.  At this time mother’s support from the Personality Disorder Hub was due to come to an end and the record states “…. she was looking forward to moving away from services and for case management to come to an end”.  Shortly afterwards the Children’s Social Care record notes that her mental health support will continue until November 2018.  It quotes the practitioner from the Personality Disorder Hub as 11  saying that mother has the ability to manage risks to her unborn child, has a good understanding of child development and the importance of taking her medication.    7.13 From the beginning of October 2018, the “enhanced” team midwife6 visited at home every two weeks.  At the local hospital information is documented in hand-held records and on an electronic maternity information system.  Mother was seen in the antenatal period and post-natal period by local maternity hospital so any documentation written in hand-held records would not be duplicated on local hospital electronic records.  Mother retained these hand-held notes and they have not been available for review.  Mother was referred to a parenting class “Mellow Bumps” but she did not attend.  Practitioners from the Personality Disorder Hub indicated at the practitioner event that her condition makes group activities very difficult for her.  The parents were still said to be living separately.  7.14 At the end of October 2018 mother telephoned the Personality Disorder Hub and expressed concerns about whether she will be a good mum.  She had left the house and said she was going somewhere to “clear her head”.  She said she had her medication with her and feared she might take an overdose.  There is no evidence that this information was shared with Children’s Social Care or with the midwife who was not aware of mother’s risk-taking behaviours.    7.15 Around the same time the social worker received an email from the consultant psychiatrist who described mother (also not aware of the recent incident) as doing well, calm, and with no episodes of self-harm or suicidal ideation.  On this basis he said she was to be discharged from the service.  However, support continued to be provided by the Personality Disorder Hub throughout the pregnancy and beyond although there is no recorded decision about his. At the end of October 2018 in a telephone conversation with a practitioner at the Personality Disorder Hub, mother stated she was struggling and feeling more isolated.  She said she had been thinking about self-harm but would not take action due to the baby.   7.16 On the 2 November 2018 mother made a telephone call to the Personality Disorder Hub. She reported having “low mood”.  She was sitting on top of a car park she was observed by CCTV and the police were alerted.  She is described as “very fearful”.  She said that father was at his mother’s and was not being supportive at present.  During the conversation the police arrived and talked mother down.  She agreed to go to the Personality Disorder Hub.  Once there, she reiterated her concerns and agreed strategies to keep her safe overnight.  Arrangements were made for the “safe and day” service to visit overnight and at the weekend. Mother was described as “chronic risk of self-harm and suicidal ideation but no evidence of acute risk”.  Information about this incident was not shared with Children’s Social Care or midwifery.    7.17 On the 5 November 2018 mother was still feeling low and stated she was thinking about going to a car park but denied being suicidal.  Possible admission to hospital was discussed but she declined this.  Her medication was subsequently increased.                                                             6 This term is used to refer to a midwife with specialist skills in respect of mental health. 12  Her GP was notified of the medication increase but no details were shared with any other agencies.   7.18 On 13 November 2018 the Pre-birth Assessment was signed off as completed by Children’s Social Care.  It stated:    “Mother has mental health issues which can be triggered by stress and if medication is incorrectly managed. Having a new born baby will increase stress levels therefore having additional support available for mother is essential to safeguard the health and well-being of the baby, mother, however has engaged well with the assessment and is currently presenting as stable.  She is able to identify her low moods and address it appropriately.  She has good rapport with her psychiatrist who monitors her medication and mood regularly.  Mother has family support from paternal family and knows where to access support from external services.  Mother does not feel she needs a Social Worker and currently there is no role for Children’s Social Care.  Case to close, however health services will be monitored closely and if concern arises in the future the case will be referred to Children’s Social Care”.  It is not clear which part of the health economy this refers to.  At this time the local hospital, who were providing antenatal care, were not aware of the assessment.  7.19 In December 2018 there are two entries in the mental health record which described mother’s mood as “fluctuating”.  This did not prompt contact with Children’s Social Care.   7.20 There are two references in January 2019 to appointments with a family therapist from the Personality Disorder Hub in respect of a “parent-infant assessment” which are shown as not attended by mother and in February 2019 mother cancelled her appointment with her mental health worker.  These cancellations do not appear to have been explored further.   7.21 Records of a conversation between a health visitor and the Care Coordinator in the Personality Disorder Hub state that the Care Coordinator had indicated that they had no concerns about mother’s potential ability to bond with her child although mother herself was expressing concern in view of her own childhood experiences.  The practitioners agreed there was a need for an early help assessment but concluded this best be done after birth of baby.   7.22 As the due date for the baby neared, the local hospital, where she was to give birth, developed a birth plan.  Mother was advised that she should remain in hospital for 72 hours after the birth of the baby.  The plan included a comment from mother about the importance of sleep deprivation as a factor in her mental health.  There is no further reference to this.    7.23 In March 2019 father is recorded by the Asperger’s Service as reporting feeling angry. He stated he had not been taking his medication (baby due in 3 weeks).    13  7.24 On 15 March 2019 mother was increasingly suffering with pelvic pain.  She reported to the antenatal midwife that she continued to have thoughts of self-harming.  Children’s Social Care were contacted in respect of the midwifery plan of care but reported that the case was closed.  In the plan of care mother’s own words were quoted and she acknowledged the risk that her health might deteriorate following the birth.  She referenced the support from the Personality Disorder Hub and denied any risk-taking activity during her pregnancy.  7.25 On 25 March 2019 mother was admitted to hospital.  The midwife made a second call to Children’s Social Care to check the information about the case being closed.  This was confirmed.   7.26 Beatrice was born in the early hours of the 27 March 2019.  It was a difficult delivery and mother was quite unwell.  She received one unit of blood but subsequently refused a second unit – against medical advice.  Despite the discharge plan for 72 hours in hospital mother discharged herself.  7.27 During the next eight weeks Beatrice was seen by a number of professionals.  The midwifery and health visitor contacts were in line with expected practice. The contacts that the parents initiated with GP or emergency/urgent care services were considered to be appropriate contacts generally in response to an identifiable concern.  7.28 On 29 March 2019 the “enhanced” midwife visited as did the practitioner from the Personality Disorder Hub who recorded mother’s mental health as good but noted she had been forgetting to take her medication.   7.29 On 1 April 2019 parents made a 111 call and were advised to go to GP which they did. They described Beatrice’s feet as going blue.  The GP examined the baby and recorded “Mum concerned about clicky knees; no abnormalities found”.  The enhanced midwife also records a visit on this date.  7.30 On 3 April mother had a telephone consultation with the GP who reduced her medication, recording that that she was to reduce antidepressants by one and continue taking the Fluoxetine.  Regular visits continued from the Care Coordinator in the Personality Disorder Hub.  7.31 On 5 April 2019 the enhanced health visitor made a joint visit with the Care Coordinator from Personality Disorder Hub. The Health Visitor’s record reflects good practice with all relevant areas discussed.  The Care Coordinator reports that she was visiting three times a week and has no concerns.  Mother is recorded as now only taking her anti-depressants.   The property is described as very untidy, particularly the bedroom. The Health Visitor noted that an early help assessment is required.  The parents agreed to an early help assessment and the referral was made.   7.32 On 8 April 2019 parents brought Beatrice to the GP.  The GP recorded a small mobile lump on cheek and re-assured the parents.  On 12 April 2019 the health visitor made a home visit and recorded that the baby was distressed and seeming 14  to be hungry.  There were no sterilised bottles.  The Health Visitor recorded positive interaction between both parents and the baby.  7.33 On 13 April 2019 the parents made a 111 call re reduced feeding and fewer wet nappies.  They were advised to go to AED where the baby was observed with low temperature and kept in overnight.  The baby was subject of a full medical examination.   7.34 On 24 April 2019 there was a home visit by the health visitor – again thoroughly recorded and reflecting good practice.   Oral thrush was noted and a prescription given.  It was noted that the family had moved house though father was still living with paternal grandmother but staying over some of the time.  7.35 On 30 April 2019 mother is recorded as having a “new patient check” presumably changing GP following the house move.  She is recorded at this point as only taking Fluoxetine.  7.36 On 8 May 2019 the Health Visitor and Personality Disorder Hub Care Coordinator made separate visits and Beatrice was taken to the GP who recorded oral thrush.  This was the 3rd visit from the health visitor and she made a thorough recording of a visit which reflected good practice.  She noted the house as “very untidy”. Mother reported that she was taking her medication. The record from the Personality Disorder Hub notes no concerns  7.37 On 9 May 2019 parents brought Beatrice to GP – with concern re bleeding from rectum and on 11 May 2019 went to AED via ambulance re bleeding per rectum - query anal fissure due to constipation.  This was followed up in phone call with the Health Visitor the next day and advice was given re feeding regime as mother had put Beatrice on “hungry baby milk”.  7.38 On 15 May 2019 the Early Help Service made a first visit jointly with the Health Visitor.  Father was described as quiet throughout.  The referral had been made by the health visitor.  The full extent of the mental health information was not known by the health visitor so this was not passed to the Early Help Worker and, as she did not know about mother’s risk-taking behaviours or lapses in medication taking during pregnancy, these were not communicated.   7.39 On 20 May 2019 mother attended the GP surgery, who recommended a type of antidepressant.  Her mood was described as low and poor sleep and lack of motivation were noted. The next day the Health Visitor made a visit – Beatrice’s weight had reduced on centile chart. Mother indicated that, despite previous assurances to the contrary she had not in fact been taking her medication and found it hard to motivate herself to do routine things.  The family were struggling with accommodation issues and mother was having some difficulty with her benefit payments.  7.40 On the 22 May 2019 the Personality Disorder Hub Care Coordinator visited and mother again indicated she had not been taking her medication. The record states 15  that on the surface she appeared upbeat and in good spirits and no acute risk was noted.   7.41 On 22 May 2019 Beatrice was taken to the GP and the 6-week baby check was completed.  The was baby examined and the notes record no abnormalities and no concerns.  7.42 On 23 May 2019 Mother telephoned the Health Visitor reporting teething problems and reduced feeding. She was given advice and told to take Beatrice to the GP if she continued to refuse feeds. Later that day Beatrice was taken to the walk-in-centre where injuries were observed and she was transferred to local children’s hospital.  8 Analysis and learning  Understanding the known and unknown vulnerabilities of mother  8.1 Mother informed midwifery and other professionals of her history and of her Emotional Unstable Personality Disorder and depression herself.  This was not checked out with the area where she had been in care and some potentially important information was missing.  Midwifery services made appropriate referrals to Children’s Social Care for a pre-birth assessment to be completed.    8.2 The pre-birth assessment was completed by a student social worker and contained relevant information provided by mother about her childhood history. Again, the allegation of possible abuse of her siblings was not disclosed.   8.3 The assessment drew on information provided by other local services, but this was incomplete, and factually inaccurate due to lack of communication between services.  Whilst the nature of mother’s history and her vulnerabilities were recorded, their potential significance does not appear to have been recognised.  8.4 The incident the police attended on 2 November was not notified to Children’s Social Care.  This may be because mother did not at that time have children, but this meant an opportunity was missed – the pre-birth assessment was signed off only a couple of weeks later in ignorance of this event.  8.5 Mother’s history of a neglectful and abusive childhood was known to the Personality Disorder Hub and mental health services.  These experiences are known to create an increased risk of compromised parenting and mother herself had expressed concern.    8.6 While those with a Emotional Unstable Personality Disorder can and often do make good and committed parents research clearly highlights the issues which they might face7.  Parental Emotional Unstable Personality Disorder is identified as a risk factor for impaired parenting behaviours and disturbed parent-child relationships.  This risk was not referenced in the care plan in place in the Personality Disorder Hub and this                                                            7 The link between personality disorder and parenting behaviours: A systematic review; Sarah Laulik, Shinning Chou, Kevin Browne, Jayne Allam 2013 16  plan did not appear to have been updated to include the information about the pregnancy until after Beatrice’s injuries had been identified and care proceedings initiated.    8.7 Throughout the pregnancy the Personality Disorder Hub Care Coordinator provided re-assurance to mother that she would make a good parent but there is no evidence of any kind of assessment. She had been involved with mother for around two years and perceived her to have made good progress during that time.  It is possible that the “rule of optimism”8 was a factor influencing her judgement.  This is a well-documented phenomenon, often referenced in Serious Case Reviews.  Caution should be exercised however in seeing this in over-simplistic terms which lay blame at the door of the practitioner, and more modern research emphasises the importance of seeing this within the context of the organisational frameworks supporting good practice such as the provision of reflective supervision.     8.8 The Personality Disorder Hub Care Coordinator did refer mother to a family therapist from within the service, but mother did not follow this up.  She was also offered access to parenting preparation classes via the midwifery service but these were group activities which her Emotional Unstable Personality Disorder prevented her from taking part in and no alternative options appear to have been considered.  8.9 Mother also suffered from depression.  Sefton’s own practice guide in respect of mental health points out that 25% of children subject of a child protection plan have a parent with a mental health problem and that it is a factor in a third of cases considered under a Serious Case Review.    8.10 Mother’s need for general parenting support were referenced in records, and father (and paternal grand-mother) seen as a source of support.  The nature of their relationship does not appear however to have been fully explored and it might have been anticipated that their individual needs would have made forming and sustaining relationships more difficult for both of them than might be the norm, but there is no record of this being assessed.  The relationship was less than a year’s duration and they had had to deal with an unplanned pregnancy resulting in the loss of the baby followed very shortly by the pregnancy with Beatrice.  Mother had moved house into what turned out to be less than satisfactory premises and was having problems with her benefits.  There is no evidence that there was recognition of the potential impact of these cumulative difficulties.  8.11 On at least one occasion mother left the home distressed following some sort of difficulty with the relationship and on another expressed concern that father was not giving her enough support. Mother shared concerns with midwifery about her need for post-natal support and in particular a worry that lack of sleep might impact on her mental health but the extent to which father would actually be there was not explored – he did always seem to be there when visits were made but both maintained he was continuing to live with his mother.                                                            8 Revisiting the Rule of Optimism Martin Kettle, Sharon Jackson 2017  17   8.12 Mother had been alleged to have abused siblings while still herself a child and had been convicted of a violent offence associated with a mental health admission to hospital.  There is no evidence that she was prone to general violent outbursts but this was not explored.   Learning Point 2:  Where risk factors are evident the importance of full information cannot be over-emphasised.  While the self-disclosure of information is positive it cannot be assumed that this is complete, and confirmation should be sought where possible.  Specifically, where there is a history as a care leaver background information should be sought form the responsible authority.  Learning Point 3: It is important for the police to take a more holistic view of a persons’ circumstances and, although not yet a parent, to consider information sharing to protect a child, albeit not yet born.   Learning Point 4:  Mother’s parenting capacity needed to be specifically assessed taking account of relevant research re parenting and Emotional Unstable Personality Disorders.  Learning Point 5:  Little information was obtained in respect of father – this is commonly reflecting in reviews where the male partner is almost the invisible male. The absence of more professional curiosity resulted in a lost opportunity.    Understanding the known and unknown vulnerabilities of Dad.  8.13 Father’s childhood history was not explored in any detail by any of the services involved.  It is now known that he was electively home educated from around the age of thirteen but the circumstances leading to this and the impact upon him were not known or explored.    8.14 He had a history of depression and had attempted suicide following the breakdown of a previous relationship.  There is no evidence that this had been considered in terms of any future breakdown of relationship and any protective action plans developed.    8.15 Father was being supported by the Asperger’s Service, but he had not told them about his current relationship or the pregnancy.  They believed he was living with and being supported by his mother.  They had no reason to carry out any kind of parenting assessment and were not informed of nor involved in the pre-birth assessment. Had father been routinely specifically asked about relationships he may well-have disclosed the information.  8.16 Although he disclosed his mental health issues to Children’s Social Care when the pre-birth assessment was being done – both Asperger’s and depression - these were not taken full account of in terms of potential impact on parenting capacity.  The student social worker did not contact either mental health or the Asperger’s Service in respect of father.  His recent contact regarding angry outbursts was therefore not known or addressed in the assessment.  18  8.17 Research clearly indicates that a pre-birth/parenting assessment would have been appropriate and that some of the features associated with Asperger’s can make parenting a significant challenge.9 Parents often have to deal with fast moving situations, and factors which can be seen as overstimulating in cognitive terms, leading to stress and the possibility of being overwhelmed. These are described as having “organic” neurological components and require specific and focussed assessment.  8.18 Some records do contain historical reference to use of drugs and smoking.  There were no indications that these were current issues, but they were not explored in the assessment.  At the booking appointment at local maternity hospital, it is documented that both mother and father smoked one cigarette a day and mother’s CO reading was 0ppm. She stated never used substances and did not drink alcohol.  Learning point 6:  It cannot be assumed that all services hold all relevant information so particular care should be taken to check this out and adopt a “think family”10 approach.  Multi-agency working in assessment, risk management, safety planning and permanence.  8.19 Mother had a long-standing involvement with the Personality Disorder Hub and there was good contact between the service and Children’s Social Care during the completion of the pre-birth assessment, including joint visits.  A student social worker sought information from other agencies, but Children’s Social Care undertook the analysis and decided the outcome on single agency basis.  Although the pre-birth assessment should not have been finalised until after the baby was born, the conclusion was to close the case.  This meant that there was no under-pinning framework to support multi-agency working.  Had the risks been more thoroughly assessed then a multi-agency meeting, such as a Child Protection conference, was likely to have been the outcome and would have facilitated both a multi-agency assessment of risk and the development of a joint safety plan.  8.20 The decision by Children’s Social Care to close the case, and the expectation that mother’s needs (both as an individual and as someone about to become a parent) could all be met by her continuing involvement with the Personality Disorder Hub, were not jointly agreed with the Personality Disorder Hub.  However, there is no evidence that this expectation was challenged once known. Mental health practitioners at the learning event said that their experience was that it was not uncommon for other services to “back away” from cases with mental health                                                            9 The Aspergers Comprehensive Handbook - Mark Hutten 10 SCIE: At a glance 9: Think child, think parent, think family - Published: May 2012; Key messages Think child, think parent, think family in order to develop new solutions to improve outcomes for parents with mental health problems and their families.  Take a multi-agency approach, with senior level commitment to implement a think family strategy.   19  components. They felt it reflected a poor understanding of the needs of people with mental health problems and mirrored the responses often found within the community.  8.21 The possible impact of the Emotional Unstable Personality Disorder as a potential parenting risk was not acknowledged and so no risk management plan was put in place within the Personality Disorder Hub.  In fact, the pregnancy and birth of the baby were seen as potentially protective factors for mother and likely to reduce mother’s risk-taking behaviours, though the evidence that this happened is dubious.  There was no evidence of a focus on the baby’s needs from within the Personality Disorder Hub.  8.22 The midwifery service had made referrals for the pre-birth assessment and checked back with Children’s Social Care regarding the outcome. They had been told the case had been closed but made a further check suggesting that they had not expected this outcome. They did not however have full information and did not challenge the outcome formally.  A discharge plan was agreed with mother and this identified where she would get her support but was not shared beyond midwifery services.  Learning point 7:  An effective pre-birth assessment is key to the development of an appropriate plan to support and safeguarded the well-being of children.  Where this is allocated to a student social worker it is important that they are fully supported and supervised and that there are good quality control mechanisms in place.  Learning point 8:   Where a number of agencies are involved, it is important that there is good information sharing.  This may be via the Child Protection planning processes, Child in Need frameworks or via an Early Help offer.  It is important that a lead professional is identified and that they take on the responsibility of coordination and information sharing.     Learning point 9:  Decision making about the outcome of an assessment should be communicated to all relevant parties and should be subject of professional challenge if not agreed or seen as inappropriate. (Sefton now has a new pre-birth protocol that states all agencies involved should take part in decision making).  Connectivity within health services  8.23 A single recording system supports practice across the mental health services so those in contact with mother in the Accident & Emergency Department (AED)/Urgent Care setting, crisis response and Personality Disorder Hub teams all had access to information held on record.  All were able to access the care plan and it informed their responses, for example staff in AED knew that it was felt to be unhelpful for mother to be admitted to hospital and generally acted in accordance.  8.24 It is not clear whether the psychiatrist accessed this joint record before responding to the request from Children’s Social Care for information.  A positive response which did not appear to take account of recent events was submitted.    20  8.25 There was no communication between the Asperger’s Service and the Personality Disorder Hub.  The Asperger’s Service do have access to the joint record but did not know about father’ relationship with mother and so had no reason to make contact with the Personality Disorder Hub themselves.  Conversely, the Personality Disorder Hub did know father was involved with the Asperger’s Service but appear not to have made any contact or shared information.  8.26 Support from midwifery and health visitors came from three different sources – two separate hospital trusts and a separate community midwifery service.  Each service operated within the expected practice guidelines and there is evidence of good practice in the collection and assessment of information from the mother.  This resulted in the referral for a pre-birth assessment and the involvement of the specialist mental health midwife. However, they do not have shared recording systems and although some joint visits with other professionals were made, there were issues with information sharing.     8.27 In particular the community-based midwife did not know that mother’s risk-taking behaviour was continuing and reported that this would have made a difference to her response.  Similarly, the early help worker was not aware of these issues and again reported that her response would have been very different had she had access to more complete information.  Learning Point: see learning point 8.    9 Good practice:   9.1 Midwifery services, both in the community and at the hospital showed good practice: • Safe sleep advice given and reiterated; • Smoking cessation addressed.  9.2 The recording in the health visiting service was of a high standard;    9.3 Local Walk in Centre reacted swiftly in a calling an ambulance and in transparent communication with the parents on the reasons for action;  9.4 Safety for the baby was well-managed on arrival at local children’s hospital;  9.5 Verbal agreement of parents re medical photographs was appropriately accepted at local children’s hospital in an urgent situation.  9.6 Mother’s support from the Personality Disorder Hub was extended beyond the normal time-span to continue support after the birth of the child.  10  Conclusions  10.1 Individually both parents had childhood and mental health histories which had potential implications for their parenting capacity and needed exploration and comprehensive assessment.  They lived with mental health conditions which 21  impacted on the development and management of relationships and effected their ability to engage in community-based support such as parenting groups.  They had been together a relatively short period of time and their living arrangements were not clearly understood.  Mother had had to deal with the loss of a previous baby, had become pregnant very quickly thereafter, had moved house very soon after the baby’s birth, into unsatisfactory accommodation, and was having temporary problems with her benefits.  Their only family support appeared to be from paternal grandmother.    10.2 There is clear guidance on the Sefton Local Safeguarding Children Board website about working with parents with mental health disorders or illnesses which indicates the likely complexity involved.  When the referral for a pre-birth assessment was made it was clear this was a complex case.  The pre-birth assessment was allocated to a student social worker and was based on incomplete information.  It did identify vulnerabilities and the need for ongoing support, but the outcome is not reflective of the findings and the case was closed.   It is not clear what management oversight there was of this process.    10.3 Closure of the case resulted in a significant missed opportunity and in there being no multi-agency meetings.  It reduced information sharing and meant there was no shared risk management plan.  The “hand-off” from Children’s Social Care to the Personality Disorder Hub was not challenged despite practitioners reporting that they feel this is a common occurrence reflecting poor understanding of mental health issues in other agencies.  10.4 The Personality Disorder Hub did recognise mother’s own vulnerability and extended the service beyond the usual two -year term but the service did not focus on the baby’s needs and the baby was inappropriately seen in terms of impact on mother – as a protective factor.  The care plan was not updated to take account of the pregnancy. There was no formal assessment in respect of parenting in the Personality Disorder Hub, but considerable optimism was recorded and expressed to other agencies. Issues of professional bias and the rule of optimism may well have been a factor in this.    10.5 During the pregnancy and after Beatrice’s birth there was (with the exception of Children’s Social Care) no lack of service engagement.  There were frequent visits from the Personality Disorder Hub, and both parents initiated contact with other parts of the mental health services at points of crisis but the crises did not cease.  10.6 There were several opportunities to re-open the multi-agency discussions on a more formal basis, for example in response to mother’s risk-taking behaviours, but these were not seen in terms of possible implications for the safety of the baby and this was not done.  10.7 Midwifery and health visiting contacts were also frequent. Individual visits and case records reflect good practice, but the quality of the interventions was undermined by the absence of full information.  Practitioners acknowledge that they would have likely tailored the service differently had they been fully aware.  22  10.8 The absence of an appropriate assessment of father is striking and has been highlighted as a common issue in Serious Case Reviews.  In this case, Father did disclose his relationship and the pregnancy to the Asperger’s Service and despite relationship difficulties being a known feature of Asperger’s syndrome, this does not appear to have been thoroughly explored.    11. Recommendations  1. All agencies working with care leavers must be cognisant of the right for care leavers for service provision up to the age of 25.  2. The LSCB to write to the Department for Education (DFE) and the Child Safeguarding Practice Review Panel to request consideration for issuing guidance specifically in relation to information sharing between Local Authorities where care leavers are not living in the area of the responsible authority.  3. The LSCB to provide practice guidance around multi-agency assessments which will make specific reference to: a) Risks in over-reliance on self-disclosure b) Importance of checking with all agencies who may hold relevant information c) Ensuring the (male) partner is fully considered within any assessment d) Highlights the importance of an informed specialist assessment where parental emotional well-being, ill health or neurological conditions are known or suspected; and e) Requiring the referrer to be informed of the outcome   4. The LSCB to promote the ‘think family’ approach by: a) Promoting the use of genograms to capture family composition b) Issuing a 7-minute briefing on the subject c) Building a bank of family assessment tools as a resource for the partnership  5. Children’s Social Care to assure themselves that the Student Social Worker Policy is being adhered to in all cases.   6. The LSCB to seek assurance from agencies that their information sharing policies are in place and include all cases, not just those that are managed under formal Child Protection procedures.  7. The LSCB to seek assurance from Children’s Social Care that decisions made about the outcome of an assessment is being communicated to all relevant parties.  8. All agencies to undertake an internal training analysis to assure themselves that staff are adequately trained (or there are plans in place for this) in their understanding of emotional health and well-being and mental health considerations and their relevance to parenting.  9. Mersey Care NHS Trust, as providers of the Personality Disorder Hub and Asperger’s Service, should assure themselves that staff give appropriate consideration to issues of safeguarding children.    NOTE: No recommendation is made in relation to escalation of professional concerns as this has been recognised in an earlier review and work is already underway. 