Death of 1-year-old girl in July 2012, as the result of non-accidental injury. C2 sustained injuries whilst in the care of mother's partner, A2. A2 was convicted of murder and sentenced to life imprisonment. Family were known to a significant number of agencies including a number of health services in different hospital settings. In the month prior to her death, C2 attended hospital with a head injury and what was identified as a possible bite mark, considered to be non-accidental. A Section 47 investigation was progressed but assessments did not involve all agencies with knowledge of the family and the case was closed. A2 had a previous conviction for criminal damage and possession of an offensive weapon, relating to an incident of domestic abuse with an ex-partner. Identifies lessons including: insufficient professional curiosity; lack of professional challenge; and need for robust and clear escalation procedures where there is disagreement between agencies. Makes recommendations including the review of the arrangements for taking photographs of possible injuries to ensure medical staff have access to this service at all reasonable times.
      
 Title:  Serious case review Family V: final overview report. LSCB: Lincolnshire Safeguarding Children Board Author: David Ashcroft 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.                             SERIOUS CASE REVIEW FAMILY V  FINAL OVERVIEW REPORT       Report by David Ashcroft, Independent Overview Report Author   FINAL REPORT FOR PUBLICATION FOLLOWING APPROVAL BY LSCB SENIOR MANAGEMENT GROUP    6 February 2014      Version 03/14  1   Introduction  1. This is the Final Overview Report for the Serious Case Review commissioned by Lincolnshire Safeguarding Children Board into the case of Child V (C2).   2. C2 was born on 9th May 2011. She lived with her mother (A1); elder half-sibling (C1); and from March 2012 with her mother’s partner (A2); who was also the father of her half-sibling (C3) who was born 4th August 2012, a few days after C2’s death.  Her growth and development and contact with health services during her first year of life were routine and unremarkable.  Her mother maintained employment during her pregnancy with C3, and A2 was her principal carer when her mother was at work.  3. There are two main incidents covered by this SCR.  This first was in early June 2012 and the second was at the end of July 2012.  These are referred to as Episode 1 and Episode 2 in this report.  4. Episode 1: C2 was brought by ambulance to Boston Pilgrim Hospital A&E Department on 1st June 2012 following a call to the 111 service by her mother concerned about a possible head injury.  She was subsequently admitted to the Children’s Ward and was examined by the Consultant Paediatrician, CON2, the following day.  CON2 identified a possible bite mark that he considered could be the result of Non Accidental Injury (NAI).  C2 was subsequently discharged to the care of her maternal grandmother, A3.    5. A referral was made by CON2 to children’s social care Emergency Duty Team (EDT) who spoke to staff and the family on the phone but did not attend the hospital.  This episode occurred over the long Jubilee bank holiday weekend and initially issues were raised about whether out-of-hours cover and the responsiveness and availability of police, health and social care personnel, and of diagnostic services were comprehensive.  Although the skeletal survey was delayed until after the bank holiday there are no other implications for out-of-hours working due to the holiday arrangements.  6. C2 was the subject of a strategy discussion between social care and the police on 3rd June and a Section 47 investigation was agreed. A decision not to proceed to an Initial Child Protection Conference was made on 12th June, although the case remained open to Lincolnshire Children’s Services as a Child in Need for the completion of the core assessment.  Subsequent investigations and the assessment were progressed, but did not involve all parties with knowledge of the family.  There was contact with the family and the children were seen, but recording on the social care ICS system was limited and incomplete, both of information obtained about the child and the family, and of the supervision and direction given by managers.  The case was closed by Children’s Social Care by 24th July, although health were Version 03/14  2 concerned about this.   At several points there were missed opportunities to escalate or resolve some of the differences of view.  7. Episode 2: C2’s principal carer, A2, called emergency services at 16.39 on 28th July as she was not breathing normally and was reported to have fallen off the settee.  C2 and C1 had been in his sole care as their mother was at work.  8. C2 was taken to Grimsby Hospital by emergency services in a critically ill condition. Appropriate medical interventions were undertaken to treat her presenting conditions, but a CT scan was reported as normal.  She was subsequently transferred to Sheffield Children’s Hospital and died there early on 31st July.  Investigations conducted at Sheffield, including a further CT scan, revealed deterioration in her condition and significant brain injuries and by 17.00 on 29th July it had been concluded that there was a high likelihood of NAI due to “shaken baby syndrome”. A2 was subsequently arrested at Sheffield Children’s Hospital and charged with murder.  9. At a meeting of the Lincolnshire Safeguarding Children Board’s (LSCB) Serious Case Review Sub-Group, on the 10th September 2012, the panel recommended unanimously that this case met the criteria under Working Together 2010, to undertake a Serious Case Review (SCR). The Independent Chair of the LSCB, Chris Cook, confirmed his decision that this case should be the subject of a Serious Case Review on the same day.  An independent author was commissioned on 8th November to undertake the review.  Individual Management Reviews were requested to be completed by January 2013.   Background and timetable  10. The purpose of this Serious Case Review is to identify what can be learned from the case about the way professionals and agencies work together in order to improve inter-agency working and to better safeguard and promote the well-being of children.  It is not an inquiry into how a child was injured, or who was culpable, which is a matter for the criminal courts, nor is it an investigation of individual practice and management competence which are subject to disciplinary and professional conduct processes.   11. The SCR was conducted under the guidance contained in Working Together 2010 that was in effect at the time the Review was commissioned.  Therefore agencies were requested to prepare Individual Management Reviews (IMRs) detailing and analysing their involvement.  It was also agreed to draw together a Health Overview Report to examine the issues arising across all health agencies. However, the SCR Panel and LSCB chair have considered the revised Working Together guidance issued in March 2013 and have sought to ensure that the Review, and particularly this Version 03/14  3 Overview Report, is prepared in the light of these revised expectations and standards. 12. This case is notable for the large number of different agencies and services that came into contact with the family.  In particular health services were accessed at a number of different hospital settings. Individual Management Reviews and short information reports were requested from, and completed by, the following agencies: Lincolnshire County Council, Children’s Social Care (CSC) Lincolnshire Police Nottinghamshire Police (short report) Lincolnshire Probation Trust United Lincolnshire Hospital NHS Trust (ULHT) for midwifery services and Pilgrim Hospital, Boston Lincolnshire Community Health Services (LCHS) NHS Lincolnshire (General Practice) East Midlands Ambulance Service (EMAS) North Lincolnshire and Goole Hospitals NHS Foundation Trust (NLaG) for Diana, Princess of Wales Hospital, Grimsby (DPoW) Sheffield Children’s Hospital Foundation Trust (SCHT) NHS Direct (short report) Lincolnshire County Council Education and School (short reports) Nottinghamshire County Council, Children’s Social Care (short report) LIVES First Responder Service (short report)  13. A Health Overview Report (HOVR), bringing together the analysis and issues across the health organizations involved, was also commissioned.  This benchmarked the clinical practice described in the IMRs against commissioned services and best evidence, and also explored how effectively health organizations had communicated with each other and with agencies beyond health as part of the inter-agency response to the family up until C2’s death.  14. This Overview Report has been compiled based on the information and analysis collected through the IMR process. It is intended for publication as the account of the learning from this case. The Overview Author has presented for discussion and challenge key themes and lines of enquiry to the SCR Panel.  This report addresses these themes and seeks to provide a final report that takes this process of analysis and peer challenge into account in identifying the learning and improvements that are needed to consolidate good practice.  This approach is in line with the revised guidance on interagency working and conducting SCRs published in March 2013 in Working Together 2013.   15. Working Together 2013 identifies that SCR reports 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; • be written in plain English and in a way that can be easily understood by professionals and the public alike; and Version 03/14  4 • be suitable for publication without needing to be amended or redacted.   16. SCR Panel meetings were held on 30th January, 7th March, 7th June and 16th July, with progress meetings involving the SCR Panel chair, Overview Author, Health Overview author, LSCB Legal Advisor and the LSCB Business Manager on 10th and 24th April.   A completed draft of the Report was presented to the Strategic Management Group in 23rd September 2013 and it was agreed unanimously to approve the report, pending some minor amendments discussed at the meeting, and also pending the outcome of the trial of A2.  A small sub-group was authorized to sign off the final report for publication, which met on 20th November 2013.   17. When the draft IMRs were presented to the Panel on 30 January 2013 it was clear that further revisions were required to a number of the IMRs and these were requested and undertaken.  This prolonged the process of completing the IMRs and delayed the start of compiling the Health Overview Report.  18. As C2 had been treated at a number of health services at different times the Panel identified at an early stage that information on these interactions needed to be comprehensive and that information from each IMR might pose new questions for examination by each agency.  It was important to establish if there were any factors that had affected the family’s choice of health setting and provider.  It was also important that the Health Overview Report was prepared to draw conclusions across the health agencies.  The reporting of the CT scan in Grimsby as normal on 28th July 2012, which was subsequently identified as in error, prompted the undertaking of a Serious Untoward Incident Report by NLaG.   This was completed and available to the Health Overview Author in April 2013.  Although this reporting error was significant it is not felt that it had an impact on the outcome for C2.  19. Initially a short report was requested from SCHT relating to the admission and treatment of C2 when she was transferred to Sheffield from Grimsby.  After Panel discussions revealed the extent of the contacts and information flows between agencies 28th to 31st July 2012, it was agreed to request a full IMR from SCHT.  This was to ensure that a full picture was available of the treatment and diagnostic interventions; the communication between, and information shared by agencies; the interaction with the family; and the attention paid to safeguarding issues particularly in relation to C1 and her unborn sibling (C3). The completion of the SCHT IMR was delayed due to leave and workload.    20. Further information was also requested from EMAS in relation to their response to the emergency calls. These factors together with illness and leave meant that the Health Overview Report was not completed until mid-July 2013, and not available to the Overview Author as a completed and signed off document until that point.  21. The trial of A2 for murder was scheduled for October 2013, and the sentencing and appeal process not completed until 20 November 2013.  This parallel process further delayed the timescale for completing and publishing the SCR Overview Report. Version 03/14  5  22. In order to ensure that there was appropriate representation in the review of professionals and organizations involved, both NLaG and SCHT were invited to join the SCR Panel from the meeting on 30th January 2013.  Attendance at Panel meeting has been good, and a high level of constructive and challenging debate has contributed to identifying clear lessons from this case.  23. Although these factors have delayed the completion of the SCR, it was felt that the learning from this case was of sufficient importance that it was appropriate to ensure that a thorough and comprehensive review was undertaken.  The SCR Panel has monitored an Action Plan of objectives and learning arising from the case since April 2013, and this is attached as Appendix 3.  All actions have been implemented.   Learning and Actions already taken  24. Agencies have already considered some of the action points arising from this case and taken appropriate and prompt management action to address obvious shortfalls in process and operational capacity. This is positive and appropriate to ensure that learning and improvement does not wait for the completion of the formal serious case review process.  Actions already taken include:  • Agreement between Children’s Social Care and Lincolnshire Police and health agencies to ensure that there are suitable staffing arrangements for strategy discussions to take place outside normal business hours; • Revised arrangements for Public Protection Unit (PPU) cover outside normal working hours; • Revised arrangement for urgent checks through the Police National Database (PND) for placements of a child by Children’s Social Care; • Revised arrangements within the police for accessing Scene of Crime Officers (SOCOs) to take photographs to allow the appropriate recording of injuries to children; • Aide memoire for Strategy Discussions issued April 2012 by CSC to ensure that all children in a family should be considered; • Revisions to the Connected Persons Procedure (relating to the placing of children with family members or friends as an alternative to foster care) issued in September 2012; • Serious Untoward Incident Report commissioned by NLaG in respect of the reporting of the CT scan at Grimsby Hospital as normal.  25. The SCR Panel has provided constructive and reflective criticism of the information gathered for this review, and has maintained a clear focus on establishing the learning from this case. The Panel and the LSCB chair have monitored the timescale for this SCR throughout its process.   The Panel has identified that there was some delays in both the completion and the authorisation of IMR reports by several agencies, and that progress chasing of agreed actions from Panel meetings could Version 03/14  6 have been more robust and prompt.  The Overview Author considers that more proactive progress chasing by the LSCB office could have reduced some of these delays, and that failures to meet agreed deadlines could have been escalated to the Board and Independent Chair more urgently.   Terms of Reference  26. Terms of Reference were agreed by the SCR Panel and are attached as Appendix 1.  The timespan for the Review was from C2’s birth (9/5/11) to her death (31/7/12). These Terms of Reference set out the purpose, subjects, scope and governance for the Review and identify those agencies requested to provide IMRs and the membership of the SCR Panel.  This Overview Report addresses the areas identified in the Terms of Reference, but has adopted a more analytical and comprehensive structure in order to draw out clearly the learning from the case and to examine and evaluate the extent to which issues were the result of individual professional practice, or were influenced by organisational culture, processes and systems within and between agencies.  Where IMRs contain detailed narrative of events and appropriate analysis this has not been repeated in the Overview Report in order to avoid duplication and to ensure that the Overview Report remains concentrated on the wider learning from the case and retains a true overview perspective.  27. The Genogram attached as Appendix 2 provides details of the subjects, their immediate family and other significant adults.  These are summarised below. SCR Index Relationship A1 Mother to C1, C2, C3 A2 Mother’s partner and father of C3 A3 Maternal grandmother A4 Maternal grandfather A5 A2’s ex-wife A6 A1’s maternal aunt A7 Father to C1 A8 Father to C2 C1 Elder half-sibling to subject, daughter to A1 C2 Subject, DoB 9th May 2011; DoD 31st July 2012 C3 Younger half-sibling to subject, daughter to A1 and A2, unborn baby during timeframe of SCR Version 03/14  7  28. A large number of staff have been involved with this case.  For the Overview Report the following are the most significant professionals involved and the following index codes are used to identify personnel in this report.  SCR Index Role/title Agency SW1 Emergency Duty Team (EDT) social worker, Episode 1 Lincolnshire Children’s Social Care SW2 EDT social worker, Episode 1 Lincolnshire Children’s Social Care SW3 East Lindsey FAST, Advanced Practitioner, allocated caseworker for C2 Lincolnshire Children’s Social Care SW4 EDT social worker, Episode 2 Lincolnshire Children’s Social Care CON2 Paediatric Consultant, Episode 1 Pilgrim Hospital, ULHT SN2 Staff Nurse, Children’s Ward Pilgrim Hospital, ULHT SS Site Sister Pilgrim Hospital, ULHT PI1 Police Inspector Lincolnshire PPU DC1 Detective Constable  Skegness   Independence  29. David Ashcroft was appointed as the Independent Overview Report Author of this Serious Case Review in November 2012.  He has worked at a senior level in children’s services for the past 20 years, including operational responsibility for all aspects of safeguarding and children’s social care in a number of local authorities.  Mr Ashcroft currently chairs a Local Safeguarding Children’s Board in the North East and is also an independent member of other Improvement and Children’s Partnership Boards. He is an accredited C4EO Sector Specialist in child protection, and a member of the British Association of Social Workers, The College of Social Work and an associate member of the Association of Directors of Children’s Services. Version 03/14  8  30. Mr Ashcroft has conducted a number of SCR, IMR, inspection and investigation assignments in children’s services, covering social care, education and health responsibilities as an independent chair and/or overview author and lead reviewer.  He has previously completed an SCR Overview Report for Lincolnshire LSCB. He has worked with Safeguarding Boards, cross-sector partnerships and health and third sector agencies to identify and resolve performance issues and to improve services.   He has no managerial connection with the agencies involved in this case.  31. The Independent Chair of the SCR Panel had no previous knowledge or involvement with this case. He is also the Independent Chair of the LSCB, and this reflects relevant government guidance that “The Panel Chair can be the Independent LSCB Chair”. All the IMRs have appropriately identified that their authors were independent of the case and have commented on the involvement of staff members where this affected different aspects or periods of the case history.    Summary of key events  32. A comprehensive integrated chronology of the case was compiled from the details supplied by each agency.  This section highlights the key events that are analyzed in the following sections of this report in order to learn the lessons from this review.   Events prior to Episode 1  33. On 11th January 2011 A2 was convicted of an offence of criminal damage and possession of an offensive weapon arising from an incident of domestic violence in relation to his ex-partner A5 that had occurred the previous November.  He was sentenced to a Community Order with 140 hours unpaid work.  He was assessed as posing a medium risk of harm to his partner and the public, but the probation report was broadly positive about his insight into his behaviour.   A2 failed to attend some sessions and following subsequent court appearances for breach of his order he started to comply from April 2012.  It is recorded that one of the factors motivating him to comply was that his partner (A1) was now pregnant (with C3).  34. C2 was born to A1 on 9th May 2011.  Her mother was recorded as a single parent and there had been no contact with her birth father (A8) during the timescale of this SCR.  A1 and C2 were seen by community midwives, health visitors, GP and C2’s passage from baby to toddler from the perspective of growth and development was unremarkable.  C2 presented with minor issues common to babies and was investigated for a heart murmur at 8 weeks that did not require any treatment (HOVR, ULHT, LCHS and GP IMRs).  35. On 3rd February 2012 C2 was seen by a GP with a history of a scratched ear and also Version 03/14  9 “2-3 red minimal petechae on her forehead possibly after force of crying” (GP IMR).  The examination did not identify any concerns and the attending adult (A2) was reassured and informed that C2 may have bilateral glue ears, a condition that could take 3 months to resolve (GP IMR and HOVR)  36. In February 2012 A1 was confirmed as pregnant.  She was visibly pregnant at the time of both the June and July episodes and C3 was born on 4th August 2012, 4 days after C2’s death.  37. By March 2012 A2 was recorded as living in the family home, was referred to as ‘Step Dad’ and as treating C2 as if she was his own child (Home Visit for 8 month assessment undertaken by Nursery Nurse, LCHS IMR).  38. On 26th March A2 2012 was taken to the GP with “a bruise to top of pinna (ear).  Started crawling. Brought by dad. Mum goes to work and dad looks after C2.  No other marks and nothing that would worry me.  Dad seems very natural and caring. Reassure”.  (GP IMR)  39. On 23rd May 2012 C2 was seen by the GP practice nurse with A2 about hay fever.  It was assumed that A2 was her birth father and that his experience of hay fever was relevant and comparable.  C2 received her routine immunization vaccinations on this visit.    40. On 28th May C2 was seen by a nurse practitioner at the GP surgery as still unwell after the vaccinations “under the weather for the past few days with diarrhoea and vomiting” and A2 who accompanied her was reassured.  This was the last time that C2 was seen by any practice staff.  There is no record that her glue ears were discussed, or any record of the head injury involving a puppy which was identified by A1 and A2 following the admission to hospital later that week.  Episode 1  41. At 18.45 on 1st June, A1 telephoned the 111 service from A3’s house seeking advice about a ‘dent’ in C2’s head.   Questioning from the health advisor provided the following history: • A1 was not sure if C2 had “banged her head because there was a soft spot at the back of her head” and that “the ‘dent’ had been there for a few days and she had been fine with it”; • That C2 was "just toddling and was falling over all the time”; • That C2 had been with her partner as she had been out at work all day, and that A2 was now at work himself and she could not ask him about the injury; • The dent had not been mentioned when C2 had attended the GP surgery as it had not been noticed then.  42. The health advisor appropriately sought advice from a nurse advisor on this call and Version 03/14  10 dealt with it as a presenting head injury and reached the endpoint that an ambulance would be called.  Neither health or nurse advisor were suspicious that this could have been a non-accidental injury and although they were concerned that a head injury had occurred, no child concern referral was made.  A1 called an hour later when an ambulance had not yet arrived and C2 was subsequently taken to Accident and Emergency at Pilgrim Hospital Boston as a result of a 999 call. C2 arrived at 22.02 by ambulance accompanied by both A1 and A2.  43. As C2 was transported from A3’s home rather than her home address, the EMAS IMR did not initially establish that she had been brought to A&E by ambulance.  This information was not recorded in ULHT records, and staff dealing with her admission and examination presumed that she had been brought to A&E by A1 and A2.  44. C2 was examined in A&E when A2 informed the doctors that she had been knocked over by a puppy and banged the back of her head.  She was subsequently admitted to the Children’s Ward at 01.30 on 2nd June, following referral for review by a senior Paediatrician.  A skull X-ray was performed and A1 & A2 were informed of the need for C2 to stay overnight for observation.    45. C2 was then seen by CON2 at 11.50 later that morning.  A history of events was taken by CON2 and he recorded that A2 said that a puppy had jumped on C2, but that he had not witnessed this as he had gone to get C2 a drink.  On his return C2 was reported as sitting up and crying with a scratch mark on the outer side of her face.  A2 reported that C2 bruised easily and that A1 had asked the GP for blood tests because of this.  There is no record of these concerns having been raised with the GP.  46. CON2 completed a full examination during which he identified a bruise on the back of C2’s left calf.  This he considered could be a bite mark, probably adult, certainly not dog.  A1 and A2 are reported as having noticed the mark that morning and agreed that it was an odd shape.  They informed CON2 that C1 sometimes played roughly with C2 and that C2 also got her leg caught in the cot sides.  CON2 considered that the head injury could be explained as accidental but not the bite, and he therefore appropriately requested a CT scan and made a referral to CSC Emergency Duty Team (EDT). This advised that he “was not too concerned about the head injury, but that he felt the bite was not consistent with a dog bite and felt that this was a NAI”.   47. CON2 made the referral to EDT at 16.20 after awaiting the CT scan to allow him to convey the full facts.  This time was close to the point when social care staff in EDT change over (17.00) and was after the PPU concluded their tour of duty at 16.00.  This combination of timing and the availability of personnel caused problems for the management of this case.  48. CON2 completed body maps but did not order photographs to be taken as he and other staff understood that there was no access to photography in the hospital.  Version 03/14  11 Photographs need to be taken as near the time of injury as possible to record the greatest detail. A skeletal survey was ordered but could not be performed until 6th June due to the extended Jubilee bank holiday.  49.  After being informed that a CSC referral would be made A1 and A2 informed a ward sister that C2’s legs had been held during the administration of the immunizations 1 week previously and queried whether this could be the cause of the bruise. A1 had not been present at the vaccination appointment.  50. A2 is recorded in ULHT records as being aggressive towards and swearing at CON2.  A2 threatened to take C2 off the ward.  CON2 explained that he was following hospital policy for a possible NAI and that C2 would need a skeletal survey but this could not be done until Wednesday 6th June.  51. Following the referral by CON2, SW1 contacted the ward at 17.30.  She was informed that A2 had been aggressive.  The results of the CT scan were given (as normal) and that a skeletal survey had been ordered.  SW1 was about to go off duty but would hand over the case to her colleague, SW2, to organize a plan.  52. SW1 called Lincolnshire Police Control Room to log the referral, she advised the police that the hospital intended to discharge C2 (which was not the case), and that CON2 had reported the bite as a NAI.  She indicated that social care was looking for someone to look after C2 overnight and that PPU would deal with the matter the following morning.  Subsequently the Control Room was advised that SW2 was taking over responsibility for the case and the Control Room asked to be advised when suitable accommodation had been identified for C2. It is not clear that there was a shared understanding between health, police and social care about arrangements for discharge and arranging care for C2.  53. SW2 telephoned A1 at the hospital and explained the process of a S47 investigation to A1 and A2.  A1 was very unhappy and verbally aggressive, complaining of her alleged treatment at Pilgrim Hospital.  She accused CON2 of being malicious as in her view the mark was just a bruise.  SW2 advised that C1 and C2 could not stay with A1 and A2 unsupervised until the investigation was completed.  A1 confirmed reluctantly that the children could stay with her parents (A3/4).  SW2 spoke by phone to A4 and confirmed he was willing to accommodate the children.  54. SW2 did not attend the hospital in person and SN2, who was the nurse in charge on the ward, recorded her concern about this. CON2 also contacted EDT as he was unhappy that SW2 did not attend the ward, but only spoke to the family by phone.  The ward was now dealing with angry and aggressive parents, and there was potential for misunderstanding and confusion.  SN1 recorded her concerns regarding the lack of a social worker presence to speak to the family; the lack of assessment of the suitability of the maternal grandparents as a place of safety and the inability of the ward staff to ensure that the course of action to protect C2 would be followed after discharge. SW2’s response was unhelpful and dismissive, and was not in line Version 03/14  12 with policy or expected standards.  She did not seem to recognize the priority of this case or the concern and anger already expressed by A1 and A2 about the referral with which ward staff were having to deal and despite her own conversation with them by phone.  This allowed A2 to later claim in his comments to the Report Author that the episode was all due to the consultant’s opinion, whereas visible co-operation between the agencies on the ward before discharge might have given the family a clearer understanding of the concerns, and the reasons for proceeding with a referral and Section 47 investigation, as was explained to them by nursing and medical staff, in line with child protection policies.  SW2 claimed that she could not attend as she was the only social worker on duty for the county (which was not the case as cover could have been arranged).   SW2 stated when interviewed that as the children were safe there was no need to visit and she thought that C2 would remain in hospital overnight.  It appears that there was some confusion between social care and hospital about the exact plan for discharge.  It would be usual to await the completion of all medical investigations before discharge, but as the holiday delayed the availability of the skeletal survey until 6th June discharge was assumed to be safe before the conclusion of all investigations.  A robust strategy discussion between all agencies before discharge on Saturday 2nd June did not take place, which might have allowed these issues to be addressed explicitly and a safe discharge plan for C2 prepared.  55. These concerns of the ward team were escalated to the site sister (SS), a senior nurse who has responsibility for the whole hospital site. The SS spoke with the family who were recorded as angry with the processes undertaken.  She attempted to provide reassurance. The SS did not believe that she was able to prevent the discharge of C2 as the social worker had agreed to it, although there was no record of any firm plan for safe discharge.  The SS was neither a paedriatric nor safeguarding specialist, who at that time had not completed Safeguarding training. However her role was not to provide a specialist opinion but to resolve the escalated concerns. Her involvement was not in accordance with expected standards as she did not fully understand her role or follow the LSCB escalation policy. In normal working hours it is possible that the escalation of this issue by ward staff would have been to the Named Nurse for Safeguarding.  56. Accordingly C2 was discharged to the care of her maternal grandparents at about 22.00 on 2 June without a social worker attending the hospital ward, seeing the child, completing checks on the proposed placement with maternal grandparents, or checking on the arrangements for the protection of the sibling, and despite the concerns expressed by health staff and the clear referral of the bite mark by CON2 as a possible NAI.  The SS and CON2 saw no reason to object to the discharge to the maternal grandparents, but there is no evidence of a robust evaluation of the possible risks for C2, the impact of such a late discharge for a very young child or consideration of further escalation of the unresolved issues.  The professional challenge could have been strengthened by reference to Working Together 2010 and local procedures, which make explicit the process to be followed for both a strategy discussion and a safe discharge. Version 03/14  13  Strategy discussion and assessment, June/July 2012  57. On Sunday 3rd June SW1 came back on duty as EDT social worker and arranged to meet with DC1 at Skegness Police Station for a strategy discussion.  The notes of this meeting record the information provided by CON2, and confirm that a S47 investigation would be undertaken.  This discussion did not include health, and there is no record that the meeting considered any specific safeguarding risks for C1, although it was recorded that she was also at the grandparents.   58. SW1 and DC1 then visited the family at A3’s home.  A1 and A2 were interviewed separately and SW1 advised that the case would be passed to the area social work team for a core assessment.  DC1 took some photographs of C2’s injury and advised that A1 and A2 would be interviewed under caution at the police station later in the week.  Neither A1 or A2 could explain the bite/bruise, but both disagreed with CON2’s diagnosis.  It appears that after the visit SW1 and DC1 discussed their views of the case and felt that the injury was not consistent with it being a bite.  There is no record of this discussion on the social care ICS system, and this view was not discussed with CON2.  Such an important difference of view should have been recorded and queried with CON2 before assuming that the bite/bruise was not NAI.  It is not clear that any alternative explanation for the mark was accepted as the basis of their view by SW1 and DC1.  59. The case was allocated to SW3 on 6th June, with full and appropriate direction from the worker’s supervisor (PS2). This was an example of good practice. It would appear from her account when interviewed for the CSC IMR that SW3 contacted the health visitor, probation (in respect of A2’s previous domestic violence offence), Nottinghamshire Social Care (in respect of A2’s previous children) and C1’s school. But there is no record of these conversations in the social care records.  She also received CON2’s letter of referral on 11th June, which clearly stated his view that the unexplained mark was a bite.    60. By the time that SW3’s regular practice supervisor (PS1) recorded an ad hoc discussion with his team manager on 12th June the account of the case had reduced from possible NAI to a minor injury and suggested that there were sufficient protective factors in place to indicate that a child protection conference was not required.  There had been no examination of the varying accounts given by A2 about the circumstances of injury, nor had the discrepancies in the accounts of various contacts with health in the days before the admission to Hospital on 1st June been tested. The decision not to proceed to an ICPC was a decision reached by default rather than by testing all the information available or consideration of whether there was a risk of significant harm.  61. Supervisory responsibility for the work of SW3 passed during the next six weeks between four practice supervisors, so there was little continuity of challenge and oversight, but it appears that a gradually more optimistic and positive view of the Version 03/14  14 circumstances emerged without sufficient challenge or testing of evidence.  This more positive view was based on the observed interactions of the family, and the low levels of concern from those that the social worker consulted, but still did not resolve the concerns from health expressed both in CON2’s referral and in the experience on the ward over the weekend.  This report cannot judge whether or not there were risks of significant harm, but it is clear that there was not a robust process to test the assumptions and judgments made by staff in different agencies. Nor was there respectful challenge of the family view, particularly that presented by A2 whose assumption of parental responsibility was not questioned by health workers and whose accounts varied and were not supported by evidence that could have been cross checked.   62. This de-escalation of the risks during this period was despite concerns recorded from health on the proposed closure of the case (which occurred on 24th July) and the failure to speak at all with CON2 and seek his views on his initial referral.  Health staff (the Consultant and ward nursing staff) should have used the LSCB escalation policy if they remained unhappy with this decision.  A core assessment was authorized for C2 on 17th July and for C1 on 26th July.  The recording is silent on how and if and when C1 was seen, spoken to (or seen alone) or checked for injuries.  Episode 2  63. On 28th July EMAS received a 999 call from A2 requesting assistance for a baby.  He stated that ‘she’s fell over, I think she passed out’.  It was reported that C2’s heart was beating but she was not breathing.  C1 could be heard crying in the background of the call and was asked by A2 to sit down.  Guidance was provided on how to assess the baby’s breathing and to perform mouth-to-mouth resuscitation.  64. During the call A1 offered the following comments: “you don’t understand, we took her to the doctors a few months ago about a head injury and they got social services involved, this is the last thing I need” and later “his girlfriend is pregnant and due in three weeks.  This is the last thing she needs.”  The call taker appropriately redirected attention to the priority need of C2’s clinical condition, but did not document or pass on these comments.   A2 also told the LIVES responder that C2 had been previously “taken to Boston Hospital with a head injury and he wasn’t going to let her go there again”.  This was a missed opportunity to raise an alert about previous injuries that had resulted in an investigation.  65. C2 left by ambulance for DPoW Hospital at 17.30 accompanied by A1 and A3.  A2 remained at the home to collect items for A1 and to wait for C1 to be cared for by A1’s sister.  C2 was subsequently met by the air ambulance and transported to DPoW, while her mother and grandmother continued to the hospital in the ambulance.  66. The initial response and management of C2 was of the standard expected, with the First Responder asking appropriate questions to aid diagnosis and establish the Version 03/14  15 circumstances of the catastrophic event.  Best practice would have been to inform the ambulance crew, and to document and escalate A2’s comments whilst the resuscitation and transfer took place and to consider the safeguarding of C1.  67. The Health Overview Report concludes: ‘It is however also evident that the snippets of information provided by A2 were unusual utterances…The conversations that A2 had with the EMAS call taker and the LIVES Responder include highly unusual statements given the gravity of the situation and should have been escalated through their respective services to safeguarding and to the hospital.  The outcome for C2 would not have changed…but improved information sharing and knowledge of the previous head injury may have raised the profile of NAI as one of the potential diagnoses and supported consideration of the safety of C1 who remained in the care of A2.”  68. C2 arrived at the hospital at 18.15. The Consultant Paediatrician diagnosed C2 with sudden loss of consciousness with respiratory arrest and peripheral generalized seizures. The plan was to arrange an urgent CT scan and chest X ray and EMBRACE (critical care transport) to be contacted (with a view to possible transfer to SCHT).     69. The account of the resuscitation provided in the NLaG IMR details appropriate diagnostic tests and interventions by the medical team for a seriously-ill child who was presenting a range of complex symptoms. Whilst these interventions were underway the A&E sister spoke to A2 by phone to ascertain a history.  A2 informed the A&E sister that C2 had a watery vomit so he put her in the bath. She was dried and nappy applied and dressed. A2 stated that he put her on the sofa and went to the kitchen to get her a drink. When he came back, in less than a minute, she was lying on her back on the floor. A2’s subsequent and rather different account of this provided to the Overview Author is given below (paragraphs 84-94).  The similarities between A2’s account of this episode and the previous injury were not noted (that the incident had happened when he had gone out of the room to get C2 a drink (see paragraph 45 above)).  70. The A&E sister contacted the CSC EDT, as she was concerned about the presentation of C2, the vagueness of the history from A2 and the fact that he had not attended the A&E department with C2.  Although she initially mistakenly called NE Lincolnshire EDT, she contacted Lincolnshire EDT within 30 minutes, who promptly arranged checks for C1 to be cared for by her maternal aunt and uncle, and notified the police and held an initial strategy discussion between SW4 and PI1.  The police inspector (PI1) twice contacted the hospital to ask for further information and was told that this could not be released because of data protection.  A police officer had to be sent to the hospital to obtain an update on the position.  NLaG have not been able to ascertain who refused this information.  Although this breakdown on communication was unfortunate it did not have a bearing on the outcome of the case.  71. A1 had told nursing staff that C2 had suffered a previous head injury and that a CT Version 03/14  16 scan had been undertaken at Pilgrim Hospital in June.  No further circumstances of the injury were recorded and there is no evidence that the results of that scan were obtained for comparison.  The medical team was not aware of this earlier episode or of the suspicion of NAI identified by CON2 in respect of the bruise/bite mark.  72. At 19.12 the Consultant Paediatrician at DPoW contacted SCHT and discussed the case with the Paediatric Intensive Care Consultant (PICC).  At this stage he was still awaiting the CT scan and was of the view that the loss of consciousness with the prolonged seizure, chest X-ray changes suggestive of oedema and the hypothermia raised the possibility of cerebral insult from near-drowning in a bath.  He noted that NAI needed to be excluded as a cause. At 20.33 the results of the CT scan were verbally reported as normal.  This was subsequently identified as being incorrect.  73. The NLaG IMR identifies regular communication between DPoW A&E, SCHT and EMBRACE illustrating the process of coming to a final decision to transfer C2 to the specialist services at Sheffield.  This communication and dialogue was good practice – but was incomplete as it was not informed by the previous history of NAI concerns, the concerns of nursing staff, or by the correct reporting of the CT scan which might have raised the greater likelihood of NAI by indicating severe trauma to the brain rather than an organic cause of C2’s condition.  74. The EMBRACE team arrived in Grimsby at 22.40 and C2 was transferred at 01.55 on 29th July following further treatment and attempts to stabilize her condition.  75. It is not clear exactly when A2 arrived at DPoW, however, when EMBRACE transferred C2 he travelled in the transport with her. Normally a natural parent, usually the mother, would travel with a child.  However, the SCHT IMR records that it was not considered unusual by staff on this occasion for the ‘stepfather’ to accompany C2, due to her mother being heavily pregnant. Neither the NLaG nor the SCHT IMRs clarify what the attending doctors and practitioners knew of the concerns that had prompted the A&E sister to contact social services or how her concerns were communicated to the night staff prior to her leaving the department before A2 arrived.  If the increased likelihood of NAI had been more strongly identified then it is likely that A2, as the person in whose sole care C2 had suffered injury, would not have accompanied her to Sheffield and earlier steps might have been initiated to protect C1 and to consider the possible safeguarding outcomes through a strategy meeting.  This seems to have been waiting on the Grimsby CT results, and when this was reported as normal both police and social services understandably continued to wait for a clearer clinical picture to emerge. 76. C2 arrived at Sheffield Children’s Hospital at 03.20 on 29th July.  According to the SCHT IMR, neurological protective treatments were commenced and monitored. A second CT scan was performed, which reported marked deterioration in keeping with cerebral oedema (swelling of the brain) and ischaemic changes due to oxygen starvation of the brain tissue. It was also reported at this time that the CT scan taken at DPoW had been identified as probably not normal. A1 and A2 were updated and Version 03/14  17 informed of possible causes, including: infection; metabolic abnormality; immunological abnormality; and possible head injury to C2. The second CT results indicated to staff that NAI was a stronger possibility. 77. The Sheffield team initiated further investigations including ophthalmology, which revealed severe retinal haemorrhages. By 17.00 on 29th July the results of these investigations – cerebral oedema and ischaemic changes, severe bilateral haemorrhages and little evidence of sepsis, alongside a vague history, suggested that there was a high likelihood of assault – possible ‘shaken baby’.    78. The Paediatric consultants at SCHT when interviewed agreed that if the initial CT scans had been sent through electronically via the PACs system (allowing it to be reviewed at a remote location) the cerebral abnormalities may have been recognized earlier.  There is some confusion in the different IMR accounts of whether, when and how images were sent and whether a written report was available. Although the medical management of C2 would have been different, it was felt that the outcome would probably not have changed for C2 due to the extensive and severe nature of the brain injuries she had already suffered.  79. The Serious Untoward Incident Review conducted by NLaG has separately identified lessons learnt for the reporting, amendment, and communication of radiology reports.   80. Social care were updated at this point and informed that C2 would most likely not survive.  Social care undertook to inform the police and ensure that C1 was in a place of safety, which was arranged with a written agreement.  The police were advised by SW3 at 18.10 that C2 was likely to have suffered traumatic brain injury. South Yorkshire police on behalf of Lincolnshire police arrested A2 at 21.49 on 29th July.  81. During 30th July C2 continued to receive paediatric intensive care and A1 was attended by a Sheffield duty midwife during the night to ensure that all was well with her pregnancy.  82. Overall, the liaison between Lincolnshire CSC, the safeguarding and social work teams at SCHT and the police was effective and appropriate.  Support was provided for A1 as a pregnant mother, and family members were able to support her and C2 during the final hours of C2’s life.  She was christened in the hospital before she died in the early hours on 31st July.   Involvement of family members and information provided by A2  83. A1, A2, A3/4, A7 and A8 were written to at the start of the Serious Case Review in November 2012 explaining the process and inviting them to contribute. They were informed at an early stage that the Serious Case Review was being undertaken and offered the opportunity to meet with the Overview Author to answer a number of Version 03/14  18 questions and to make any observations that they wished. A further invitation to participate was sent to all these family members in May 2013.  A1 responded but did not feel able to contribute due to the parallel processes of care and criminal proceedings. A further offer to meet with A1 in November after the trial was declined. No other response was received except from A2 who asked to meet with the Overview Author and a meeting was arranged at the end of May.    84. At this meeting both the episodes in June and July 2012 were discussed. A2 was at that time charged with murder of C2 and due for trial in October 2013.  He was made aware that any answers he made to the Overview Author would have to be disclosed for this criminal process.  There were a number of points made by A2 that provided a different perspective from the accounts of the agencies involved.  In his account the family had been concerned to ensure that C1 was well looked after during the episodes, and decisions about who should accompany C2 by ambulance were made on a pragmatic and considered basis from the family’s perspective.  The context for these arrangements was not apparent in the agency reports  85. In respect of the events in early June A2 commented on the concern of himself and A1 about the head injury over the bruise/bite mark reported by CON2.  A2 claimed that nurses were concerned about the head injury as well, and also claimed that the nurses said that “CON2 gets it wrong all the time”.  There is no evidence to support this statement, which is categorically denied by nursing staff. Indeed nursing staff explained the safeguarding procedure and concerns to him at the time, and were themselves alert to these risks. SN2 is recorded as pointing out that CON2 opinion was that the bruising was unexplained and therefore this was the rationale for the referral to EDT.  The ULHT IMR expresses the view that she handled the escalating situation with A1 and A2 with great tact and professionalism.  86.  A2 also expressed concern about delays in being seen; in waiting for treatment for C2’s raised temperature; and talked further about his dissatisfaction with the hospital. He had considered making a complaint but felt that “they wouldn’t get anything out of it” and had not pursued a formal complaint. He also expressed his concern about the fact that social care did not visit the hospital and “did no background checks”.    He stated that the allocated SW3 was “really nice and supportive” when she visited them later and had seen the family together.  87. This account from A2, which characterises the hospital as the ‘bad guys’ and the social worker as helpful, is interesting in that health staff, both CON2 and nursing staff, were concerned that the presentation and history they were given had raised doubts, while social care appeared, certainly to A2, to be less convinced that there was any evidence of concerns.  In hindsight one can see an accumulation of evidence which did not raise concerns at the time or as separate incidents, but which if pulled together might have presented a more complex picture of the circumstances surrounding C2’s care and well-being.  These issues include the earlier history of unexplained injuries to the ears seen by the GP (about which there were no immediate concerns), the inconsistencies in the accounts of the immunisation visit, Version 03/14  19 the late presentation of the head injury, and the fact that all the explanations for the bruise offered by A1 and A2 related to times before the A&E admission.  This Report does not conclude that there was clear evidence of significant harm and continuing risk, but there was a failure for this to be tested through effective multi-agency discussion and challenge.   All the pieces of the jigsaw were not put together.  88. In respect of the events in July A2 stated that when he found C2 he assumed she was unconscious. He said he had been looking after C1 and C2 while A1 was at work.  He said “things had happened’ and that he had dropped C2 in the bath.  He had considered calling an ambulance but thought about the “trouble last time”. He stated he was "devastated. Didn’t want to be judged. Panicked. I dressed her and checked her". He stated she seemed fine and said he thought if he did phone hospital “they would ask if she was weeing and drinking like last time, and then say go home and watch her”. A2 said he considered that there was no point in being off work and worrying A1. A2 said he was worried about Social Care involvement, as they had just been told there would be no further action following the previous incident. He stated when he found C2 in the living room he placed her back on the settee; he shook her in panic and smacked her on the back and then contacted an ambulance.  C2 appeared to be fitting.  89. A2 confirmed that the First Responders and ambulance had arrived quickly and that he had been given clear guidance on resuscitation over the phone when he had called 999.      90. A2 had been phoned from DPoW and gave the initial history. “They asked for details of the incident and A2 spoke to them but said he didn’t mention the shaking as it did not seem important. A2 stated that if they had asked, he would have told them.”  91. Once he reached the hospital A2 said that they did a CT scan and he asked, "could it be a head injury?" He said the hospital said no. They were considering diabetes, meningitis etc.  A2 said he felt this meant that C2’s condition could not be ‘me dropping her in the bath’. He did not disclose the shaking as he was confident it was not his fault. As with his account of the previous episode in June he claimed the incident has occurred when he was out of the room fetching a drink for C2.   92. A2 stated that the support and care offered at SCHT was good and supportive.  He felt there had been early liaison between Grimsby and SCHT and that the EMBRACE transfer was good.  93. When asked by the Overview Author if he wanted to say anything further, A2 said "I didn’t even tell A1 that I dropped her in the bath. No way I would risk having children taken off us. No one sees me with my children, they make assumptions. I made a mistake". 94. The notes of the interview with A2 were shared with him following the meeting, and the summary above is drawn from these notes. Version 03/14  20  Conclusions  95. It is the conclusion of this Serious Case Review that the death of C2 was neither predictable nor preventable.   The subsequent trial of A2 has established that he was responsible for the murder of C2.  The judge concluded that A2’s failure to tell the truth meant that the medical teams spent time investigating other possible causes of her injuries. The judge also made clear that A1 was completely exonerated of any involvement.  96. Although there are lessons to be learnt from this case there is no evidence that any different circumstances would have modified or changed A2’s behaviour and actions, or that the outcome for C2 could have been different.  There were discrepancies and differences in the information known by agencies; in the history reported by the family; in the judgments reached in good faith by professionals.  None of these suggest unequivocally that there was a clear risk of significant harm that should have been acted upon differently, for example by removal of C2, at the time of episode 1, although the opinion of CON2 that there was an unexplained bite mark should not have been discounted.  Opinion on this injury should have been clarified with CON2 as part of the S47 investigation.   However, the failure to challenge the differences of view, or to escalate them to resolution, and to use multi-agency processes constructively to test information and agree a plan focused on the child’s best interests, together with the gaps in recording, were all missed opportunities to ask more searching questions. These are of concern and provide important lessons from this Serious Case Review.   97. At episode 2 the injuries sustained by C2 were life-threatening, and there is evidence of prompt and appropriate action to treat her by a series of teams and interventions. In general interagency liaison worked well, including with the transfer to South Yorkshire services in Sheffield. What was not picked up during episode 2 was some of the information that might have increased the probability that NAI was considered of greater likelihood at an earlier stage.  This would not have changed the outcome for C2, but reveals the importance of maintaining a clear focus on safeguarding issues.  98. Episode 1 More attention to, and evaluation of, a range of safeguarding questions in June 2012 might have enabled agencies to be more alert to possible risks to C2 and also to her siblings and therefore to have developed a proactive relationship with the family that was focused on the possible risks to all three children, including the unborn C3.   99. This more proactive relationship with the family could have been through a Team around the Child (TAC) approach, a Child in Need (CiN) plan or through a Child Protection Plan (CPP).  Had CON2’s view been accepted that the bite mark was a NAI or at least unexplained, and if the presenting head injury had been reconsidered, a child protection conference might have been called and more detailed information Version 03/14  21 about the family could have been gathered and more fully evaluated.  It would certainly have presented a more complex picture to support work with the family, but it is in my view unlikely that the case would have met the threshold for implementing a CCP even after discussion at conference, given what was known at the time.  Holding an ICPC, however, might have established with the family the nature and level of the concerns shared by agencies and why these were potential risks, and placed the whole history of C2 short life in a clearer context. At the very least a fuller strategy discussion would have tested whether there was sufficient risk of significant harm to justify proceeding to a conference. All this would have supported closer working with the family.  Instead, a more optimistic view of the risks developed during June, it was decided that a Child Protection Conference was not justified and the case was closed a few days before the final episode and C2’s death, without a TAC or CiN plan.   While this is missed opportunity there is no firm evidence that it would have affected A2’s behaviour or actions, or would have protected C2 more effectively.  100. Greater professional curiosity and better exchange of information might have challenged the varying accounts and explanations provided by A1 and A2 in order to evaluate better whether there were safeguarding risks and how these might have been managed.  This might have probed more closely the assumption of parental responsibility by A2 in his presentation to health agencies, and the degree to which he provided the history of C2’s injuries and well-being to professionals even when not present at the reported incidents.  His account to the Overview Author suggests that he was well aware that he had not told the whole story about C2’s injuries in both June and July and how they might have been caused.   101. Episode 2 C2 was seriously ill and her condition critical from the time of the 999 call on 28th July.  The emergency response was timely and appropriate to her presenting symptoms, but did not adequately consider the safeguarding implications of the case and of information provided by A1 and A2 in a number of separate comments.  Medical opinion from both DPoW and Sheffield suggests that it is unlikely that C2 would have recovered.  However, there was a failure to incorporate information about her previous episodes of hospital admission and possible injury or to question the likelihood of NAI, which was compounded when the initial CT scan was incorrectly reported.  102. Overall, the case illustrates weaknesses in the robust, prompt and sceptical appreciation of safeguarding risks across several agencies, which should have placed a proper professional curiosity alongside the positive parenting observed, and the immediate priorities of care and treatment that were put in place.  The case illustrates that, in circumstances where there are different views and opinions, and not sufficient challenge and curiosity, safeguarding processes need to prompt the critical evaluation required to assess risks clearly and to decide on an appropriate course of action.    Version 03/14  22 103. Where there is clear evidence of significant harm there are robust processes for deciding on a course of action to protect children.  What this SCR indicates is that children can come to harm where there are few obvious signs and where only hindsight suggests information that might have given rise to greater concerns. Appropriate procedures and process were in place – to gather information, to conduct a strategy discussion, to escalate concerns – but these were undermined by inconsistencies in recording, failures to challenge and check information, and by a lack of focus on the child(ren).  The Lincolnshire Safeguarding Children Board is recommended to consider how it can reinforce the need for a critical and probing safeguarding mindset across all staff and agencies, so that staff are equipped be alert to potential safeguarding risks in all situations.  104. Although there is no evidence to conclude that this would have predicted or prevented C2’s death, there were weaknesses in the handling of this case by both individual workers and agencies.      105. There were significant discrepancies in the history provided by A1 and A2 during Episode 1 and their explanations of the circumstances surrounding the head injury and bite mark.  At various times they suggested that the injuries and observed mark were caused by a puppy; by possible rough handling from C1; or by handling when the immunizations were administered.  The puppy was not mentioned by A1 on the original 111 call even though her focus was clearly on the head injury.  A2 had not witnessed this event although he offered it as an explanation.  A1 had reported her concerns on the 111 call when A2 was not present and his account could not be checked.  A1 had suggested to CON2 that the bruise might have arisen from the administration of the vaccinations, but it was A2 who had taken C2 to this appointment as A1 was at work and this appointment was 10 days before the examination by CON2.  The timeframe varied as to when the head injury became apparent, when the bruise was noticed, and when any precipitating incident might have occurred.  106. During a traumatic incident when parents are concerned about the welfare of a child it is not uncommon for accounts to vary, or for alternative explanations to be offered, as an answer is sought to explain the injury.  However it is striking that these discrepancies were not noted or probed by the health staff responding to the family, nor were these discrepancies recorded and used to inform subsequent strategy discussions or assessment of risk by police and social care.  107. The EDT social worker (SW2) should have attended the hospital to liaise with hospital staff over the discharge of C2 on 2nd June. Both A1 and A2 were reported as angry, upset and unhappy with the response they received.  An earlier referral by the hospital to CSC rather than late on a holiday Saturday would have assisted in better planning before discharge, although CON2 was awaiting the full CT scan before making his referral. Adequate checks should have been made of the maternal grandparents before a discharge to their care was agreed, and explicit arrangements made to try to ensure the family was able and willing to comply with these Version 03/14  23 arrangements.  Discharge should have been a jointly agreed arrangement between social care, police and health, rather than a fait accompli to which everyone acquiesced. The concerns of health staff about discharge and the clear identification by CON2 of his suspicion of NAI should have been given higher priority and discussed and resolved between agencies.  There are appropriate procedures to ensure this standard of service is provided, and SW2 did not meet these expectations.  108. Escalation of concerns should have been more robust, provided challenge to colleague professionals, and been focused on the possible risks to the child(ren). The strategy discussion on 3rd June should have involved health as well as the social worker and police and should not have discounted the bite mark as possible NAI without talking with the referring doctor, CON2.  The view formed by SW2 and DC1 at their first visit to the family – that the bite mark was not a NAI – set the tone for future work and engagement with the family.  This positive view was reinforced by the observed care provided for the children.  The discrepancies in information provided by the family to the health visitor and to hospital staff should have been picked up and reviewed both with the professionals involved and with the family.  109. There were serious gaps in the social care recording of the developing understanding of the family circumstances during the assessment process in June and July. There appears to have been an early assumption that this was a child in need case which was likely to be closed with no further action.  Handover between workers and supervisors did not support a critical appraisal of the issues in the case, and allowed a partial and optimistic view of the family circumstances to prevail.  This view may not have been inaccurate, but there is little evidence of challenge and checking to establish this as an evidenced view.  110. The Social Care IMR provides evidence of a number of instances where workers have subsequently recalled both information and decisions that were not recorded fully at the time or are only summarized retrospectively in the care assessment completed at the end of the process.   111. These lapses are of concern as they involve different workers and therefore suggest a more general laxity in recording rather than a single individual failure.  The Serious Case Review process has illustrated that safeguarding concerns were not always well understood or given sufficient priority.  There are examples of failures to follow existing processes such as using strategy meetings effectively, involving all relevant agencies; and clarifying discharge arrangements, or seeking out all the information available.  112. This case also demonstrates some good and appropriate practice.  The direction given to the SW3 by the agency practice supervisor when the case was allocated on 6th June was clear and appropriate and if followed through and recorded would have provided a clearer assessment of the case. The response of emergency services and the LIVES First Responder on 28th July was prompt and appropriate, although the statements from A2 about social services involvement should have been passed on Version 03/14  24 or triggered some level of concern. The liaison between Lincolnshire EDT, police and SCHT during episode 2 was clear, with appropriate questioning and prompt sharing of information.   The support provided to A1 as a heavily pregnant mother of a seriously ill child at SCHT was caring and appreciated by the family.  113. However, it is clear from the focus of several of the IMRs that the overriding focus of several health agencies has been on explaining and justifying the appropriateness of their medical and care interventions rather than of examining whether there are safeguarding lessons to be learnt.  This is itself an important lesson that greater awareness of possible safeguarding risks is needed amongst partner health agencies.  The view that awareness of safeguarding issues would not have changed the medical treatment provided or the outcome for C2 given the extent of her injuries does not mean that it is not necessary to be alert to these safeguarding concerns.  At the least this has a direct bearing on the response provided to the other siblings to ensure their safety and the support, access and credence accorded to members of the family.  114. In summary there are several areas where lessons should be learnt from this Serious Case Review.  These are:  Lack of professional curiosity, particularly in relation to the accounts given of the injuries to C2;  Discrepancies in information not challenged through checking with agencies involved;  The need for a prompt response, in person, to both the family and health staff when concerns are raised, especially out-of-hours; The need to have clearly understood and safe discharge arrangements  The need to hold prompt, inclusive strategy discussions;   The need for robust and clear escalation when there is disagreement between agencies;  Consistent and regular supervision to challenge and question the emerging picture;  Recognition of safeguarding risks alongside clinical interventions, particularly when treating seriously ill children.  In addition there should have been more explicit recognition by all agencies that there might be safeguarding risks for both C1 and C3 if there were concerns about C2.  There seems to have been little consideration of the family dynamics and the fact that A2 was a relatively new part of the household, about whom there had been previous concerns of violent behaviour.  115. Overall, there should have been greater focus on the child, and consideration of the risks to, and experience of, a young child who it is now known had suffered a series of unexplained injuries about which different accounts had been given.  116. A number of specific recommendations have been made arising from the IMRs Version 03/14  25 and these are contained in the Action Plan (Appendix 3).  In addition this Report recommends that the Lincolnshire LSCB should consider the findings from this report as part of its Learning and Improvement Framework and review to what extent further audit and training work is required to address the issues identified.  117. In addition this Report recommends that urgent consideration should be given by ULHT to the overhaul of arrangements for taking photographs of possible injuries to ensure that this service is available for medical staff at all reasonable times.   Parallel Processes 118. Expert opinion and legal advice.  No specific expert opinion has been deemed necessary and legal advice has been available to the Panel through the attendance and involvement of the Legal Advisor to the LSCB.  The Legal Advisor has played an important role in quality assuring the draft IMRs, providing feedback to authors and ensuring that they address the prime issues of this case.  This has been a positive and effective example of partnership working and a concern for consistent and high quality of analysis.  119. A2 was charged with murder of C2 and was convicted in October 2013 and sentenced to life imprisonment.  There has been no appeal.   120. A Serious Untoward Incident Review has been conducted into the circumstances of the mis-reporting of the CT scan at DPoW Hospital has been undertaken by NLaG.     Recommendations  121. The Lincolnshire Safeguarding Children Board is recommended to consider how it can reinforce the need for a critical and probing safeguarding mindset across all staff and agencies, so that staff are equipped be alert to potential safeguarding risks in all situations (para 103).  122. The Lincolnshire LSCB should consider the findings from this report as part of its Learning and Improvement Framework and review to what extent further audit and training work is required to address the issues identified (para 116).  Version 03/14  26 123. That urgent consideration should be given to the arrangements for taking photographs of possible injuries to ensure that this service is available at all reasonable times where there are safeguarding concerns (para 117).         David Ashcroft Independent Report Author 6 February 2014  Version 03/14  27 