Death of a 6-month-old infant due to a non-accidental head injury in June 2016. Father called an ambulance to Child A's home as he had found Child A floppy. The Child could not be revived and a forensic post-mortem confirmed a severe bleed to Child A's brain. Mother had been known to Adult Mental Health Services since 2010 and previously to Child and Adolescent Mental Health Services; she had been discharged to GP care and her mental health was stable. Father had a history of depression due to breakdown of a previous relationship and not seeing his child. Family is white British. Learning: not all professionals have the same level of expertise in all areas of practice, so use of those with expert knowledge, e.g. mental health, can provide a more in depth understanding of the client; robust communication is key in understanding concerns across all agencies particularly where there is cross border working; NICE guidance indicates that routine enquiry into domestic abuse should be undertaken during pregnancy. Uses a mixed methods approach based on systems methodology. Recommendations include: hearing the voice of the child, particularly for younger children, where parental issues may be the more obvious focal point; understanding of coercive control; to formulate guidance on the importance of engaging with fathers; to reconsider the effectiveness of prescriptive thresholds guidance; robust systems in place to share information relating to safeguarding concerns; to implement a communication model across partner agencies. Please note that this report was written in February 2017 but was published in November 2018.
      
 Title:  Serious case review case 5: Child A: overview report. LSCB: Walsall Safeguarding Children Board Author: Karen Rees Date of publication: 2018  This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC.  This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above.                              1 Walsall Safeguarding Children Board       Better Together for Children www.wlscb.org.uk      Serious Case Review  Case 5   Child A         Overview Report   Author: Karen Rees   Presented to Walsall Safeguarding Children Board (WSCB) February 2017    2 CONTENTS  1 Introduction 3 2 Circumstances leading to the review 3 3 Methodology 3 4 Reviewer 5 5 Process and Scope 5 6 Parallel Processes and Family Engagement 5 7 Background Prior to Scoping 6 8 Key Phases 7 9 Thematic Analysis 19 10 Good Practice 32 11 Conclusion and Learning 33 12 Recommendations 35  Appendix 1: Terms of Reference (Redacted for publication) 38  Appendix 2: Falkov’s Crossing Bridges Model 42  Appendix 3: Pathways to harm, pathways to protection 43  Appendix 4: A Model of Communication 44      3 1. Introduction   1.1. This Serious Case Review is undertaken following a notification of a childcare incident to Ofsted on 12th June 2016 and subsequent discussions with the National Panel which concluded that the criteria for a Serious Case Review was met.  1.2. Regulation 5 of the Local Safeguarding Children Boards (LSCB) Regulations 2006 sets out the functions of LSCBs. This includes the requirement for LSCBs to undertake reviews of serious cases in specified circumstances.   1.3. Regulation 5(1)(e) and (2) set out an LSCB’s function in relation to serious case reviews, namely:   5(1)(e) undertaking reviews of serious cases and advising the authority and their Board partners on lessons to be learned.   (2) For the purposes of paragraph (1) (e) a serious case is one where:  abuse or neglect of a child is known or suspected; and  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.   1.4. The request for a Serious Case Review was agreed by the Independent Chair of the WSCB on 19th July 2016.  2. Circumstances Leading to the Review  2.1. An ambulance was called to the home of Child A by Father in June 2016. He informed the call handler that he had gone to get Child A’s bottle, came back and found that Child A was floppy.   2.2. Child A was brought into Area B’s (see 5.2 below) Accident and Emergency Unit. Upon arrival, there were no signs of life. Cardiopulmonary respiration was being performed by paramedics and resuscitation continued. Child A could not be revived.   2.3. On examination Child A had a very small bruise on the right side of the face. Child A had no major injuries but there was evidence of a bilateral haemorrhage in that both the eyes were cloudy. No other injuries were found. A forensic post-mortem was carried out; this confirmed that there was a severe bleed to Child A’s brain; Child A was six months old at the time of the incident; the sibling was 19 months old. 3. Methodology  3.1. Working Together to Safeguard Children 20151 does not prescribe a fixed methodology for Serious Case Reviews, but states that reviews should be conducted in a way in which;                                                        1 HM Government (2015) Working Together to Safeguard Children    4  recognises the complex circumstances in which professionals work together to safeguard children;   seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did;   seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight;   is transparent about the way data is collected and analysed; and   makes use of relevant research and case evidence to inform the findings.   3.2. This serious case review used a mixed methods approach based on systems methodology. Individual Management Reviews (IMRs) and Chronologies were requested from the agencies that had provided services to Child A and the family. A panel of professionals from the Safeguarding Children Board Serious Case and Significant Incident subcommittee (SCSISC) met to quality assure the material that had been provided by agencies before onward circulation and again to review the overview report and provide a degree of governance to the review process.   IMRs/Written Reports were received from (see further details 5.2)   Clinical Commissioning Group (CCG) Area A (GP; Area of residence and Father’s GP)  CCG Area B (GP; Mother and Children’s GP)  Hospital Trust Area A (Health Visiting, Inpatient and community midwifery post-delivery, ante natal outpatients)  Hospital Trust Area B (Accident and Emergency, Ante Natal Community Midwifery)  Mental Health Team Area A (Psychiatric Liaison Serves to Hospital Area A)  Mental Health Team Area B (Mental Health Services to Mother)   Local Housing Group  Local authority Area A (Children’s Social Care and Early Help)  Police   Ambulance Service Nil Returns were received from;  Substance misuse services  Children and Family Court Advisory and Support Service  Probation Services  Walk in Centres (Area A)  3.3. Members of the panel, practitioners and their line managers, report authors and safeguarding leads came together for two Practitioner Learning and Reflection Days (PLRD). It is of note, however, that many of the practitioners that were involved with the family during the timeframe of the review are no longer in post but all agencies were represented. Attendees at the first PLRD had an opportunity to review all the IMRs prior to and during the day.  The PLRD also included group work whereby attendees identified areas where learning had occurred.   The second day enabled a review of the emerging themes, learning and recommendations. In keeping with Working Together 2015 guidance, the PLRDs ensured full engagement from agencies who had provided services to the family and attempted to understand the systems that practitioners were working within to understand why practitioners practiced in the way that they did and how they made decisions.     5 4. The Reviewer  4.1. Karen Rees is an Independent Safeguarding Consultant with a nursing background. Karen worked in Safeguarding roles in the NHS for a number of years. Karen is completely independent of WSCB and its partner agencies.  5. Process and Scope  5.1. Full Terms of Reference and Project plan were agreed at a meeting of the SCSISC on 3rd August 2016 and are attached as Appendix 1.   5.2. For the purposes of this review health agencies will be known by the service that was provided and by area that it was provided from. The family lived close to the local authority border and health services were received from two areas. (Area A being the area in which the family resided and Area B being the neighbouring authority area). All other services either worked across borders e.g. Ambulance and Police or service was only received based on address e.g. Early Help, Children’s Social Care and housing provider.  Agency Services Provided within the Scope of Review GP Area A  Primary care to Father GP Area B Primary care to Mother and children  Hospital Area A Inpatient and outpatient midwifery, post-natal community midwifery at home, health visiting to family. Hospital Area B Community midwifery at GP practice A and E service at time of death, health visiting Services to GP Practice Area B Mental Health Team Area A Psychiatric liaison Services to Hospital in Area A Mental Health Team Area B Commissioned to provide services to adults with Mental Health Issues who are registered with GPs in Area B (i.e. Mother) 6. Parallel Processes and Family Engagement  6.1. At the time of conducting this review there was an open coroner’s inquest and ongoing criminal investigations. The Coroner was made aware of the Serious Case Review.   6.2. The criminal investigation was in its early stages. The author contacted the officer in charge of the investigation in order to seek consent to provisionally speak to the family about their experience of the services they had received. Working Together 2015, states that family members should be invited to contribute to reviews. The author was mindful of guidance available from Association of Chief Police Officers and Crown Prosecution Service2 to support the liaison and information                                                       2 Association of Chief Police Officers and CPS (2014) Liaison and information exchange when criminal    6 exchange when there are parallel processes. West Midlands Police consented to professionals taking part in the PLRD.   6.3. Although the guidance gives advice about how to involve family members without jeopardising the criminal proceedings, West Midlands Police did not give consent for the family to be approached by the author prior to the conclusion of the criminal investigation.   This decision was respected and therefore arrangements to meet with the family were not possible leading to gaps in the ability to gather the views and perspectives of the family on information provided by professionals in the interim report.   6.4. The family were therefore informed about the review in writing and sent a leaflet about the method of conducting the review including the use of family records.  Arrangements were made to meet with Mother and Father following the conclusion of the criminal justice processes.  Mother and Father’s views are included in relevant sections throughout the report.    6.5. Both grandmothers were also contacted but It was not possible to engage with them and therefore their views are not included.    6.6. This review was initially written without involvement of the family and was interim until the family could be involved. This did not, however, prevent lessons being learned in how agencies worked together, nor did it prevent recommendations and learning being applied across agencies.  6.7. The IMR for the GP in Area B, who the mother and children were registered with, indicated that  as consent from Mother could not be gained, the GP agreed to meet with the GP IMR author and share relevant and proportionate information to produce their IMR. This is in keeping with guidance obtained locally and nationally.  6.8.  Following the first PLRD, the GP practice contacted Mother and gained her consent for her records to be used for the review, leading to more information available at the second PLRD.  7. Background Prior to Scoping Period  7.1. Much of the background of Child A’s family comes from the Police IMR. Child A was the second born to parents with the sibling having been born 13 months previously.   Parents had been in a relationship for approximately 3 years. At the time that Child A died, the family were living in a two-bedroom ground floor flat rented from the local housing group. Information suggests that very soon after starting their relationship they became inseparable and before moving to their own property they lived with both extended households. Neither parent worked, relied on welfare benefits and lived in social housing. They are both White British and lived in an area where this population formed the largest single ethnic group.                                                         proceedings coincide with Chapter Four Serious Case Reviews or Welsh Child Practice Reviews     7 7.2. Mother concurred with this knowledge of the couple’s background and cited that they were like ‘Siamese twins’ and did everything together. Father also agreed that they were always together.  7.3. The family lived very close to the neighbouring authority border and this did present some complexity in the multi-agency working with services provided by both areas at differing times.   7.4. Mother had been known to Adult Mental Health Services in Mental Health Trust B since 2010 and previously known to Child and Adolescent Mental Health Services. She was initially diagnosed with paranoid schizophrenia3 and was known to the Early Intervention Psychosis Service4. Her care transferred to the Complex Care Team5 when her diagnosis was changed to borderline personality disorder6. This change in diagnosis and the impact of Mother’s mental health diagnosis on her parenting was subject to debate and discussion during the PLRD.  This is subject to further analysis within this review (See Section 9.2). Maternal is recorded as a carer for Mother and this role later switched to Child A’s Father.   7.5. Agencies were not able to provide any background information related to Father, although it did come to light during the review that his GP was aware that he had a child by a previous relationship that he had no contact with. 8. Key Phases  8.1. For the purposes of this review the journey of the children’s story will be highlighted using relevant information in key phases that inform the later areas for analysis. Relevant information from the IMRs was extracted and discussed in the PLRD seeking to understand the multiagency working and learning.    8.2. It is of note that prior to the scoping period the family were not known to Children’s Social Care. Mother had been discharged from mental health services to the care of her GP, who reported that her mental health was stable and she remained very well.   Key Phase 1: First pregnancy to delivery of first child (February to November 2014)                                                        3 Paranoid schizophrenia is a sub-type of schizophrenia. It has been the most common type of schizophrenia. Schizophrenia is defined as “a chronic mental disorder in which a person loses touch with reality (psychosis).  The clinical picture is dominated by relatively stable and often persecutory delusions that are usually accompanied by hallucinations, particularly of the auditory variety (hearing voices), and perceptual disturbances. These symptoms can have a huge effect on functioning and can negatively affect quality of life. Paranoid schizophrenia is a lifelong disease, but with proper treatment, a person with the illness can attain a higher quality of life.   4 Early Intervention Service – This team support young people and adults aged 14 to 35 who are going through a first episode of psychosis, or who seem at risk of going through a first episode of psychosis.  5 Complex Care Service - This service provides community support to people with severe and enduring mental health problems such as schizophrenia and bipolar disorder. The team is a multidisciplinary team that includes specialists in personality disorder. 6Borderline personality disorder (BPD) is a serious mental disorder marked by a pattern of ongoing instability in moods, behaviour, self-image, and functioning. These experiences often result in impulsive actions and unstable relationships. A person with BPD may experience intense episodes of anger, depression, and anxiety that may last from only a few hours to days. Some people with BPD also have high rates of co-occurring mental disorders, such as mood disorders, anxiety disorders, and eating disorders, along with substance abuse, self-harm, suicidal thinking and behaviours, and suicide. While mental health experts now generally agree that the label "borderline personality disorder" is very misleading, a more accurate term does not exist yet.    8 8.3. The couple first came to the attention of services when an application for housing was made to a local social housing group. The online application was completed In April 2014 by Child A’s Mother. This stated that she was currently living with her mother and siblings and would need her own home as she was expecting her first child. Mother did not include any partner in this application.   8.4. During early and mid 2014 Child A’s Father consulted his GP with feelings of depression due to the breakdown of his previous relationship and not seeing his child. Father concurred that he struggled emotionally not seeing his child. In keeping with the practice protocol for mild depression7, he was given a self-help leaflet. The practice protocol also includes information being given to patients about the service of a Community Psychiatric Nurse within the practice. Child A’s Father did not access this facility.  He attended later in 2014 when it was decided to commence medication. During this time, he was not reviewed by the GP and although sick notes were issued for depression, he did not have any further medication. In the latter part of 2014 Father attended his GP on another matter; depression was still noted. There was no exploration of Father’s current social situation.  The practice was not aware of his new relationship or any children from that relationship, prior to notification of the childcare incident in 2016.   8.5. In May 2014 the Community Midwife from Area B forwarded an ante natal risk assessment to Area A Hospital (the local hospital for the area that Mother lived). The risk assessment detailed a diagnosis of paranoid schizophrenia. This constituted a referral for shared care between GP and consultant, in line with the mental health pathway for pregnant women. The assessment advised that Mother was currently not taking any medication. At this time, there was no other action.  8.6. Mother told the author that she was very happy to be pregnant. She stated that from the age of 19, she had wanted to have a baby and have her own family. Father also expressed this view and stated that he was excited to be a father.    8.7. A few weeks later the ambulance service was called to the address of Maternal Grandmother due to a report that Mother was 13 weeks pregnant, had fallen and was bleeding. The ambulance report stated that following a full assessment there was no reason to transport to hospital.  It was agreed that she would self-present to Accident and Emergency for further examination. No other agency appears to have detailed this incident in their records; the IMRs for Area A and B hospitals do not detail an attendance at this time. It is therefore not known whether Mother attended another facility, or whether she changed her mind about attending Accident and Emergency.  8.8. In June 2014, the Named Midwife for Safeguarding at Area A Hospital received a call from the Community Midwife in Area B.  The midwife expanded on the mental health history, she stated that mother had been diagnosed with Schizophrenia in 2010 and sectioned under the Mental Health Act.                                                       7 Depression is a common mental health problem – it affects nearly 1 in 6 people in the UK. The main symptoms of depression are losing pleasure in things that were once enjoyable and losing interest in other people and usual activities. A person with depression may also commonly experience some of the following: feeling tearful, irritable or tired most of the time, changes in appetite, and problems with sleep, concentration and memory. Possible first treatments for mild to moderate depression include a self-help programme, a treatment called computerised cognitive behavioural therapy and a physical activity programme (exercise). - NICE Guidance     9 The information stated that the GP had not confirmed the diagnosis.  It appeared that the GP would need to make a referral back to the mental health team, as Mother had not been seen by them for a considerable amount of time.   8.9. Information received from the GP practice, indicates that the referral was made in July 2014. This was following a conversation between the community midwife, the GP and a review with Mother. Mother had stopped her medication and was feeling well. The GP referral did not reference the diagnosis as she was well known to mental health services; the records showed the diagnosis of borderline personality disorder following the mental health review in 2013.  8.10. This referral back to mental health services when Mother became pregnant, was in line with the Perinatal Mental Health Pathway. The GP wrote a complex letter to the Mental Health Team. The referral was declined, as the GP referred due to concerns expressed by the midwife regarding the medication but had not detailed any concerns of a mental health nature. Indeed, information from the GP records state that Mother was clinically stable.  8.11. The information given to Area A Hospital by the midwife, did not give details of any concerning behaviours or concerns for current mental health state, that may have indicated a risk to an unborn baby at this point. Details from the GP record indicated that the midwife was contacting the GP about Mother stopping medication.  It was clarified that she had done this because she was worried about the effect on the baby. Mother, on meeting the author, concurred that this decision had been her decision, that she felt very well and did not need her medication. She stated that the medication was an antidepressant and not an antipsychotic.  8.12. Because of the conversation detailed above, the Community Midwife agreed to make a referral to Children’s Social Care. There is no record that Mother knew about this referral; Mother and Father told the author that they were not told about this referral. The referral was received by the Multi Agency Screening Team in social care at the end of June 2014. It detailed concerns as above but indicated that the diagnosis, according to the GP records was psychosis, self-harm, overdose and personality disorder. It stated that Mother was not taking her medication and was not engaging with her GP. It is not clear what the ‘non-engagement’ related to as the GP records and IMR do not indicate this. It may have been that this was more about non-compliance from a medication perspective rather than non-engagement. The referral also detailed that Mother had stated that she had a previous miscarriage and had become upset when she detailed this. Records do not show any previous pregnancy. This added to the concern the Midwife was raising. There is not any mention of a partner or other family in this referral that would indicate the level of support that Mother had.   8.13. The duty social worker discussed this referral with the team manager. It was agreed that there would be no further action at this point and the Midwife would be advised to offer Early Help support to Mother. There is no record that this was communicated to the Midwife, even though the social care records indicated that it was agreed that the Early Help Coordinator would inform the named midwife for safeguarding of the advice for Early Help referral. This did not lead to any Early Help offer at this point. The PLRD events heard that feedback to referrers was an issue at this time but that following concerted work, there is now always a letter back to referrers detailing the outcome.     10 8.14. At the end of August 2014, Police were called to the home address of Paternal Grandmother. The log detailed an altercation between Child A’s parents and Paternal Grandmother with whom they had been residing. Paternal Grandmother had asked parents to leave as she felt that they had taken over her house. They had refused. Officers responded to this as a domestic abuse incident; they attended the property where they found that the couple had packed up and were in the process of leaving, stating that they had made arrangements to move to stay with Maternal Grandmother. Mother and Father both recall this incident as an argument over the financial contribution paid by Mother and Father to Paternal Grandmother for living costs.  8.15. This incident did not lead to a referral to the DART8 at the time as only incidences involving families where there were children, or a pregnancy were subject to this process. Given the nature of the incident and the absence of evidence of any children who could have been at risk, this was in accordance with policy. Mother did not appear to be pregnant to the officers and this was not disclosed as an issue by anyone at the address (she would have been 6 months pregnant at this point). There was a discussion at the PLRD that mother had a high Body Mass Index9 (BMI) and midwifery colleagues confirmed that pregnancy may not be noticeable in women with a high BMI.   8.16. The ambulance service received a call in October 2014 in respect of Mother, with a report of waters having broken and that she was experiencing contractions. Mother was found lying on the floor outside the property. She was conveyed to hospital. Hospital staff found no evidence of premature labour. It is not detailed by the Ambulance Service or the Hospital whether anyone was in attendance with Mother. Mother disclosed that she had been taken off her medication for schizophrenia by her GP. Mother also informed an unknown practitioner (there is a note in the records but it is not signed) that there was a domestic happening at home and stated there was lots of shouting. None of the information gathered related to mother lying on floor outside property, mental health medication or the reported ‘domestic at home’ was explored further by any of the staff who had contact with her during this episode.    8.17. Five days later, Mother was reviewed at Hospital A following the above attendance, she reported she was not taking her medication but planned to restart this after the birth. She stated that her mood was up and down but was feeling positive overall and that she did not feel the need to see a community psychiatric nurse.  8.18. The next time that Mother was seen is when she was admitted in premature labour on at the beginning of December 2014. Concerns were raised by Mother that she would not stay on the ward if her partner could not be with her. It was documented that she attended the ward for examinations and pain relief but stayed where she could be with her partner for the rest of the time. Father told the author that Mother liked him to be with her and that she often asked him not to go out if she was not going with him.                                                         8 Domestic Abuse Response Team: at the time, all referrals were sent to the team for planning protection of children and victims. This was only where there were children or a pregnancy within the family 9 The body mass index (BMI) is a value derived from the mass (weight) and height of an individual. The BMI is an attempt to quantify the amount of tissue mass (muscle, fat, and bone) in an individual, and then categorize that person as underweight, normal weight, overweight, or obese based on that value.     11 8.19. When she did arrive on the delivery suite, she was reported to be emotional and had no belongings with her. Mother stated her partner could not go and collect them as they had no money. Mother was provided with a gown and other sundries that she needed. Mother again left the delivery suite on several occasions and had to be called back to be reviewed by the consultant. There was no exploration of the reasons for having attended hospital with no belongings or any further assessment of her social, financial or mental health situation at this point. Domestic abuse enquiry was not undertaken either as part of routine admission assessment or as a result of concerns noted.   8.20. On the same day, a midwife contacted the Health Visitor expressing concerns that Mother was due to deliver, had a diagnosis of schizophrenia and irrational behaviour but engaged with health. This liaison was good, and the health visiting records record the conversation.  The records do not show the outcome of any assessment of this information or how this information would be used to inform the future health visiting offer to the family. It is not clear what the irrational behaviour referred to nor whether the midwife was referring to information from Mother self-reporting her diagnosis, from professional conversation or records. It is of note that it is not possible to tell from any records whether this was a community midwife from Area B or a hospital midwife from Area A.  8.21. Further concerns were recorded in midwifery records that Mother was asking to leave the ward for a cigarette whilst in labour. She was on an intravenous drip and advised that it was not appropriate to leave the ward during labour and she did not ask to leave again.  Key Phase 2: Birth of Sibling to 2nd Pregnancy (November 2014- May 2015)  8.22. There was a lot of activity in this phase and the information below reports a summary of the events that occurred and the key points that will inform the analysis.  8.23. The period immediately following delivery of sibling showed further concerns expressed by midwifery staff of the parents being off the ward for extended periods of time. At the PLRD there were discussions related to this, leading to conclusions that the absences were over and above what would be expected to be usual for new parents. The baby was prescribed antibiotics as a preventative measure due to infection risk from prematurity and spontaneous rupture of membranes. The baby also required nursing on a ‘Cosy Therm’ mattress10. Parents, although aware of the need to take the baby to the special care baby unit for the medication and the times that medication was due, were not on the ward at this time. A midwife also recorded concerns of the parents’ ability to cope with the demands of parenting. There were also positive aspects noted on occasions with Mother giving appropriate care and when spoken to about being away from the ward parents did not leave again. There is no recording of which elements of parenting were of specific concern. A debate at the PLRD centred on whether the issues pointed to possible bonding concerns; it was agreed that there were some indicators of this but no real recorded evidence of ongoing concern. There was no exploration at this time of the support that the parents would have on discharge from family and friends.  8.24. When the baby was two days old a further telephone call was made by midwifery staff to Children’s Social Care expressing concerns that parents were leaving the baby. The Midwife was advised to                                                       10 Cosy Therm mattress supplies regulated heat to prevent hypothermia in new-born babies.    12 observe. There is no exploration as to where or why parents were leaving the ward. It is not clear if parents were aware that contact was being made with Children’s Social Care. This contact resulted in advice to offer Early Help.  8.25. Mother told the author that she was very scared that her baby was ill and could not cope with seeing her baby receiving treatment under a lamp and with goggles on. Mother stated that no one asked her why she was leaving and that no one explained what was happening to her baby and she became emotional. Mother stated that it was her own mother who reassured her.  8.26. A midwife discussed the offer of Early Help support but Mother declined as she stated that she had good support at home from Maternal Grandmother who was also detailed as Mother’s carer.11 Carer would have been a term that Mother would have been used to during her time in mental health services. This was the first time that midwifery staff were aware that Mother had a carer. As Mother was well at this time it is likely that the carer role was minimal at this point.  8.27. During this inpatient admission, a doctor recognised that there had been no formal assessment of Mother’s mental health and duly referred to the Mental Health Team in Area A who provide a mental health liaison service to the hospital. The referral detailed concerns about a lady with schizophrenia who had stopped taking her medication during pregnancy and had no planned mental health follow up. The Community Nurse Specialist visited the ward and had a discussion with a midwife prior to seeing Mother. The Midwife reported no concerns with mental health and that Mother had been interacting and caring for her baby well. The Nurse Specialist saw Mother with Father and found her to be well with no obvious evidence of current mental illness. Mother declined a full mental health assessment but showed good insight into her illness and treatment and stated that she planned to see her GP to restart medication if necessary. She appeared to be open about her previous mental health illnesses and admissions but stated that she had been well for the last 18 months; Father concurred with this. Mother gave consent for the nurse to contact Maternal Grandmother, which she did; no concerns were identified.   8.28. The Nurse Specialist contacted the Mental Health Team in Area B who confirmed that Mother had remained well and care had been transferred to her GP.  No contact was made with the GP by the Nurse Specialist for any further information. The Nurse Specialist was not made aware of the other concerns that had been raised by various midwives during this admission or previously. The Nurse specialist did not appear to know that further contact had been made with Children’s Social Care earlier that day or that Mother had declined the offer of Early Help.  8.29. The next day, further concerns were raised by a midwife as parents had stated they were tired. These were discussed with the parents and Mother stated that she would need her medication and would arrange for someone to bring it in. Mother said that although she now had her own property, she would be going home to Maternal Grandmother’s house and that her mother was a good source of support. Early Help was again offered and this time accepted.                                                        11 A carer anyone who provides support for a relative, friend or neighbour. A carer is not paid for their role, and is different from a paid professional like a care worker or home help.     13 8.30. The next day an Early Help referral was received having been signed by Mother.  Mother told the author that her own mother had advised her to accept the Early Help so that they could see she was a good parent and would not take her baby from her.   8.31. It appears that Mother and baby were discharged home to the home of Maternal Grandmother, at some point on the same day and the community midwife visited the family home the next day. It does not appear that there was any handover from the hospital of any concerns that the hospital had raised or about the referral to Early Help. The transfer sheet from the hospital to health visitor did detail an Early Help referral but not the detail as to why this was required. The Community Midwife saw Mother and baby on a few more occasions but did not detail any further recording of observations related to the concern that the hospital had raised.  8.32. The first contact with the Health Visitor was in accordance with the Healthy Child Programme (HCP)12 provided for those in receipt of Universal Services (at this time ante natal contact in Area A was not universally achieved). The Health Visitor recorded no concerns with the baby. The family were advised about not smoking around the baby and safe sleeping advice was given. The Health Visitor noted that Mother was very open about her mental health history and that she was due to see her GP to review her medication. The Health Visitor recorded no concerns regarding mental health and used her knowledge and skills from her previous role as a mental health nurse, recording that Mother engaged appropriately. There was no recording of the role that Father played or the home environment. Exploring this further at the PLRD, the Health Visitor stated that there were no concerns about the environment and that this was Maternal Grandmother’s home. Father and grandmother were noted to be present and therefore, following NICE guidance, routine domestic abuse screening was not completed.  8.33. The Early Help Family Support Worker contacted the family and visited the home. Recording detailed a warm and clean home and that the baby appeared well looked after and appropriately dressed but remained under the care of the midwife due to concerns about slow weight gain. Mother appeared to be open about her mental health and stated that she had started her anti depressant medication . She had not yet seen the GP. Mother stated that she did not recall signing the Early Help consent form and both her and Maternal Grandmother were clear that they did not require any support. Father was recorded as present but nothing else was recorded about him. The Early Help Support Worker contacted the Health Visitor following this visit.  The health visitor affirmed that she had visited the family and that she had no concerns with no evidence on any impact of the concerns raised and that baby was well.   8.34. During this period the Early Help Support Worker continued to have contact with the family and liaised with her manager, the Health Visitor, the Mental Health Team in Area B and the GP. This was to ensure that Mother addressed the issue of her medication and that her mental health remained stable, even arranging for an appointment and accompanying her to the GP practice. This was                                                       12 The HCP offers every family a programme of screening tests, immunisations, developmental reviews, and information and guidance to support parenting and healthy choices – all services that children and families need to receive if they are to achieve their optimum health and wellbeing.27 Oct 2009 Healthy Child Programme - Gov.uk     14 despite the fact that the family did not consent to formal Early Help support but did not appear to mind the contact.  The Health Visitor offered to talk to the family again about the Early Help offer and feedback to the support worker. She did this and again the family reaffirmed that they did not require this support. Mother told the author that she felt pressured into restarting her anti-depressant medication despite the fact that she felt well and did not feel that she needed it. Mother indicated that having her baby made her very happy and that she no longer felt any depressive symptoms.   8.35. Just before Christmas, the Health Visitor carried out the 6-8-week review, she noted that the baby was progressing as expected and recorded good attachment with Mother. This was the first real indication of the lived experience of the baby. Domestic abuse was again not assessed as Father was present.  Mother was now reporting that she had a medication review with the GP and was taking an anti-psychotic and an anti-depressant. At the PLRD it was confirmed that the anti-psychotic was likely to have been used as relapse prevention rather than treatment of current psychosis. Mother was concerned that baby had a cough but that it was not affecting feeding and advice was given against smoking in the home. Nothing is recorded about Father or the home environment at this visit. Mother informed the Health Visitor that Early Help were still involved even though she did not want this service.  8.36. Following Mother’s attendance at the GP practice, the GP agreed to a referral to the Mental Health Team in Area B.  Following a review of the previous notes and current identification in the referral of Mother remaining well with no concerns, the decision by the Mental Health Team was to take no further action and for her to remain under the care of her GP.  8.37. At the end of January, the Early Help Support Worker made further contact with an unannounced visit to the home of Maternal Grandmother after not getting a response by telephone earlier in the month. Mother was found to be doing well and stated she had settled well into her new home. There was no record of contact with the baby or Father at this visit. A further visit was scheduled for the next day. There is no record as to whether this visit took place. A final visit by the Early Help Support Worker took place the following week. Mother reported to be very well and seeing her GP regularly about her medication. The record shows that the baby was sitting in a baby chair and dressed appropriately for the weather.  Mother was informed that she could contact Sure Start at any point if she needed further support. At this point, Early Help ended their intervention; records did not indicate that this was shared with any other professionals.   8.38. During this period the baby received immunisations as expected and no other concerns were raised.  8.39. The Health Visitor attended the family home to undertake the 3-4-month introduction to solids visit (HCP). Advice was given against adding rusk to the bottle. The home environment was recorded as being satisfactory and although an ashtray was evident with cigarette butts, Mother assured the Health Visitor that smoking only happened outside the property. The Health Visitor recorded that Mother’s mental health remained stable and described Mother as a confident lady who maintained eye contact and was appropriate in her conversation and responses. The Health Visitor advised about the benefits of floor play for the baby; at this point the family were reported to be saving for a carpet.      15 8.40. At the end of May 2015 that parents attended the GP practice as the baby had a rash. The GP recorded a ‘very happy child growing well’. This again references the lived experience of the baby and no concerns were highlighted.  Key Phase 3: Pregnancy of Child A (knowledge of) to birth of Child A (June-December 2015)  8.41. The first contact in this phase was a telephone call in June 2015 from the Midwife to the Health Visitor.  This was to advise that Mother was pregnant and had stopped all medication, but that Child A’s sibling was well looked after. Mother had told the midwife that she was well supported by her mother and partner and there were no concerns. No further detail of the conversation or actions related to relapse prevention or actions were recorded by the Health Visitor or the Midwife. The Health Visitor contacted Mother on the same day leaving a voicemail message requesting a call back to confirm the expected date of delivery and to book a developmental review for the sibling.   8.42. The GP made a timely referral to the Mental Health Team in Area B for review, monitoring and support with medication in this pregnancy.  The Mental Health Team agreed to offer a routine outpatient appointment.  8.43. Mother attended her first ante natal appointment at Area A Hospital in July 2015 and was reviewed by a midwife and doctor. Concerns were raised about a high Body Mass Index and advice was given. Mother asked for support with stopping smoking and disclosed about her mental health and that she had stopped her medication due to her pregnancy. She informed the ante natal clinic doctor that she was seeing a community psychiatric nurse at the GP practice. This is not borne out in information obtained from the GP or the Mental Health Teams. A review of mental health was planned at 34 weeks’ gestation. No other communication occurred from the hospital at this point.  8.44. At this time, Area A hospital had introduced electronic records that had domestic abuse screening included in assessment questions. Questions related to previous and current domestic abuse can be answered by use of drop down pick lists of no/yes/declined to answer/ unable to ask. There is then a box to identify additional notes. On this occasion the ‘unable to ask’ was selected but no rationale was recorded.  8.45. In August 2015 officers from the housing group attended the family home to undertake a routine 9-month tenancy check. Every room was reviewed and the check was passed with no concerns reported.   8.46. The Health Visitor carried out a planned antenatal contact and a developmental review for Child A’s sibling at the beginning of September 2015. Sibling was reported to be meeting developmental milestones and growing as expected; it was noted that excellent interactions and attachment were observed between the parents and child. The home environment was recorded as satisfactory. Parents denied smoking in the property and support was requested to stop smoking; the Health Visitor gave a contact number for that support. Father was present so again, considering guidance, domestic abuse screening was not undertaken. The Health Visitor also completed an ante natal assessment. Mother disclosed about her schizophrenia and that she had stopped taking her medication due to pregnancy. There was no recording of any risk identified or any liaison with    16 midwifery services or GP following this contact.    8.47. Later in the month, Mother attended ante natal clinic at the hospital and was diagnosed with gestational diabetes. This resulted in a requirement to attend an educational session to learn about dietary management of diabetes, a transfer to a different consultant who specialises in managing diabetes in pregnancy and the booking of an ultra sound scan for October 2015. It was noted that there were no concerns for unborn Child A, that Mother’s mental health was stable and that she was due to see the Mental Health Team in November.  8.48. Two follow up ante natal appointments at the hospital were then defaulted that resulted in a telephone call to which Mother responded that she had been unwell. A further appointment was booked and attended by Mother and Father. There is no recording of what the reported illness was related to. Mother informed the consultant that she had not been testing her blood as required as she did not have any testing strips. Mother reported to the author that she did test her blood sugars during pregnancy and told the author how and when she did this. It was possible that she started doing this after she had been given testing strips. Father said that he remembered her testing her sugar levels.   8.49. Towards the end of October 2015 Mother attended the antenatal clinic at the hospital with concerns of a bump to the abdomen and reduced foetal movements. No further exploration was undertaken in respect of the nature of the ‘bump’. Routine domestic abuse screening was not undertaken as Father was in attendance. Mother attended for further follow up on seven days later and advice was given related to increased blood glucose and encouragement to stop smoking. Mental health was not discussed or recorded; routine domestic abuse screening was not undertaken and on this occasion, it is not clear why as Father is not recorded as being present. Mother attended again for a routine review in November and was again advised in relation to raised blood sugars. At a further follow up a week later it was recorded that Mother was not taking the medication to manage raised blood sugars that had been prescribed the previous week, as she thought that it was contraindicated in pregnancy.  8.50. At the end of October, mother had registered Father with the housing group as a person living with her at her tenancy but not as a joint tenant.  8.51. During this time the Mental Health Team had been trying to engage with Mother; she had defaulted an appointment in September which, in accordance with the Mental Health Trust Defaulted Appointment Policy, was followed up by telephone call from the duty worker to Mother. No concerns were noted therefore another routine appointment was offered for November. This too was defaulted and rearranged. There was no communication from the Mental Health Team to midwifery services or health visitor via the GP or otherwise.  8.52. At the end of November, at a routine appointment at the hospital, Mother was encouraged to opt for an elective caesarean section due to the gestational diabetes. Mother declined this as she preferred a normal delivery. The records noted that the schizophrenia and depression were reviewed and that Mother was coping without medication. The review did not include contact with any agency that was monitoring and supporting her mental health. At a further follow up in the first week of December it was noted that Child A was breech and therefore an elective section was    17 booked which Mother agreed to.  Key Phase 4: Birth to Death of Child A (December 2015-June 2016)   8.53. Mother attended the hospital as planned for the scheduled caesarean section. It was not documented if Father was in attendance.  8.54. When Child A was born, there were immediate concerns; it was noted that the cord was around the neck and breathing needed to be aided. The heart rate was low as well as low blood sugars. Child A was transferred to the neonatal unit where good recovery was made. Mother attended the neonatal unit twice that evening and was updated by the doctor that Child A had recovered well and may transfer to the ward the next day. At this point, there was no mention of Father or the sibling.  8.55. The next day Father attended the hospital and was noted to be doing all feeds, Mother visited the neonatal unit as well. During the next two days both parents were reported to be caring for Child A. There were reports that the parents were missing from the ward on occasion but it is not clear if this was when they were visiting Child A on the neonatal unit.  Mother and baby were discharged eight days after delivery.  8.56. The community midwife visited the following day as well as two days later and reviewed Child A and Mother. Apart from some slight jaundice there were no concerns noted. The final midwifery visit was at the end of December. Mother was recorded as being good emotionally but there was no obvious review of mental health or a discussion about medication.   Father and sibling were not mentioned in the records; neither was the home environment or any issues noted about parenting of two very small children. No liaison took place with the GP or the mental health team who Mother had been referred to and it did not appear that the Midwife was aware of the defaulted mental health appointments.   8.57. The first visit of the Health Visitor had been planned but the family were not at home and a rearranged visit took place the following day. This was a different health visitor than had visited the family previously. At this visit Child A’s sibling was reviewed and noted to not yet be walking or pulling to stand (Sibling was now just under 14 months old). Parents were advised how to encourage motor development. They were also advised against adding rusks to the bottle, something that the previous health visitor had also advised about. There is no record of what arrangement was made to follow up this potential developmental delay.  8.58. Child A was noted to be well at this visit. The Health Visitor reviewed Mother’s mental health and Mother stated that the GP had advised to start her medication again for schizophrenia when she had finished her antibiotics. Mother reported that she was feeling well. The Health Visitor discussed that domestic abuse can be a feature within some relationships. This was a way of raising awareness of domestic abuse. The Health Visitor informed parents of the DART process and that health visitors offer support where there are incidents of domestic abuse; both parents were present. This is the first time domestic abuse had been discussed. The Health Visitor noted in the red book13 that the                                                       13 The Personal Child Health Record (also known as the PCHR or 'red book') is a national standard health and development record given to parents/carers at a child's birth. The PCHR is the main record of a child's health    18 Midwife had recorded that the home environment was dirty. The Health Visitor discussed this with parents who became upset and had not seen what had been written. It was recorded by the Health Visitor that the home conditions at this visit were acceptable. Neither the Health Visitor nor the Midwife recorded descriptors as to the reason for their assessment of ‘dirty’ or ‘acceptable’. At the PLRD this was explored and the Health Visitor was able to state that Father explained the flat was untidy when the Midwife visited as he had not had time to wash the dishes and there were clothes on the floor waiting to go in the washing machine.   8.59. The Health Visitor undertook a routine 6-week check at home at the end of January as arranged; no concerns were identified. Sibling was not mentioned in recordings about this visit. The Health Visitor reviewed Mother’s physical and mental health and no concerns were noted. Mother was reminded to attend the GP surgery to discuss her medication. It did not appear that the Health Visitor liaised with the GP or the mental health team who were monitoring Mother’s medication and mental health. Father was not mentioned at this visit. The home conditions were reported to be much improved but there was no indication what had improved. Mother was asked to attend well baby clinic in three weeks’ time. At the second PLRD, the health visitor was able to recall that she had observed Father demonstrating to her that he had undertaken the strategies suggested at the previous visit by the health visitor, and that the sibling was now pulling to stand.  8.60. At the beginning of February 2016, the GP received a letter from the hospital detailing a defaulted appointment for a hip scan for Child A (routine following breech presentation).  The letter requested referral back if any concern was identified. Child A was seen that day by the GP for a routine 6-8 week medical assessment. The assessment showed no concerns; hip examination is part of the routine screening at this assessment. Child A then received immunisations as expected at the GP practice when they became due in February, March and April 2016.    8.61. It was during this phase that there was an open referral from the GP to the mental health team in Area B. As detailed previously the referral was made in the ante natal period but appointments were defaulted. The appointment rearranged from November 2015 was to be for mid-January 2016. Records show that Mother phoned to cancel this appointment as she was recovering from a caesarean section. Mother was seeking a home visit if this was an option. A home visit was arranged for end of February.  8.62. The home visit was carried out by a doctor supported at the doctor’s request by an occupational therapist from the mental health team. Mother was not at home at the time of the visit but arrived home with Father and both children when contacted by phone; they had been shopping. Child A was asleep in the buggy but sibling was entertained and played with by Father. Both parents took part in the assessment.  No mental health concerns were noted and Mother was to continue with the same treatment. No mention is made of the home conditions at this visit but on interview with the IMR author, the occupational therapist recalled that the flat was slightly unkempt but this was not of a level to cause concern. Although asking about abuse at any time in a patient’s life is part of the routine medical assessment of patients, the paperwork detailing this element is not in the records                                                       and development. The parent/carer retains the PCHR, and health professionals should update the record each time the child is seen in a healthcare setting.      19 for this visit. The recordings for this visit do identify that Mother was in a stable relationship with her current partner who was very supportive.  8.63. The outcome letter from this visit was not sent to the GP until April 2016. It was stated at the PLRD that this was due to significant capacity issues within the administration team and would not be usual. It was noted that after the death of Child A, the Mental Health Team Leader contacted the GP who informed the team leader that Mother had not taken any medication since May 2015 and that Mother had suffered no ill effects as a result. This is notwithstanding that the result of the assessment visit was to continue treatment.  8.64. A follow up appointment was arranged by the mental health team for May 2016, but this was not attended. This was followed up and a further appointment was made for a home visit on in June.  8.65. In June 2016, when Child A collapsed,  father telephoned for an ambulance stating that Child A was not breathing. Details in the Police IMR indicated findings at the property suggestive of neglect i.e.  “………. Furthermore, poor home conditions demonstrated by parental/adult failure to discard used nappies, items of clothing abandoned on floors culminates alongside the evidence of smoking with related paraphernalia easily accessible to children, grubby bedding, unhygienic toilets and an inaccessible second bedroom due to cluttered storage of items.”    8.66. The hospital in Area B, who carried out a child protection medical examination on Child A’s sibling also reported extensive nappy rash that had not been adequately treated that could have been indicative of neglect.          9. Thematic analysis  9.1. The individual management reviews and the discussions at the PLRD highlight several themes for further analysis. Focusing on the systems that practitioners were working in during the timeframe for this review leads to valuable learning.  Mental Health of Parents  9.2. Much of the activity and concern within this review was related to the mental health of Mother. There are several aspects of this activity that provide insight into the information known to professionals, their understanding of Mother’s diagnosis and medication and the impact on her as a parent that give weight to further analysis leading to learning.  9.3. Father’s mental health problem was only known to his GP and it is not clear if he was ever asked about his health and well-being or his social history by any agency. He was present at both ante natal assessments by midwifery staff and there were no observed mental health concerns documented for Father. It is not clear if this was asked or if, when asked, there was no disclosure.  Where parents have additional needs such as mental health a whole family/think family approach is required.  An understanding that in fact there were two parents who had mental health problems should have refocussed attention to move to a whole family approach.     20 9.4. When the midwifery service first became aware that Mother had a mental health diagnosis and had stopped her medication there was immediate concern. This was raised initially by the Community Midwife in Area B and relayed to the Health Visitor and the hospital in Area A. Part of the reason was that the Mental Health Pathway for pregnant women indicates shared care between GP and consultant, but it was also suggested that there would be an impact on the unborn baby.   9.5. Following discussion with a safeguarding lead in the hospital in Area A, a referral was made by the Midwife in Area B to Children’s Social Care. The information shared was that Mother had a diagnosis of paranoid schizophrenia and that she had stopped her medication. Ultimately this led to the offer of Early Help and support, with a focus on restarting medication. There was little communication from those supporting Mother in her pregnancy and who were contacting Children’s Social Care to those professionals who had in depth knowledge of and were managing Mother’s mental health needs. Even when mental health professionals from Area A Mental Health Team carried out their assessment and found no concerns, this did not seem to have an impact and there was a continued pursuance of a focus on medication by Early Help when Mother and baby had been discharged.   9.6. The focus was on diagnosis and treatment rather than any impact on Mother, initially as a prospective parent through to being a parent of two small children. There was no assessment of her capacity to be a safe and effective parent. Practitioners were focussing on the medical treatment of mental health conditions as opposed to any presenting behaviours that may have impacted on parenting capacity.  9.7. There has been much written about parenting capacity and parental mental health. Cleaver et al 14 conclude that much research indicates that parents with a mental illness, as a single parental problem, can be effective and loving parents and do not present a risk of harm to their children. They also cite research that indicates many parents find that the bond can be especially strong and negative effects can be offset by good support networks. Mother told the author that she was very happy that she had become a parent and that this had a positive impact on her mental health.  9.8. Much of what is recorded about Mother’s diagnosis was taken by self-report with very little checking back with mental health professionals or GP. Mother never gave her current diagnosis, stating that she had a psychotic illness as opposed to personality disorder. It is not clear how well her change in diagnosis was communicated to her and at what point and whether she understood the differences. Some professionals knew of her more recent diagnosis, but this did not always appear to be applied consistently. Mother indicated to the author, several diagnoses that she had regarding her mental health; this included schizophrenia and personality disorder.   9.9. At the PLRD there was much discussion about this and it was included in the learning that emerged from the group work on the first day. Mental health colleagues were able to provide descriptions of the similarities and difference between the two conditions. The main issue arising out of this discussion was that in fact NICE Guidance related to borderline personality disorder, discourages prescribing for the condition.  In cases of schizophrenia, medication is important and primary first                                                       14 Cleaver, H., Unell, I. and Aldgate, J. (2011) Children's needs – parenting capacity: child abuse: parental mental illness, learning disability, substance misuse and domestic violence (2nd ed.) (PDF). London: The Stationery Office (TSO).    21 line of treatment. Mental health colleagues stated that it is usual to prescribe for individual symptoms associated with the borderline personality disorder. It can be seen therefore that the anti-depressant and anti-psychotic medications would have been to provide for symptomatic relief.   9.10. Mental health colleagues were also able to confirm that the decision to change diagnosis is not unusual. Symptoms initially may appear to be psychotic in nature but following a period of assessment can be found to be behavioural leading to a diagnosis review to borderline personality disorder. It was also confirmed that this change in diagnosis was discussed with Mother when she was transferred to the team that manage patients with this diagnosis. It is not clear how much Mother understood of this as she continued to inform professionals of her original diagnosis.  9.11. What may have provided for more thorough understanding of risk in this case would have been to concentrate on behaviours as they pertained to parenting capacity.15 This would have placed the focus on the future children within the family, taking a whole family approach. Use of theoretical frameworks in safeguarding children can provide a sound and evidence based assessment of risk. This may have provided Children’s Social Care with the clarity that they needed to understand the behaviours that may have posed a risk. For example, there were some indicators or cues that may have been linked to mental health but these were not explored further by any further questioning e.g. the concern about miscarriage that did not appear to feature in any medical records and the presentation reporting to being in early labour where there was no evidence of labour. These and other examples may not have been linked to her mental health diagnosis but were not explored and did not feature in any assessment.  9.12. Professionals did not articulate effectively if there was any specific risk posed by Mother’s mental health presentation, moreover there did not appear to be any documented mental health behaviour or presentation of any concern. Other than his GP, no professional documented any observation or assessment of Father’s mental health.  9.13. In trying to understand why practitioners were so wholly focussed on medication, professionals at the PLRD hypothesised that this was due to a lack of in-depth knowledge of mental health conditions.  It was argued for more training for all staff in mental health. This was not necessarily wholly agreed with by all participants but use of the experts to check out the important points may have been helpful.   9.14. The hospital Trust in Area A has a Mental Health Guideline for all staff that work in Maternity Services. This was not applied robustly by the staff working within those services and the Trust made a recommendation in their IMR to address this issue. The guideline gives guidance to health visitors and GP requirements at ante natal and booking visits, but the guideline is not written for those staff. Indeed, in this case, Mother’s GP was over the border in Area B. Had this guideline been applied by the staff it is aimed at, there may have been a better understanding of Mother’s mental health diagnosis. There would have been a comprehensive plan of assessment and review of any mental health presentation at key points throughout her ante natal and immediate postnatal periods. The                                                       15 Parenting Capacity: The ability to parent in a good enough manner long term from Conley, C. (2003). A review of parenting capacity assessment reports. Ontario Association of Children's Aid Societies (OACAS) Journal, 47(3): 16– 22    22 guideline could be strengthened specifically for women who have significant history of mental health conditions where there are no current mental health presentations of concern.  9.15. National guidance16 for all staff working with mothers where mental health is a concern, suggests that an integrated approach to care in the ante natal and post-natal period offers best practice in order that mothers and babies are afforded the best and safest care.   9.16. It appears that Mother’s decision to stop medication in pregnancy was not fully explored with her, her mental health team or GP. It is known that psychotropic medication taken in pregnancy can pose a risk to the unborn baby. There is a general caution to mothers-to-be about taking any medication in pregnancy and may have been the reason that Mother chose to stop her medication. Mother indicated to the author that she made the decision to stop her medication for fear of harming her baby.  Indeed, mother did not take her medication for gestational diabetes either as she believed it would be contraindicated in pregnancy. Best practice in managing psychotic illness in pregnancy, indicates that the risks to the unborn of taking medication should be weighed up against the risks of relapse in maternal mental health by not taking it.  Applying this practice within a multi-agency meeting alongside Mother may have provided an opportunity to have a more robust view of the risks, whilst working in partnership with the Mother. In this case, the evidence did not point to any negative impact on Mother’s behaviour or mental health by not taking medication. This was confirmed by two mental health teams and her GP as well as the Health Visitor.  9.17. In this case, given that the parents had mental health issues, it would have been helpful to apply a ‘think family’ approach to the possible impact of parental mental health on any children in the family e.g. using Falkov’s ‘Crossing Bridges Family Model’ outlined by the Social Care Institute for Excellence Guide 3017. This helps practitioners to identify protective factors and support networks against risk and vulnerability in the context of the parental mental health and child’s needs. It would                                                       16 GUIDANCE DOCUMENT: Health Visiting Programme: Pathway to support professional practice and deliver new service offer Maternal mental health pathway 3 https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/212906/Maternal-mental-health-pathway-090812.pdf  NICE Clinical Guide https://www.nice.org.uk/guidance/CG192/chapter/1-Recommendations#recognising-mental-health-problems-in-pregnancy-and-the-postnatal-period-and-referral-2  NICE Pathway https://pathways.nice.org.uk/pathways/antenatal-and-postnatal-mental-health  17 SCIE 2014 Think child, think parent, think family: a guide to parental mental health and child welfare http://www.scie.org.uk/publications/guides/guide30/files/guide30.pdf  Learning Point 1:  Not all professionals have the same level of expertise in all areas of professional practice. Use of those with expert knowledge in a given area (e.g. Mental Health) can support professionals to have more in depth understanding of their client/patient. ‘Checking out’ and ‘checking back’ are important elements when dealing with parental self-reports. (Recommendation 1) Learning Point 2: Use of national and local guidance related to Maternal Mental Health, by all health staff ensures that there is clarity of assessment and planning for women who have a history of mental health conditions who may or may not have a current presentation of concern. (Recommendation 5c)     23 have provided evidence of thorough assessment of these issues and any impact on the children (See Appendix 2).    9.18. Communication related to Mother’s mental health including defaulted appointments was not robust. Some of this may have been due to the complexities of cross border working. The community midwifery service for ante natal care came from Area B as it is based on GP practice. The post-natal community midwifery service came from Area A as it is based on the hospital of delivery.    Midwifery services at Area A Hospital made no contact with the GP over concerns that had been raised with children’s social care about mother’s mental health  The health visitor who worked in Area A made no contact with Area B GP  The Mental Health Team in Area B made no contact with health visitor or midwifery service in Area A  The Hospital Midwives in Area A did not communicate any concerns to the Community Midwives in Area A  The communication pathway between community midwifery service antenatally in Area B and the post-natal community midwifery in Area A should have been via the patient held ‘Green Notes’ and the discharge summary.  Neither of these contained the information about the concerns that had been expressed in the ante natal and immediate post-natal period.  Domestic Abuse Routine Enquiry  9.19. There is no evidence that domestic abuse was a feature in this relationship. Due to the prevalence of domestic abuse being estimated at 1 in 4 women and that domestic abuse often starts or escalates in pregnancy18, it has long been advocated that all pregnant women should be screened for domestic abuse in a safe environment with access offered to support networks should they be required.  This is reiterated in more recent NICE Guidance (2014)19 and NICE Pathway (2016)20                                                        18 Department of Health (December 2005) Responding to domestic abuse: a handbook for health professionals  19 https://www.nice.org.uk/guidance/ph50  20 http://pathways.nice.org.uk/pathways/domestic-violence-and-abuse   Learning Point 3:  Application of theoretical frameworks can help to refocus assessments and provide an evidence base for concern, as well as providing good quality information for onward referrals related to specific issues of risk and vulnerability. (Recommendation 1 & 4) Learning Point 4:  Robust communication is key in understanding concerns across all agencies and to afford prevention of harm. This can be particularly complex where there is cross border working. (Recommendation 5d)    24 9.20. It is also known that there is a greater risk of domestic abuse in relationships where one or both partners have mental health issues. Application of domestic abuse routine enquiry was therefore an important aspect of assessment to recognise any risk and vulnerability to the children in the family.   9.21. The absence of any thorough assessment of elements of domestic abuse as a feature within this relationship in line with NICE guidance and pathways, means it could not be ruled out.  It could also be argued that no opportunities were given for disclosure by either parent. Research shows that it often takes several opportunities and enquiries before some victims will disclose, and some never do, suggesting that asking once is probably not enough to allow for a victim to come forward for support. Creating space to allow for screening and disclosure may have been an important aspect for both parents.  9.22. Managers and safeguarding leads at the PLRD identified varying levels of policy and practice related to the issue of routine enquiry. Midwifery and health visiting services indicated that it is policy and usual practice to ask the question. Mental health colleagues ask the question of all patients during routine assessment, however the evidence within the mental health records of this is missing in this case.  The Mental Health Trust in Area B has a domestic abuse policy that covers this element of asking the question.  The policy states that this would not necessarily happen on first contact, it does not detail the risks of asking it in front of partners or carers. The GP practice have policies and procedures alongside training for safeguarding.  The GP IMR author for Area B, indicated that there was a training need for GPs related to domestic abuse enquiry and support for victims and included a recommendation to address this.  9.23. From discussions at the PLRD it appeared that there were several possible reasons why routine enquiry was not achieved in this case.  9.24. Practitioners are aware that they should not ask about domestic abuse in the presence of a partner. On many planned and routine assessment appointments, Father was present. In fact, comments earlier about the couple being inseparable from very early in their relationship and the fact that the couple were nearly always seen together, may have provided cues about coercive control.21   Coercive control has received much attention recently with a new law making coercive and controlling behaviour a criminal offence22 as it is a dangerous element of domestic abuse. Again, that is not to say that coercive control was an element in this relationship, but assessment and routine enquiry did not provide any opportunity for either disclosure or, to rule it out as a feature.  9.25. There is no evidence that arrangements were made to see Mother on her own as a routine part of achieving routine enquiry in the ante natal period. Opportunities were available when mother was seen alone but these did not lead to the question being asked as they were outside of the usual routine appointments and not seen as assessment opportunities e.g. when Mother was an inpatient in the ante natal period and Father was off the ward, or when seen following the bump to the                                                       21 Coercive control is a term developed by Evan Stark to help us understand domestic abuse as more than a “fight”. It is a pattern of behaviour which seeks to take away the victim's liberty or freedom, to strip away their sense of self. It is not just women's bodily integrity which is violated but also their human rights. 22 Home Office (2015) Controlling or Coercive Behaviour in an Intimate or Family Relationship Statutory Guidance Framework    25 abdomen.   9.26. There were comments from all staff that knew Mother that she was a very confident lady, she appeared to be in control of managing her mental health and appeared to take the lead in the relationship. It is known that 1 in 6 men are thought to be victims of domestic abuse and that domestic abuse in males is underreported. Father should have been individually assessed as a parent, especially given his role in the family. That may have afforded opportunities to disclose domestic abuse should he have chosen/needed to. Father’s disclosure to the author regarding Mother not wanting him to go anywhere alone, may have become knowable to professionals if they had questioned why Mother kept leaving the ward.    9.27. Some practitioners stated that they did not feel confident to ask the question of the couple about experience of domestic violence or abuse or, had asked but in the presence of both parents. This would suggest that there may be further training requirement into the understanding of routine enquiry and coercive control as a feature of domestic abuse.  9.28. A discussion at the second PLRD provided more clarity as to the systems and organisational support for routine enquiry in domestic abuse:   Police officers who are called to a domestic incident will always speak to both parties separately giving space for safe support and disclosure.   Mental health staff have updated polices to include domestic abuse screening as part of their routine assessment.  It is now included in training for staff, leading to a better understanding and application of the policy.    The Royal College of General Practitioners provides guidance to GPs regarding domestic abuse. This does not advocate routine enquiry but does state that GPs should enquire sensitively where any indicators may be suggestive of violence or abuse.   Area A Hospital Trust do not have a specific domestic abuse policy to support practitioners to undertake routine enquiry in line with national guidance.  At the time of this case, they were using Safeguarding Children Procedures and NICE Guidance. This is being addressed and a policy is currently being written and will include mandatory use of DASH23 risk assessment. This will need to be followed up by training in the application routine enquiry and DASH risk assessment to give practitioners the skills and confidence to be able to apply the policy.   9.29. Professional curiosity was not applied to possible cues about domestic abuse. e.g. returning to the ward emotional in December.2014, in December 2014 mentioning a ‘domestic at home’ and on October 2015 when Mother presented with reduced foetal movements following a bump to the abdomen.  These incidences did not lead to opportunistic screening of domestic abuse or any                                                       23 DASH risk assessment: (domestic abuse, stalking and ‘honour’-based violence). Consists of a series of questions to work out the level of risk a victim is facing     26 further exploration as to the detail of those incidents. If Mother hinting at issues, had been testing out whether there was support around any disclosure of domestic abuse, these were missed.   9.30. Mother told the author that there was never a time when there was any domestic abuse. She indicated that they had usual squabbles, but that she never felt in fear of Father. Father indicated that he found it difficult that Mother did not want him going out by himself, even if that was to go to see his mother.   9.31. Recently published findings from a study of serious case reviews24 cites professional curiosity in many areas as a tool for safeguarding. In this case, there was a lack of professional curiosity to explore cues that may have related to domestic abuse.   9.32. The attendance by police officers to parental grandmothers’ home in August 2014 was discussed at the PLRD. Although it could be initially argued as a missed opportunity there are many factors that impacted on this. At the time only incidents involving children or an identified pregnancy were shared with multi agency partners using the Domestic Abuse Response Team. This was seen as a dispute between the parents and Paternal Grandmother and not a relationship issue and was rated as standard risk. With the current Multi Agency Safeguarding Hub approach to domestic abuse, all referrals related to domestic abuse are shared where there are children in the family. In this incident, the absence of a disclosure or knowledge of children or pregnancy, the information would not be shared. It was agreed that there is therefore no learning from this incident.   Role of Father   9.33. One of the key themes throughout all the IMRs and noted at the PLRD was the lack of information, assessment and understanding of the role that the Father of Child A and sibling took within the family. The only knowledge of Father came from his GP who was able to give information about the nature and cause of Father’s depression. This was not shared with any other professional working with the family as the GP did not know that Father was in a new relationship and had two children.  9.34. All services appeared to focus on the needs of Mother and her mental health problems to the exclusion of any concern about whether Father was a positive or negative factor in the lives of his children and partner.                                                        24 Peter Sidebotham et al. (2016) Pathways to harm, pathways to protection: a triennial analysis of serious case reviews 2011 to 2014 London, Department for Education. Learning Point 5:   NICE Guidance indicates that routine enquiry into domestic abuse should be undertaken.  An environment for safe disclosure, alongside an embedded culture of professional curiosity that encourages opportunistic exploration of indicators, provides robust evidence that the issue has been thoroughly assessed. The outcome should be carefully and safely recorded. Without this, any possible impact on the lived experience of the children is not possible.  Practitioners should be supported to apply these principles with policies and training that underpin practice (Recommendation 1)     27 9.35. Midwifery staff often commented on Father being present.  There was no record of any information or assessment about him as a parent or any history when they carried out their ante natal risk assessment when Mother booked for antenatal services.   9.36. At the PLRD the health visitors that were present gave more information on how he interacted within the family home. After the birth of Child A’s sibling it was noted that Father was always present but that he was usually in the background undertaking household chores and was the one who apologised if the flat was not clean and/or tidy. After the birth of Child A it was noted that he was much more ‘hands on’ especially with Child A’s sibling. This was possibly due to the fact that Mother was recovering from major surgery having had a caesarean section and that there was now a toddler to look after.  During a visit to Child A by the Health Visitor, Father was noted to be interacting well with the sibling.  9.37. There was no assessment of need of Father as a partner and parent that included an understanding of his history, other children and mental/physical health that would inform current risk and vulnerability. There was therefore no indicators of harm or protective factors.  9.38. Apart from the Area A GP, practitioners involved with the family, did not know that he was the father of a child that he did not see and that this had led to a depression that he was consulting his GP for. His GP did not explore his current social situation so was not aware that he was a father of two small children.  9.39. Mother informed the author that Father was a very good and caring father. It was he who did a lot of the hands-on child care. Mother stated that she was often fearful of handling the children in that she may do something wrong stating that Father was better at it. Mother stated that she was involved in all of the financial side of managing the household and made sure her children had everything that they needed.   9.40. Father concurred with this view and indicated that he loved being a Father and loved caring for the children. He agreed that he did most of the general childcare and household tasks. The lack of assessment of Father meant that this was not known by the professionals. All of the attention regarding caring for the children was centred on Mother when in fact, it was Father that carried out most of their care.  9.41. Engaging fathers has been the subject of focus in previous serious case reviews24 25. Where fathers are either not engaged or where their role in the family is not understood, professionals are not aware of what extent a father may be a risk or protective factor within a family.  9.42. In this case, nothing of concern was noted and no concerning behaviours were observed.  There was, however, no comprehensive assessment of Father’s history, wishes and feelings as a parent, or as a possible support and carer of his partner who had a mental health diagnosis.  There was also no robust assessment of him as a man who was being treated for his own depression and who was a main carer for his children.                                                        25 https://www.nspcc.org.uk/preventing-abuse/child-protection-system/case-reviews/learning/hidden-men/     28 9.43. This was discussed at the PLRD in order to understand why Father did not feature in robust assessments. This case remained within universal services. At that time, even if the family agreed to an Early Help Assessment, it is unlikely that further assessment of Father would have occurred. The second PLRD heard that this has now much improved following a concerted move to include fathers in Early Help Assessments.  Universal Services in health were either not aware that Father was a parent (GP) or were not concerned as to whether he was a risk or a protective factor, observing him to be an attentive partner and father. There does not appear to be an embedded culture of engaging directly with fathers and including them in assessments of needs in their own right or as a parent.  9.44. What is clear in this case, is that this father was not an absent carer, nor was hard to engage with but practitioners largely focussed on the needs of Mother. When practitioners were concerned about whether Mother should be taking her medication, his views and influences on her decision making were not explored or understood either positively or negatively.  9.45. Research by the University of Worcester and the Fatherhood Institute26 concluded that health visitors are well placed to include fathers in their work with families using the Healthy Child Programme. An evaluation of a training programme proved to have been positive in raising awareness in the importance of engaging with fathers and provided ideas of new and innovative ways to achieve this.   9.46. If an assessment had highlighted that Father had a previous child and that his separation from his child had led to depression, that he was the main carer for Child A and sibling, the level of need of the children in this family may have increased.  It would have been known that both parents were experiencing mental health problems and the family may have been viewed from a health visiting perspective as having additional needs under Universal Plus (Health Visiting Programme)27  (discussed further in the next section).  Family Support and Thresholds for   9.47. The result of the midwifery referral into Children’s Social Care was to offer Early Help support. This decision was based on the fact that Mother had a mental health diagnosis and was not taking her medication. At the time of the referral there was no checking with mental health services or the GP                                                       26 Nolan, M (2014) Evaluation of a Training Programme and Toolkit to Assist Health Visitors and Community Practitioners to Engage with Fathers as Part of the Healthy Child Initiative: A developmental study using action research. University of Worcester 27 The Health Visiting Programme offers four levels of service as part of the Healthy Child Programme https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/407644/overview1-health-visit.pdf Learning Point 6:  There are associated risks by not engaging and assessing the protection and support or potential threats that fathers may pose to children and/or their partner. Fathers’ needs are as important as mothers’, particularly where they live in the same household and provide equal parenting to children. Understanding both parental roles and needs can improve outcomes for children. (Recommendation 3)    29 as to whether this would pose any risk to any unborn or new-born baby. There was no further probing from Children’s Social Care as to what the specific concerns may be i.e. what behaviours were observed that indicated risk and what protective and resilience factors were in place. Children’s Social Care therefore, saw no role for statutory intervention (Section 4728) or invoking child in need (Section 1729). The Social Care IMR author questioned this decision and it was discussed at the PLRD.  9.48. Further exploration suggests there were differing Thresholds used to support this family by different agencies at the same time.  9.49. The Thresholds Guidance in place in 201330 (and this has not changed in the newer version in 2015) states that level 1 identifies that where no additional support needs are required needs are met by universal services. This would be managed from a health visiting perspective at Universal Level (Healthy Child Programme).  Level 2 would be where there are additional needs but that they could be met by Universal services and a Health visitor may use Universal Plus (Health Visiting Programme) to meet those needs.   9.50. When the Early Help referral was made, it indicated that Early Help support could not be provided by a single agency (health) as the referral was for an Early Help Assessment and support from Early Help services so would be at level 3 according to the Thresholds Guidance. This did not lead to the Health Visitor re-evaluating the package of care and escalating intervention to Universal Plus (Health Visiting Programme) based on the fact that there were identified additional needs requiring Early Help Assessment.   9.51. Community midwives at the time were not aware of any referral for Early Help.  9.52. The Health Visitor received information about the Early Help referral in the transfer form from the hospital but this did not detail the reason for the referral. When the new birth contact was carried out, the Health Visitor did not mention this to Mother or explore any areas for Early Help.   9.53. Mother refused an Early Help Assessment and support since she did not see a role for it as she was in control of her mental health condition and had the support of her mother as her carer. Professionals did not explore the nature of the support offered by Maternal Grandmother either as a                                                       28 Section 47 Children Act (1989): Local Authority duty to investigate where it is made aware that a child might be suffering or likely to suffer significant harm.  29 Section 17 Children Act (1989) Provision of services to children in need and their families 30 Walsall Safeguarding Children Board (2013) MULTI - AGENCY THRESHOLD GUIDANCE: Identifying Need and Analysing Risk when working with Children in Walsall  Learning Point 7:  Transfer of all information known to hospital maternity services, including reasons for any onward referrals, provides robust communication to enable community services to have information necessary for their ongoing interventions and care. (Recommendation 5a)    30 support with parenting or as a carer in respect of Mother’s mental health.  9.54. The Early Help support worker was tenacious in not giving up in ensuring that mother attended the GP and accessed her medication. She continued her contact even though Mother repeated that she did not want support, stated that she did not remember consenting to it and even told the Health Visitor that she did not want it. It is fair to say that at no time did the family refuse access to the Early Help worker nor were they dismissive of her.  The  service continued with the best intentions but with no robust consent. After Mother had been to the GP and without a further documented visit to the family in their own home, Early Help intervention ended.   9.55. Mother informed the Early Help support worker that she was in regular contact with her GP; although the support worker had previously contacted the GP, there was no further liaison at this point relying on Mother’s self-report. It was very early days for this new family in their own home.  9.56. There were several flaws in the level of support and how it was managed and these were contributed to by all of those involved.  9.57. The initial referral to Children’s Social Care and the ensuing Early Help offer was not based on all the known facts and there was a lack of robust assessment to inform that referral.  Gaps in the referral were:  Lack of information about Father  No assessment of the financial difficulties that were seen when mother stated they had no money  No recognition that parents were going to be moving from Maternal Grandmother’s home to their own property with a new baby  No assessment of the reasons for parents’ absences from the ward for extended periods  A reliance on Mother’s self-reporting of her mental health   No robust understanding of the mental health diagnosis whether it did indeed pose any risk to a baby   9.58. It can be seen by exploration of the case, that it was indeed possibly a right decision that the case did not meet the Threshold for Children’s Social Care statutory intervention (level 4).  It could be argued that assessment at level 3 was indicated with the health visiting service offering support at Universal Plus (Health Visiting Programme).     9.59. If Early Help had been offered for a different reason and to both parents and baby as a family, rather than the focus being purely on Mother’s medication and mental health, there may have been agreement from the family to receive additional support.  Learning Point 8: The provision of comprehensive information to inform referrals is an important factor in the decision making related to thresholds for intervention (Recommendation 2)     31 9.60. The Thresholds Guidance quotes Working Together 201331 (Guidance in place at the time)   “...if parents and/or the child do not consent to an early help assessment, then the lead professional should make a judgement as to whether, without help, the needs of the child will escalate. If so, a referral into local authority Children’s Social Care may be necessary.”  There was no documentation that a judgement was made that was based on knowledge of all the issues and shared with other professionals in Universal Services.  9.61. It can be argued, therefore, that the needs of this family, at this point were at level 3. There should, therefore have been a lead professional identified.  It would have been the role of that lead professional to instigate a multi-agency meeting to identify where all professionals felt that the Early Help offer needed to focus.  Professionals could then have discussed whether or not the refusal of the service was an increased risk or whether the needs of the children could be met at level one. In this way it would have been noted that the Thresholds Guidance was not being applied in the same way across all agencies.  9.62. When Mother presented as pregnant with Child A, there were again concerns about her not taking mental health medication but this did not result in any conversation with, or referral to Children’s Social Care. There was no consideration that an Early Help referral was required. This was a very different approach to activity in the first pregnancy.   9.63. It could be argued that there were now increasing needs as Mother was also diagnosed with gestational diabetes and appeared to be non-compliant with monitoring and treatment of this.  She also had a baby who was very young (at the time of Child A’s birth sibling was only 13 months old).  The age of the children was an increased risk from a vulnerability perspective as research identifies that very young children feature in higher percentages in serious harm and serious case reviews.  9.64. The reasons for this not resulting in any onward referral at level 3 or any thought of a multi-agency meeting to collate and share all information were discussed at the PLRD. It was argued that the focus had moved away from mental health to physical health (i.e. gestational diabetes) and that this did not instil the same safeguarding concerns that mental health had done previously. It was also now known that there had been no apparently negative impact on Child A’s sibling, which may have provided confidence that parenting capacity was good enough. This was not offered or documented as evidence that no referral for Early Help was required or that Universal services were the appropriate level of intervention.  9.65. Multi Agency Statutory Guidance in place (both now and in 2013)2,25 states that early identification of levels of need and help to meet those needs is better than reacting later.   9.66. Throughout the journey of these children there was no robust multi agency communication. There were missed opportunities for agencies to come together for a formal review of the level of intervention that the assessment of the children’s needs required. Assessments did not appear to                                                       31 HM Government (2013) Working Together to Safeguard Children    32 have focussed on what the lived experience of Child A and the sibling might be. This resulted in a lack of attention to the voice of the children in identifying levels of need. There were two specific times that could have led to a multi-agency review:   The point of discharge after the birth of Child A’s sibling when there had been referral to Children’s Social Care and a psychiatric assessment of Mother. The information relayed to community services (Midwifery and health visiting) was poor. A discharge planning meeting may have led to better understanding of the concerns and a robust plan moving forward.   Refusal by parents of Early help did not lead to a review of the level of need and intervention. A multi-agency meeting to discuss all the information known, alongside the family may have led to a more robust understanding of the needs of the whole family.  This may have resulted in a more definite plan of care.   9.67. At the second PLRD it was agreed that at the time of this case there were difficulties with Thresholds Guidance not being applied consistently across all partners. Some were showing resistance to take the lead role. Following a training programme, recent audit has shown that the situation has improved.  9.68. There have been discussions and changes with some LSCBs related to the use of Thresholds Guidance. Written Thresholds Guidance was introduced to improve the understanding as to the required level of intervention to meet a child’s needs. Difficulties have arisen due to the complexity of many families and application of written thresholds being too prescriptive.  This has taken away the support for professional judgment and agreements across partner agencies as to the best way of supporting individual families. A professional conversation about the specific issues faced by individual children and families to inform decision making and agreements as to the required level of intervention may provide for clarity.  This would need to be alongside a culture of respectful challenge and escalation where agreement cannot be reached. 10. Good Practice  10.1. It is important to note that many practitioners offer a good level of service to their clients/patients and follow policies and procedures that are provided to guide practice. Whilst recognising gaps in practice, Serious Case Reviews can also provide evidence of this as well as practice that goes over and above what is expected.  Attendees at the PLRDs were asked to identify these from their own and other agencies. It is important to highlight these as areas where learning can occur.   The Early Help Support worker was tenacious in her visiting and went beyond what was expected to ensure Mother attended the GP. She contacted the GP to liaise about the need for medication review and to set up an appointment and accompanied Mother to the Learning Point 9:  The application of standard thresholds across all agencies supports the robust assessment of children’s needs and can provide evidence to parents based on all available factors to support the argument for early help and support. Written Threshold guidance may be confusing and too prescriptive in some circumstances. (Recommendation 4)    33 surgery.   The Mental Health duty worker made telephone contact with Mother following the defaulted appointment as per the Defaulted Appointments Policy.   The Area B Mental Health Team, conducted a home visit when it was apparent that the reason for defaulted appointments was due to surgery.   The doctor at Area A hospital ensured that the psychiatric liaison team reviewed Mother before discharge after the birth of Child A’s sibling.   The Area A Psychiatric Liaison Nurse gathered information from the Midwife on the ward prior to speaking to Mother and liaised with the Mental Health Team in Area B.   The Community Midwife, from Area B contacted the safeguarding named midwife in Area A and the Health Visitor about the concerns with Mother’s mental health and the ceasing of medication.   The Health Visitor carried out an ante natal contact based on information received from the community midwife.   The Health Visitor followed up the issue of the Midwife recording the home being dirty and was also able to advise on wound care when mother had been discharged from midwives.   The health visitor used her knowledge and skills from her mental health training to effectively identify and record how mother presented and interacted.   The GP (Area B) referred Mother to mental health services for a review of her mental health and medication due to concerns expressed by community midwife.   The GP (Practice Area A) ensure that all patients seen for a mental health issue, are given the details of the Practice CPN.  11. Conclusions and Learning 11.1. From the material studied and the conversations and debates that took place in the process of reviewing this tragic case, no professional could have identified concerns to such a degree that would have given an opportunity to safeguard Child A from death.  11.2. It is clear, however, that cues may have been missed to further explore several elements of the lived experience of the two children in this family.  11.3. By using the model put forward in the Triennial Analysis of SCRs20 depicted in Appendix 3, it is possible to draw conclusions and learning in terms of ‘Pathways to Harm and Pathways to Protection’.     34 11.4. The events leading up to the death of Child A are unknown by professionals and therefore it is difficult to identify exactly which focus might have provided more insight into pathways to harm. During the process of the review, nothing came to light that would have indicated any risk of significant harm being identified so even using hindsight bias32 it is difficult to pinpoint where immediate protection could have been afforded.   11.5. In thinking about the ‘pathways to harm’ there were missed opportunities to gain a better understanding of the mental health of both parents as it pertained to parenting capacity, fully assess any domestic abuse, and an understanding of Father’s role. A further pathway to harm was the vulnerability of Child A due to being a baby under one in this unassessed environment.   11.6. Opportunities to provide the right level of support across a multi-agency arena can provide ‘pathways to protection’.  11.7. Application of professional curiosity to pick up on some of the cues that were available at various points, as well as maintaining a healthy scepticism of the self-reporting by family members that all was well, may have led to a robust Early Help offer.  That in turn may have revealed more about the family functioning and parenting and the lived experience of the children.   11.8. Practitioners focussed on Mother’s mental health diagnosis and medication rather than on any behaviours that may have indicated pathways to harm. Observed behaviours in Father were not recorded possibly because his mental health issues were not known to practitioners that knew he was a parent.   11.9. Previous studies into serious case reviews nationally20, 33 have highlighted that professionals must maintain a healthy scepticism and respectful uncertainty to see beyond what is often being presented by parents. A process of ‘checking back’ with professional colleagues may provide opportunities to detect hidden issues and provide pathways to protection, particularly where the self-report is not in the professional’s area of expertise (e.g. Mental Health).   11.10. Maintaining a healthy scepticism of parents can be difficult to do and requires skill so that a trusting relationship can be built and maintained. Not all parents, or indeed these particular parents, are dishonest or hide what is really happening at home.  Maintaining the professional curiosity and applying knowledge and skills to all cases and not just those where there are very apparent concerns leads to pathways to protect from harm (E.g. domestic abuse and role of fathers).  11.11. The lack of professional curiosity and not maintaining a healthy scepticism appear to have led to a significant gap in communication with the GP. Only the Early Help support worker contacted the GP.                                                       32 Roese, N. J., & Vohs, K. D. (2012). "Hindsight bias". Perspectives on Psychological Science, 7, 411–426.  Hindsight bias occurs when people feel that they “knew it all along,” that is, when they believe that an event is more predictable after it becomes known than it was before it became known. Hindsight bias embodies any combination of three aspects: memory distortion, beliefs about events’ objective likelihoods, or subjective beliefs about one’s own prediction abilities.   33 Laming, Lord (2003) The Victoria Climbié inquiry. Report of an inquiry by Lord Laming. Cm 5730, London: TSO.    35 Other health professionals who were expressing concern about the medication being stopped did not contact the GP to check out what Mother was saying.  This led to lack of clarity about the impact of medication being stopped on mental health and therefore parenting.  11.12. It was reported in the GP IMR for Area B, that the practice would have been made aware of any safeguarding issues as a meeting was held regularly with the health visitors and that issues of this nature would be highlighted. It is not clear that this is robust for families that live over the border in Area A, as the health visiting service was received in Area A and not B. The GP in Area B has clarified that they are not aware if the health visitors cover both areas. (Recommendation 5b)  11.13. As stated above, robust application of thresholds for intervention at the right level also provides for pathways to protection. Early help was refused by mother.  This should have led to a review of the need for this intervention and a multi-agency decision, coordinated by an identified lead professional.  This would have led to a decision about whether to ‘step up’ the level of concern and intervention based on this refusal, as per the Thresholds Guidance and from learning from SCRs. The focus of the need for Children’s Social Care or early intervention and help should be based on all assessed needs and not on one specific area of concern.   11.14. It appears that many of the reasons why the frameworks and policies were not applied robustly was either due to a lack of knowledge and confidence or merely that as risk of harm to the children was not apparent.  The need to apply frameworks robustly was not evident, thereby leading to lack of evidence that pathways to harm had been effectively assessed and therefore possibilities to intervene early for protection may have been missed.  12. Recommendations  12.1. The learning in this case provides a window on the system and it is believed that information that has come to light at the PLRD suggests that the issues that it has highlighted may not be applied only in this case and that there are implications for the wider system. The following recommendations therefore seek to address this.  12.2. This Serious Case Review covers two LSCB areas and therefore arrangements must be made to share the learning from this SCR with Area B LSCB.  12.3. Where agencies have made their own recommendations in their IMRs, both LSCBs should seek assurance that action plans and are underway and impact is assessed within those organisations.  1. Pathways to Harm (Learning Points 1,3 and 5)  Walsall Safeguarding Children Board (WSCB) Serious Case and Significant Incident Sub Committee (SCSIC) must seek to embed the learning from this review and assess the impact across agencies. Amongst a range of issues are the following:  Domestic Abuse routine enquiry and understanding of coercive control  Hearing the voice of the child, particularly for younger children, where parental issues may be the more obvious focal point.  Access to mental health expertise where that is not a professionals’ areas of knowledge    36  Assessment of social circumstances in primary care where adults are diagnosed with depression  Think Family  2. Quality of Referrals (Learning Point 8)   WSCB should seek assurance as to how widely training is being accessed across the partnership and learning applied from this case related to quality of referrals to Children’s Social Care and respectful challenge of referrers where there are gaps in information to support those referrals.  3. Engaging Fathers (Learning Point 6)  a) WSCB must undertake an options appraisal to understand how relevant partner agencies will apply the learning in this case regarding the roles of fathers in their respective organisations and to include how information is shared to GPs when men become fathers and are not registered at the same practice as mothers (in the same/similar way to the notification to mothers’ GPs).  b) WSCB should formulate guidance on the importance of engaging with fathers. This should include:   the importance of gathering background information   assessment of needs   ensuring unmet needs are supported with appropriate offer of services and/or referrals   4. Thresholds (Learning Point 3 & 9)  a) WSCB should seek assurance that all partner agencies understand the requirement for the Lead Professional in an Early Help Assessment or offer to be from the most relevant organisation and service in terms of the identified need.  b) WSCB should seek assurance that all Early Help offers are robustly supported by the relevant Lead Professional. That assurance should also include that refusal of early help by parents is followed up in line with the Thresholds Guidance, coordinated by the Lead Professional, and that parents are made aware of the concerns leading to the need for the Early Help Offer.   c) WSCB should reconsider the effectiveness of prescriptive thresholds guidance and identify if other models would be more effective e.g. professional conversation model  5. Communication  a) WSCB should seek assurance that there is robust information shared from acute midwifery to community health services in respect of any safeguarding referrals that have been made during inpatient admission. (Learning Point 7)  b) WSCB should seek assurance from the CCGs to ensure that where a GP practice is in a different CCG area to the Health Visitor, that there are robust systems in place for sharing of information related    37 to safeguarding concerns. (Para 11.12)  c) WSCB should seek assurance from the CCGs that health providers in the locality strengthen the current Mental Health Pathway and that it is in use across all relevant health providers.  Consideration should be given for opportunities to develop an integrated pathway in line with current best practice. (Learning Point 2)  d) WSCB should consider implementing a communication model across partner agencies such as the example presented in Appendix 4. (Learning Point 4)  Appendix 1: Terms of Reference   38   Better Together for Children www.wlscb.org.uk  Serious Case Review Child A Terms of Reference  1. Introduction  The request for a Serious Case Review was agreed by the Independent Chair of WLSCB on 19th July 2016.  Regulation 5 of the Local Safeguarding Children Boards Regulations 2006 sets out the functions of LSCBs. This includes the requirement for LSCBs to undertake reviews of serious cases in specified circumstances.   Regulation 5(1)(e) and (2) set out an LSCB’s function in relation to serious case reviews, namely:   5(1)(e) undertaking reviews of serious cases and advising the authority and their Board partners on lessons to be learned.   (2) For the purposes of paragraph (1) (e) 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. Case summary  Child A was the second child born to the parents. An ambulance was called to the family home by Father in June 2016. He informed the call handler that he had gone to get Child A’s bottle, came back and found him floppy.   Child A was brought into the local Hospital’s Accident and Emergency Unit. Upon arrival, there were no signs of life. CPR was being performed by paramedics and resuscitation continued for about an hour unsuccessfully. Child A could not be revived and his time of death was recorded.  On examination Child A had a very small bruise on the right side of his face. He had no major injuries but there was evidence of a bilateral haemorrhage in that both his eyes were cloudy. No other injuries were found.   A forensic post-mortem was carried out; this confirmed that there was a severe bleed to Child A’s brain. He was six months old at the time of the incident; his sibling was 19 months old.  3. Scope of the Review  The review will take into account agency involvement with Child A, his sibling and parents from the time that agencies were first aware of mother’s pregnancy with Child A’s sibling until the date of Child A’s death. The approximate timeframe will therefore be two years four months from February 2014.  4. Terms of Reference to be addressed by all agencies:  In addition to production of a chronology and overall analysis of agency involvement and services offered to the child and family, the following specific questions should be addressed by all agencies.  Appendix 1: Terms of Reference   39  a. In respect of domestic abuse routine enquiry:  i. What assessment was carried out by your agency? ii. What was the result of those assessments? iii. What ongoing care and support was offered as a result? iv. Following the assessment, which professionals and organisations was the result communicated with, regarding any ongoing care and support needs or onward referral?  v. If routine enquiry was not achieved, please comment on why and what plans were made to follow up.   b. In respect of mental health of parents:  i. What assessment was carried out by your agency? ii. What was the result of those assessments? iii. What ongoing care and support was offered as a result? iv. Following the assessment, which professionals and organisations was the result communicated with, regarding any ongoing care and support needs or onward referral?   c. In respect of parental relationships with each other and the children:  i. How did parental history inform your assessments? ii. What information did your assessments provide about parental history? iii. What did your assessment show about the role that mother and father took within the family? iv. What did your assessments identify that life was like for the children of the family?  v. Was any additional care and support required or action was taken as a result of your assessments?  vi. Following the assessment, which professionals and organisations was the result communicated with, regarding any ongoing care and support needs or onward referral?   d. In respect of wider family and community support:  i. From your assessments, what did your agency understand of the support networks for this family? ii. What ongoing care and support was offered as a result? iii. Following the assessment, which professionals and organisations was the result communicated with, regarding any ongoing care and support needs or onward referral?   e. Risk, vulnerability and voice of the child:  i. How were long term aspects of risk and vulnerability identified and how did these inform your agency support? ii. Please comment and provide analysis of evidence of the voice of the child and visibility of the children in this family.  f. In respect of all assessments carried out by your agency:  i. Were escalations pathways utilised and to what effect? ii. Were care plans SMART? iii. How was the impact on addressing identified needs monitored?  iv. What arrangements were made for reviewing care plans?  g. Cross border working:  i. Were any cross border issues identified by your agency? ii. If so, how were these resolved? iii. How were any system issues dealt with (related to cross border working)? iv. Please comment on any positive/good practice identified with relation to any cross border working identified.  h. Service arrangements/Case allocation: Appendix 1: Terms of Reference   40  How was this case allocated in your organisation? Please comment and analyse the impact of the following:  Individual or team allocation  Key worker (or equivalent) involvement  How many practitioners/workers were involved or made assessments?  i. Communication and information sharing:  Other than what is already included above, what other communication did your agency have with others who were involved with the family? Please ensure that you cover what specific information was shared and how. Where there is no evidence, please comment on this.  5. Methodology  Working Together 2015 states that:  SCRs and other case reviews should be conducted in a way which:   • recognises the complex circumstances in which professionals work together to safeguard children;  • seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did;  • seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight;  • is transparent about the way data is collected and analysed; and  • makes use of relevant research and case evidence to inform the findings.   This review will therefore use methodology that adheres to these principles by analysing agency involvement presented in Individual Management Reviews and engaging with practitioners that had direct involvement with the family.  6. Overview Author  Walsall Safeguarding Children Board have commissioned Karen Rees, an Independent Safeguarding Consultant from 402k Consultancy Ltd. to undertake this SCR  7. Individual Management Reviews are Required from the following organisations:   Area A NHS Trust:   Health Visiting   Midwifery   Other hospital Departments e.g. Out patients and A & E   General Practitioner (via Clinical Commissioning Groups) o Area A o Area B  Area A Mental Health Foundation Trust   Area B Foundation Trust (Adult Mental Health)   Area A Metropolitan Borough Council  o Children’s Social Care o Children’s Centres/Early Help  Appendix 1: Terms of Reference   41  West Midlands Police   Housing – Area A Housing Group   8. Timeline for Review   Safeguarding Board decision and commissioning discussion   19th July 2016 Scoping Meeting 3rd August 2016 Terms of Reference agreed 3rd August 2016 Terms of reference, chronolator and IMR templates and guidance to authors w/c 8th August 2016 IMR Authors’ briefing 17th August 2016 IMRs / Chronology submitted  30th September 2016 QA & distribution to all Learning and Reflection Day attendees                           7th October 2016 Practitioner Learning and Reflection Day                              20th October 2016  1st Draft of Overview Report Distributed to all attendees 24th Nov 2016 2nd Review Learning and Reflection ½ Day                           1st December 2016   Version 2 circulated                                                   15th December 2016  Comments on V2 latest by   22nd December 2106 Version 3 to Board members                                               28th Dec 2016 Final Draft Overview report presented LSCB  Jan 2017    9. Family engagement   The family of Child A will be invited to contribute to the review by the author following consultation with the case Senior Investigating Officer from West Midlands Police.       42 Appendix  2: Falkov’s Crossing Bridges  Model From SCIE Think Family Guide  http://www.scie.org.uk/publications/guides/guide30/files/guide30.pdf     43 Appendix 3: Pathways to Harm, Pathways to Protection from Triennial Analysis of Serious Case Reviews     Appendix 4: Example Communication Model Developed by  Karen Rees and  Ellen Footman, NHS  Safeguarding Leads,  in consultation with     Worcestershire Health Safeguarding Forum 44    RECORD ASK Check back Check back SHARE DO Check back Make sure you have: Not made any assumptions Understood what you have been told Who else is working with the adult or family member/carer? Do they have concerns?  Am I more or less worried? Who needs to know? Do I have or need consent to share information?    Do I need advice? Make sure that you have: Not made any assumptions A shared understanding of the action to be taken. Agree what action will be taken, by whom and the time scales Consider escalating concerns if you disagree with the decision Make sure that:  Your information has been heard and clearly understood by the recipient  You have a shared understanding of the issues/ priorities Decide what you need to share and with whom Have all relevant detail available Be clear and concise using straight forward language and avoiding the use of jargon Provide examples where possible to illustrate what you mean Note whether information has been shared with or without consent and the rationale for doing so 