Death of a 4-month-old baby boy from a serious head injury in November 2010. Baby H died three days after presenting to hospital in cardiac arrest. Issues include: significance of mother's young age on parenting capacity not recognised by agencies; lack of agency engagement with and knowledge of mother's partner; and lack of professional scepticism. Identifies themes for learning including: training for medical professionals to recognise indicators of unusual or abusive injuries; professional recognition of parents who may need additional support due to their age or social circumstances, including parents who are reluctant to acknowledge extra support needs; and importance of acquiring comprehensive social and family histories. Makes various interagency and single agency recommendations covering children's services, health services and open access organisations including Children's Centres.
      
 Title:  A serious case review: 'Baby H': the overview report. LSCB: Lancashire Local Safeguarding Children Board  Author: Peter Maddocks Date of publication: 2013  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.                            Overview Report Baby H redacted published version Page 1 of 106        Lancashire  Local Safeguarding Children Board     A Serious Case Review  ‘Baby H’  The Overview Report    August 2011       Overview Report Baby H redacted published version Page 2 of 106 Index  1 Introduction and context of the review ..................................................... 4 1.1 Rationale for conducting a serious case review .................................... 5 1.2 Reasons for the review and terms of reference .................................... 5 1.3 The scope of the serious case review .................................................. 5 1.4 The terms of reference .................................................................... 7 1.5 Particular issues identified for further investigation by the individual management reviews: ............................................................................... 8 1.6 The terms of reference for the overview report .................................... 8 1.7 Membership of the case review panel and access to expert advice .......... 9 1.8 Independent author of the overview report and independent chair of the serious case review panel ......................................................................... 10 1.9 Parental and family contribution to the serious case review ................. 10 1.10 Time scale for completing the serious case review .............................. 11 1.11 Status and ownership of the overview report ..................................... 12 1.12 Previous serious case reviews ......................................................... 12 1.13 Inspections of services for children in Lancashire ................................ 13 1.14 Summary conclusion of the review panel .......................................... 14 1.15 The family and other significant people ............................................ 23 1.16 Cultural, ethnic, linguistic and religious identity of the family ................ 24 2 Overview of agency involvement ............................................................ 26 3 Procedures and legislation .................................................................... 39 4 The critical reflection and analysis from the individual management reviews. . 41 4.1 Summary .................................................................................... 41 4.2 Significant themes for learning that emerge from examining the IMRs ... 44 4.3 Good practice identified through the review ...................................... 45 4.4 Did all agencies and professionals give due and proper consideration to all diversity issues, including ethnicity, religion, language, disability, culture, social background and integration? .................................................................... 47 4.5 Did all agencies keep the child and his experiences at the centre of their assessments of and interventions with the family? ....................................... 53 4.6 Were information sharing and communication systems within and between agencies and across boundaries effective? ..................................... 60 4.7 Was historical information given appropriate emphasis within assessments and interventions? .................................................................................. 66 4.8 Was the parents/carer's young age appropriately considered and did it have any impact on services delivered or needed? ........................................ 68 4.9 Did agencies understand the role of the child's father and the extended family, including the role of mother's partner? ............................................. 70 4.10 Were any safeguarding and child protection issues identified and dealt with appropriately by agencies? Were agency responses correct and timely? .... 72 4.11 Did they follow safeguarding procedures when necessary? .................. 76 4.12 Did agencies have the necessary resources and capacity? .................... 77 4.13 Were professionals working with the family suitably skilled and adequately supervised? ........................................................................................... 78     Overview Report Baby H redacted published version Page 3 of 106 4.14 Is there evidence of management decision-making? ........................... 79 5 Analysis of key themes for learning from the case and recommendations ...... 80 5.1 Learning from previous serious case reviews ..................................... 81 5.2 The use of CAF and coordinating early intervention and help for vulnerable children ................................................................................................ 82 Recommendation one .......................................................................... 83 5.3 The role of primary health care providers such as GPs and health visitors in safeguarding children .............................................................................. 84 Recommendation two .......................................................................... 85 5.4 Training and access to safeguarding advice in open access services or smaller accident and minor injury or walk in centres ..................................... 85 Recommendation three ........................................................................ 86 5.5 Access to information out of hours and co-ordinating information ......... 87 Recommendation four ......................................................................... 89 Recommendation five .......................................................................... 90 Recommendation six ........................................................................... 90 5.6 The value of using hypothesis and balanced judgment ......................... 90 Recommendation seven ....................................................................... 92 5.7 Organisational learning and memory to improve the critical evaluation and analysis of services and responding to the Munro Review; ............................. 92 5.8 Issues for national policy ................................................................ 95 6 APPENDICES ....................................................................................... 96 6.1 Appendix 1 – the family’s genogram ................................................. 96 Appendix 2 - Procedures and guidance relevant to this serious case review ....... 97 Legislation ............................................................................................. 97 The Children Act 1989 .......................................................................... 97 The Children Act 2004 .......................................................................... 98 Safeguarding Procedures ......................................................................... 98 The Lancashire Safeguarding Children Procedures ..................................... 98 National guidance ................................................................................... 99 Working Together to Safeguard Children (2010) ........................................ 99 Framework for the Assessment of Children in Need and their Families 2001 .. 99 Common Assessment Framework (CAF)................................................. 100 Appendix 3 Balanced Judgements ............................................................ 101 Appendix 4 – Shaken Baby Syndrome ....................................................... 103      Overview Report Baby H redacted published version Page 4 of 106 1 Introduction and context of the review  1. Baby H was a male four month old white British child who died in November 2010. Prior to his death he had been admitted via a local general hospital to a specialist regional hospital where he died. It is believed that he had received brain injuries that are considered to be non-accidental and indicative of Baby H having been shaken1 or other physical trauma.   2. It is because there is a suspicion that Baby H may have died as a result of abuse and it is believed that with the benefit of hindsight, previous injuries might also be indicative of abuse, that a serious case review was commissioned.   3. Baby H had lived with his mother and her partner (DS) together with his sibling who was not injured. The siblings had been born in Cumbria and had lived there with their maternal grandmother for three months until the family had moved to Lancashire to live with the ‘paternal’ (partner’s) grandparents in September 20102 when baby H was three months old.   4. Baby H’s father was not in contact with the family at the time of the injury and his whereabouts remain unknown to the children’s mother and all the services that have been involved with the family.   5. The possibility of a shaking injury was part of a differential diagnosis at the first hospital3. It was after Baby H had been transferred to a specialist regional children’s hospital where evidence of injuries were diagnosed the following morning that the relevant procedures were invoked and action was taken to ensure that Baby H’s sibling remained safe.   6. Work began on compiling a chronology in January 2011, which coincided with the appointment of the independent chair of the serious case review panel and of the independent author of this overview report. Neither the chair nor the overview author has worked for any of the services contributing to this serious case review. Further information about their relevant experience and knowledge is provided in section 1.8.                                           1 More detailed information about the danger and extent of babies being shaken is provided in appendix 4 and later chapters providing the analysis of learning from this serious case review.  2 In accordance with national and local procedures for the conduct of a serious case review in England, contact was made with the previous area where the family lived and information was requested for consideration by the review panel. The LSCB in that area are aware of the serious case review.  3 The differential diagnosis initially placed greater emphasis on a severe infection and for example was exploring sepsis as a possibility. Baby H’s sibling was admitted to a separate hospital to allow medical tests. The diagnosis was not included in information sent with the transfer service who transported Baby H to the regional hospital.      Overview Report Baby H redacted published version Page 5 of 106 7. The SCR panel and the LSCBs acknowledge the contribution of information to this review by the children’s mother. Further information is provided in section 1.9.  1.1 Rationale for conducting a serious case review  8. Regulation 5 of the Local Safeguarding Children Board Regulations 2006 requires a Local Safeguarding Children Board (LSCB) to undertake a review of a serious case in accordance with procedures set out in chapter 8 of Working Together to Safeguard Children (2010).   9. The LSCB should always undertake a serious case review when a child dies and abuse or neglect is either known or suspected to be a factor in their death.   1.2 Reasons for the review and terms of reference  10. The reason for undertaking this review is that Baby H may have died as a result of non-accidental injuries that could be indicative of having been shaken. There is evidence that he had experienced previous injuries that with the benefit of hindsight may have been recognised at the time as being indicative of abuse if further enquiries had been completed. Injuries had occurred whilst he was living in Cumbria and after he moved to Lancashire. For this reason, the LSCB in Cumbria has provided individual management reviews to this serious case review by Lancashire. The overview report has been provided to both LSCBs. There are recommendations addressed to both of the LSCBs.   11. The serious case review panel at their first meeting on the 10th February 2011 confirmed the scope and terms of reference. The scope and terms of reference of the review was routinely discussed and updated at panel meetings to take account of any new or emerging information and reflection.   12. The purpose of the review is to establish if lessons are learned from the case through a detailed examination of events, decision-making and action. In identifying what those lessons are, to improve inter-agency working and better safeguard and promote the welfare of children in Lancashire.  1.3 The scope of the serious case review  13. The period of the review is from the beginning of mother’s pregnancy to the date of Baby H’s death; this is from November 2009 to November 2010. All information known to a service providing an IMR should be reviewed. Any information regarding involvement prior to the period of the detailed chronology and analysis is to be summarised in the IMR and in the overview report.     Overview Report Baby H redacted published version Page 6 of 106  14. However, the SCR also sought to establish if there was anything in the parental history, or the history of mother's partner, that could and should have led to different actions and decisions being made in respect of both children. Therefore all agencies were asked to check their records for mother, father and mother's partner, and include anything of note in their IMRs.  15. All agency chronologies should include detailed information about when the children were seen, spoken to or observations made about them.   16. Agencies that identify significant background histories on family members pre-dating the scope of the review should provide a brief summary account of that significant history.   17. Reviews of all records and materials should be considered including;   Electronic records   Paper records and files  Patient or family held records.  18. Individual management reviews should be completed using the template provided by the Lancashire Local Safeguarding Children Board (LSCB), and be quality assured and approved by the most senior officer of the reviewing agency.  19. The following agencies have provided an individual management review that was to be completed in accordance with Working Together to Safeguard Children (2010), Chapter 8 and the associated LSCB guidance and relevant procedures4.   Health services that include:                                           4 The IMRs from AHCFT, the Lancashire Hospital and Lancashire Police were commissioned at the first meeting of the panel on the 11th February 2011 when the police had further information about the timings of Baby H’s admission to the Infirmary and the delay for invoking of safeguarding procedures that involved the police and children’s social care services. Other services were asked for information to assist the review; these services were children’s social care services in Lancashire and the ambulance services in both Cumbria and Lancashire. These services had far less involvement and initially an IMR was judged unnecessary; in these circumstances those services provided a short report or letter clarifying specific points of information raised by the review panel. For example children’s social care services in Lancashire had no contact with Baby H or his family before the referral from hospital the day after he was admitted. However, as further information was presented to meetings of the panel it became evident that because of the delays that occurred in making the referral to children’s social care and police services and some indication that initial strategy meetings did not involve the children’s hospital directly it was decided that an IMR was required; this was provided within a very short timescale compared to other services.      Overview Report Baby H redacted published version Page 7 of 106 o Cumbria Partnership NHS Foundation Trust (covering health visitor, GP contact and walk in treatment unit prior to moving to Lancashire) o Cumbria Hospital NHS Trust (covers hospital birth of Baby H and subsequent treatment of an injury to his shoulder aged four weeks) o Two reports from Lancashire PCT (one on behalf of the GP services and another on the health visiting services after the move to Lancashire) o GP o The Lancashire Hospital o AHCFT Trust (The children’s hospital where Baby H was transferred in November 2010 after his initial admission to Lancashire hospital )    Lancashire Police (who became involved after Baby H’s injuries were diagnosed as possibly being the result of a non accidental injury)  Lancashire County Council Early Years Services (two Children’s Centres that provided advice and services to mother and her sons between September and November 2010)  The regional ambulance service provided information in a letter and information was similarly provided by children’s services in the midlands. These were not IMRs reflecting the little contact or involvement those services had.  1.4 The terms of reference I. Keep under consideration if further information becomes available as work is undertaken that indicates other agencies should carry out individual management reviews.  II. To establish a factual chronology of the action taken by each agency;  III. Assess whether decisions and action taken in the case comply with the policy and procedures of the Lancashire Safeguarding Children Board;  IV. To determine whether appropriate services were provided in relation to the decisions and actions in the case;  V. To recommend appropriate inter-agency action in light of the findings;  VI. To assess whether other action is needed in any agency;  VII. To examine inter-agency working and service provision for the children;  VIII. To establish whether interagency and single agency policies adequately supported the management of this case;      Overview Report Baby H redacted published version Page 8 of 106 IX. Consider how and what contribution is sought from the family members;   X. To develop a clear multi agency action plan from the overview report.  1.5 Particular issues identified for further investigation by the individual management reviews5: 20. In addition to analysing individual and organisational practice, the individual management reviews should focus on:  I. Did all agencies and professionals give due and proper consideration to all diversity issues, including ethnicity, religion, language, disability, culture, social background and integration?  II. Did all agencies keep the child and his experiences at the centre of their assessments of and interventions with the family?  III. Were information sharing and communication systems within and between agencies and across boundaries effective?  IV. Was historical information given appropriate emphasis within assessments and interventions?  V. Was the parents/carer's young age appropriately considered and did it have any impact on services delivered or needed?  VI. Did agencies understand the role of the child's father and the extended family, including the role of mother's partner?  VII. Were any safeguarding and child protection issues identified and dealt with appropriately by agencies? Were agency responses correct and timely? Did they follow safeguarding procedures when necessary?  VIII. Did agencies have the necessary resources and capacity? Were professionals working with the family suitably skilled and adequately supervised? Is there evidence of management decision-making?  1.6 The terms of reference for the overview report  21. Provide a multi agency overview report in accordance with the national guidance in Working Together to Safeguard Children.  22. In addition to the requirements of Working Together to Safeguard Children (2010) and taking into account the specific issues identified above, the overview report author should:                                           5 These are the detailed issues that are analysed by the IMRs and in the detailed analysis in chapter five of this report.      Overview Report Baby H redacted published version Page 9 of 106 I. Comment on whether the individual management reviews have addressed the terms of reference and all relevant issues;  II. Examine the inter agency working and communication between all involved agencies;  III. Determine whether services which were provided, actions taken and decisions made were in accordance with current policies, procedures and government guidance;   IV. Consider, using the benefit of hindsight, whether different decisions or actions may have led to a different course of events;  V. Provide an executive summary on behalf of the LSCB.  1.7 Membership of the case review panel and access to expert advice  23. An independent person was appointed to chair the case review panel from the outset. Section 1.8 includes information about her experience and knowledge.   24. The case review panel that oversaw this review comprised the following people and organisations;   Position Organisation Lynne Pickles Independent Chair of Serious Case Review Directorate Safeguarding Manager Directorate for Children and Young People, Lancashire County Council Designated Nurse Safeguarding and Looked After Children Lancashire Commissioning PCT Head of Patient Safety and Safeguarding Lead NHS Lancashire  Early Years Lead Lancashire County Council Integrated Service Manager Lancashire PCT Children's Services Manager/Professional Lead  School Nursing Cumbria Partnership Foundation Trust Designated Nurse Safeguarding Cumbria PCT Head of Nursing and Family Services Cumbria Hospital NHS Trust Detective Chief Inspector Lancashire Constabulary Head of Paediatrics  Lancashire Hospital Nurse Consultant/Named Nurse for Safeguarding Children Alder hey Children's NHS Foundation Trust and  Liverpool LSCB      Overview Report Baby H redacted published version Page 10 of 106 Business Manager Cumbria LSCB Business Manager Lancashire LSCB Business Coordinator (administrative support to panel) Lancashire LSCB Peter Maddocks (observer) Independent Author of Serious Case Review   25. The independent author of the overview report attended every meeting of the panel.  26. The panel had access to legal advice from a solicitor in the council’s legal service.  27. Written minutes of the panel meeting discussions and decisions were recorded by a member of the LSCB staff team.  1.8 Independent author of the overview report and independent chair of the serious case review panel  28. Peter Maddocks was commissioned in December 2010 as the independent author for this overview report. He has over thirty-five years experience of social care services the majority of which has been concerned with services for children and families. He has experience of working as a practitioner and senior manager in local and national government services and the voluntary sector. He has a professional social work qualification and MA and is registered with the General Social Care Council. He undertakes work throughout the United Kingdom as an independent consultant and trainer and has led or contributed to several service reviews and inspections in relation to safeguarding children. He has undertaken agency reviews and provided overview reports to several LSCBs in England and Wales.  29. Lynne Pickles was appointed as the independent chair of the serious case review panel. She was the Head of Service, Review and Protection Team with another local authority in the North West region of England.  1.9 Parental and family contribution to the serious case review  30. The children’s mother and DS were made aware of this serious case review when it was commissioned and agreed to contribute information to the review6. The independent chair of the serious case review panel met with mother in July 2011.                                           6 This has been the subject of advice from the police and acknowledging the importance of not compromising the enquiries by the police or the coroner into the circumstances of the injuries and death.      Overview Report Baby H redacted published version Page 11 of 106 31. Mother has had no contact with the children’s biological father since before their birth. The children were conceived during a relationship that occurred after mother and DS had separated amicably and were continuing to be friends; they subsequently resumed their relationship during mother’s pregnancy before Baby H was born.  32. According to mother the biological father had been informed about the pregnancy but had been unwilling to acknowledge or have any contact or involvement with them. Mother has not sought any further contact. Mother is opposed to the father being asked to make any contribution to the review even if he could be contacted.   33. Mother had initially felt ‘overwhelmed’ but felt confident that she would manage with the support of her family.  34. Mother did not feel that she needed support from services although knew that they were available. She felt very well supported by the community midwife (CM1) and was disappointed when she had to be transferred to the health visiting service. Mother did maintain her contact with CM1 by attending her community classes.   35. According to mother’s account during the meeting she thought that she had carried Baby H beyond her due date; this is different to the information available to the SCR panel that suggests that Baby H was delivered in the week before his due date.   36. Mother described how she was reluctant to have very much direct support from her mother or from others; she felt that she was able to establish a routine quickly and wanted to do everything to ensure that they were done properly.   37. Mother enjoyed taking the children to activities such as the Children’s Centres and introducing them to other children and parents.   38. Mother felt generally satisfied with the support that was provided by the different services and in her overall view the services that she and her children had received had been good. She confirmed that staff had been approachable and if she had felt she needed support or advice she would have been able to ask for it.   1.10 Time scale for completing the serious case review  39. The case review panel met on five occasions between February 2011 and July 2011. The initial chronology of services involvement was completed by January 2011.  The first draft agency reviews were completed in February 2011 although final drafts including IMRs that were commissioned after the second panel meeting were finalised in June. The first draft of the health     Overview Report Baby H redacted published version Page 12 of 106 overview report that was produced by Cumbria and Lancashire was completed in July 2011. The final report was presented to an extraordinary meeting of the LSCB in Lancashire on the 16th August 2011 and the LSCB in Cumbria on 18th August. Liverpool LSCB considered the report at their review sub-group on 17th August 2011.    1.11 Status and ownership of the overview report 40. The overview report is the property of the Lancashire Safeguarding Children Board (LSCB) as the commissioning safeguarding board. Since June 2010, all overview reports provided to LSCBs in England have to be published in full. This overview report provides the detailed account of the key events and the analysis of professional involvement and decision making in relation to Baby H and his family.   41. The report has to balance maintaining the confidentiality of the family and other parties who are involved whilst providing sufficient information to support the best possible level of learning.   42. In reading this report, it is important to remain clear about the purpose of the overall review and of this overview report in particular. The review examines with the benefit of hindsight, if it possible to identify whether alternative judgments and decisions could or should have been taken, and whether different outcomes might have been achieved for Baby H. The review does not investigate the circumstances of Baby H’s death. That is a matter for the Coroner and for the police.  43. The review aims to be very challenging of all services for the purpose of building on the considerable knowledge and expertise that has developed in relation to the safeguarding of children in the UK. In doing this work, the panel are mindful about how complex or unclear some of the information and events may have looked to practitioners at the time of events.  44. An executive summary is provided at the conclusion of the review. This provides a brief summary of events and the most significant points of learning identified as a result of the review. The LSCB will determine how and what further information is provided to the family at the conclusion of the review and following the formal evaluation by Ofsted7.    1.12 Previous serious case reviews                                           7 In England, Ofsted have the responsibility for evaluating the thoroughness of the serious case review.  This leads to judgements ranging from inadequate to outstanding in relation to detailed aspects of the review. The executive summary includes a statement about that evaluation.      Overview Report Baby H redacted published version Page 13 of 106 45. The LSCB in Lancashire had undertaken nine previous serious case reviews between 2007 and 20108. The LSCB in Cumbria have published executive summaries in relation to four serious case reviews.   46. Reference is made to these previous serious case reviews by several IMR authors and is also referenced where relevant in this overview report. The purpose of this is to highlight where similar issues or themes have been identified in previous reviews. This ensures that action already recommended is not unnecessarily repeated. If previous action has not sufficiently addressed an issue, the review will highlight this and make further comment at the conclusion of the report.  47. Chapters four and five of this review describe in greater detail the specific lessons to emerge from a detailed analysis of this serious case review and include comments on how learning from previous reviews has been used.  1.13 Inspections of services for children in Lancashire and Cumbria  48. All children’s services in England are subject to inspections9. The local authority in Lancashire was subject to a Comprehensive Annual Assessment (CAA)10. In December 2009 the CAA annual rating given to children’s services in Lancashire was good11. This means that services were above minimum national standards.   49. The unannounced visit12 of inspection of duty and referral arrangements for children in the county took place in late 2010 which contributes the overall assessment of children’s services. The assessment of children’s services for 2010 was good.  50. Children’s services in Cumbria were assessed as performing well in their last annual assessment and this was also reflected in their latest unannounced                                          8 These reviews were completed prior to the changes to the statutory guidance relating to publication of overview reports after the coalition government’s notice issued on the 10th June 2010 under section 16(2) of the Children Act 2004 which amended the previous national guidance in Working Together to Safeguard Children.  9 The coalition government may change aspects of the inspection arrangements. 10 The coalition government announced the abolition of the CAA from 2010. 11 This profile includes findings from across Ofsted’s inspection and regulation of services and settings for which the council has strategic or operational responsibilities, either alone or in partnership with others, together with data from the relevant Every Child Matters indicators in the new National Indicator Set (NIS). 12 The inspection was carried out under section 138 of the Education and Inspections Act 2006. It contributes to Ofsted’s annual review of the performance of the authority’s children’s services, for which Ofsted will award a rating later in the year, subject to any changes that the coalition government may introduce. The inspections are part of a national programme of enhanced inspection of children’s services introduced in 2009 following the death of Peter Connolly (Baby P) and the two subsequent serious case reviews in Haringey.      Overview Report Baby H redacted published version Page 14 of 106 inspection on front-line practice and processes for children in need and children who may be in need of protection in 2011.   1.14 Summary conclusion of the review panel  51. The purpose of conducting a serious case review is to undertake a detailed examination of the events within the context of the judgements, decisions and actions taken by the various professionals involved with Baby H and his family for the purpose of drawing out learning to inform future policy, service development and individual practice.   52. The Munro Review commissioned by the coalition government in 2010 has stressed the importance of looking at such information within the context of people’s professional and organisational arrangements. In other words individual professionals are influenced and affected by the circumstances within which they work.   53. Such influences include the stability of the organisation they work in, the workload of individuals and their overall services, the quality of their training and knowledge, the clarity of working arrangements in matters such as recording and sharing essential information.   54. Serious case reviews also have to take account of the fact that human behaviour can be unpredictable and that services such as health, police and social care are by their nature and purpose often responding to events, accidents and incidents involving children that may or may not be the result of abuse.   55. Research and the evidence from other serious case reviews shows that abuse is the product of several different factors and the complex interplay between them.  56. The panel are very mindful that by examining events and decision making through hindsight, it can fundamentally distort how obvious the right or wrong judgements and action looked to practitioners at the time that the events were taking place.   57. This is particularly the case when for example medical teams have been presented with a very ill child late at night without any immediately visible signs of injury and is accompanied by what appear to be concerned parents.   58. It is important that review panels work hard at understanding the emotional pressures and the contradictory information that practitioners often have to assimilate very quickly and within emotionally charged circumstances such as an emergency room. A review panel can mistakenly try to describe what appears to be a well ordered range of information when in reality what was presented at the time was ambiguous, disordered and opaque.      Overview Report Baby H redacted published version Page 15 of 106  59. The review panel have to consider what it could be reasonable to expect individual practitioners and services to have known and consider whether any alternative decisions or actions could realistically have been considered at the time. The review team try to understand why people did what they did, and identify why there may have been aspects of decision making or action that could have been different.   60. Safeguarding work with vulnerable children is probably the most complex activity undertaken anywhere in public services and arguably by any organisation or profession.   61. The important purpose of a serious case review is to look at what happened for the purpose of helping individuals and services contribute to their personal and organisational memory and intelligence with the aim of extending the capacity of their services to identify potentially vulnerable children and thereby prevent injuries as far as can be reasonably expected.   62. An important question for the panel, the LSCB and for the wider community is whether the serious injury or death of a child subject of a serious case review could have been predicted or prevented. This report provides the supporting analysis that Baby H’s death was not predictable and therefore could not have been prevented by the professionals involved with him.   63. The panel have identified that Baby H had been injured on two previous occasions. In hindsight, he probably could have been the subject of a more coordinated and formalised plan of support; the CAF could have been used at an early stage; an important factor in this case appeared to be mother’s motivation and apparent ability to seek out support for herself.  64. After the first injury there should have been interagency discussion that would have supported better levels of information sharing and probably would have resulted in more formalised enquiries into Baby H’s circumstances before November 2010.  65. This in itself would not have meant that either child would have been removed from the care of their mother and her partner. It would have provided a clearer focus for coordinating help and given higher priority to the children. It would have encouraged and provided clearer purpose for professionals to enquire more comprehensively into the circumstances of the children and their family.  66. This case shows that although the death of Baby H could not have been predicted on the basis of information known to professionals at the time there were a range of factors that could have made professional help more targeted and alert to the possibility that Baby H’s mother and partner could     Overview Report Baby H redacted published version Page 16 of 106 face difficulties in responding to the demands of parenting twovery young children.   67. A continuing theme from serious case reviews both locally in Lancashire and Cumbria and nationally is that child abuse and injury is rarely related to a single cause but is very often a product of the interplay between several different factors that combined in particular circumstances result in harm especially to very young children such as Baby H.   68. Some of the most significant factors that are frequently highlighted as a contributing factor in child abuse and deaths were not present in this case; for example we know that adult mental health, domestic violence and substance misuse are frequent contributory factors that were not visible in this case13. The apparent absence of these factors may have contributed to some professionals being less sceptical and enquiring when Baby H was seen with an injury.   69. There was other information that should have indicated that the children were potentially more vulnerable such as the circumstances of the children’s conception, the age of their mother and her partner with all the attendant additional demands for a parent. When Baby H sustained an injury to his shoulder it should have been seen as a highly unusual injury for such a young child.  70. It is for this reason that it remains important for all services to ensure their front line staff are provided with the appropriate knowledge and professional development that enhances and updates their ability to recognise information or factors that can indicate signs of vulnerability and can make reasoned and informed judgments when presented with a child.   71. In this case Baby H was presented at several health clinics or centres including his GP surgery as well as at two Children’s Centres and a group for very young parents.   72. An important point of learning to emerge from this serious case review is the extent to which the indicators of vulnerability were not known about by some people for example when the family moved to a new area. Some practitioners did not apparently recognise early indicators of vulnerability when mother became pregnant in the midlands. There were also occasions when indicators were not given sufficient relevance or significance by others or were simply not known about.                                            13 The assessments undertaken since Baby H died suggest there may have been incidents of domestic violence that were not reported to any service.      Overview Report Baby H redacted published version Page 17 of 106 73. This will have implications for strategic policy as well as individual practice. It will present challenges particularly at a time when so many services have to find ways of delivering services within reduced resources and are undergoing fundamental change and reorganisation.   74. Although mother was not diagnosed as having depression she described feeling ‘overwhelmed’ and her partner consulted the GP about his emotional health14.  75. In addition to these factors of vulnerability, Baby H was born to a very young mother as a result of an unplanned pregnancy and where their birth father rejected any responsibility. The pregnancy occurred as a result of a very short relationship before mother and her previous boyfriend resumed their relationship. He was also very young. They moved several times. This was information that would have indicated a degree of vulnerability. After the first occasion when Baby H was presented with an injury this should have been regarded as an additional important indicator.   76. Even without the benefit of the relevant family history, when Baby H was presented with an injury to his shoulder that should have been regarded as highly unusual in such a young child, this should have provoked a level of informed and professional curiosity about Baby H’s circumstances.  This equally applies when a child suddenly becomes unwell with symptoms that could be attributable to abuse.  77. The case shows the importance of everybody who provides a service to children needing to be familiar with the learning from reviews such as this and having the capacity to formulate appropriately informed and respectfully sceptical hypotheses in regard as to what may for example have caused a child to become unwell or to become injured.   78. The case illustrates the important role of primary health care services in particular in being able to identify vulnerable children and providing the gateway to appropriate help and support including when necessary the protection of their physical and emotional well being.  79. Hindsight allows reflection as to whether different action and decisions could or should have been taken, and whether this would have prevented the tragic death of Baby H. It is also important to reflect on the extent to which                                          14 A distinction needs to be made between a formal diagnosis of depression and more generalised feelings of low mood; the birth of a first child represents a very significant challenge both emotionally and physically for parents and for this reason is monitored sometimes using the tools that are referred to in later sections of this report. A problem with many of the tools is that it inevitably relies on what parents are prepared to report or disclose; acknowledging low mood can be regarded as taboo for a variety of reasons and perhaps especially for a parent who wants to show that they are coping in spite of their all of their circumstances.     Overview Report Baby H redacted published version Page 18 of 106 organisational arrangements either help or hinder professionals in making appropriate judgments and decisions. Practitioners have to work with very complex and often contradictory information and family circumstances, and often under very difficult and challenging circumstances.  80. In this case for example, we explore whether a more explicit strategy that identifies teenage parents as having an entitlement to targeted and additional support would help. The health overview author comments on the evidence from several national studies or research that describe the importance of early support and intervention with vulnerable young children.   81. The review has explored the difficulties that confronts practitioners and clinicians when information is not readily accessible for example in a GP practice or A&E out of hours; this arises partly as a result of delays15 in transferring information between different GP practices although the records were transferred within national time limits of seven weeks although there was a further delay before the information could be uploaded to the electronic system. The health overview author for example refers to the benefit of children transferring into new practices being offered an initial GP consultation.  82. The review also explores the importance for open access services such as Children’s Centres and walk in medical centres accessing additional levels of expert knowledge and advice. We explore the difficulties that occur if individual practitioners are trying to make judgements in isolation from other potential sources of information and expertise; this can be a particular problem outside core office hours.  83. The panel acknowledge that some of the services involved in this case had a single contact with Baby H. Most of the professionals who came into contact with Baby H carry significant workloads and responsibilities.   84. The case should cause reflection as to how fundamental parts of modern safeguarding systems function effectively particularly as important organisational reforms are likely to be introduced in how services are commissioned and delivered. It raises questions for example about how patient information is recorded, transferred and accessed routinely on a 24/7 basis. These reflect national issues and are not necessarily issues that managers and LSCBs can resolve within their areas.   85. The role of GPs in the oversight of very young children’s care is evident from this and other cases examined through serious case reviews. It is the GP who will receive information about significant events such as presentation at a                                          15 The analysis provided in later chapters and by the health overview author acknowledges that the reason for the delays in transfer of information is not entirely clear due to conflicting dates provided as to when a request for patient records was made and when it was recorded by Cumbria.     Overview Report Baby H redacted published version Page 19 of 106 walk in centre. It is the GP who should have access to an adequate family history. It is the GP who will be consulted about illnesses and ailments within the family.   86. GPs have a central role to play in managing large quantities of information. The GP along with other people in the primary health care system are crucial to good information management. The review highlights the contribution that information management such as Read codes can bring16.   87. Throughout the brief history of this case, the individual practitioners in the various services and settings were mostly dealing with the family in isolation from each other with some notable exceptions. Many had incomplete information for example about the issues of vulnerability.   88. Baby H’s mother presented herself to health staff as a young mother who was coping well with the apparent support from her partner and extended family. She was motivated to seek out and attend groups at the Children’s Centres in particular. She sought advice from health professionals and seemed to act on that advice. She appeared keen to be integrated with her local community in spite of her frequent moves and appeared to accept the contact and advice offered to her from health care professionals.   89. To all intents and purpose the family did not appear to be regarded as particularly vulnerable or in need of additional support by most of the professionals who came into contact with mother and her children; her partner was largely absent from any of the contacts. With hindsight and by collating and analysing the information that is explored in this review, this picture of a well functioning family was not the complete picture and is an important point of learning for all professionals coming into contact with children about not taking information on ‘face value’.  90. Even without this hindsight, there were factors that could have been given more significance at the time. The very young age of mother and her partner, the fact that the partner was not the biological father, the pattern of frequent moves and the demands of two young children should have been information that was well understood. Not all of it was known to everybody who came into contact with the children.                                           16 The Read code is named after Dr James Read who died in the summer of 2011 and used to be a GP and began to develop his system in the 1980s. Read Codes are a referenced thesaurus of clinical terms which enable clinicians to make effective use of computer systems. The codes facilitate the access of information within patient records to enable reporting, auditing, research, automation of repetitive tasks, electronic communication and decision support. The smaller effort required for these tasks, brought about by coding information, means codes are increasingly used across the health service and therefore most computerised practices use Read Codes. The EC has adopted another coding system, ICD-10 (International Classification of Disease, version 10), and so possibly the UK will change to this in due course. Read coding though contains all the ICD-10 terms and lots more besides and whichever system is used, the principles are the same.     Overview Report Baby H redacted published version Page 20 of 106  91. The significance of non biological fathers and the general invisibility of information about men in households that include young children in particular are regularly highlighted in serious case reviews and demonstrate the importance for all professionals establishing the identity of men. In this case not only was mother’s partner’s status and relationship to her children not adequately identified, but when he consulted his GP in Cumbria with symptoms of stress that were apparently related to the birth of Baby H, this was not followed up beyond the individual consultation.   92. The panel has identified several examples of good practice that are described in chapter five. Generally the services that had contact with the family worked with considerable dedication and skill in providing physical health care and treatment.   93. The panel have attempted to collate information about the extent to which resources are a factor for services involved with Baby H. None of the services have identified this as a difficulty although not all services have commented in detail. It is apparent that there are issues ranging from investment in staff training and induction, IT and information systems and the deployment of some practitioners.   94. It seems probable that some practitioners were not sufficiently trained to recognise potential indicators of abuse; some of this reflected a mistaken belief that being qualified for one job would be sufficient to transfer appropriate knowledge to a different role. There is possibly a mindset on the part of some practitioners that was reluctant to consider abuse as a ‘diagnostic’ possibility in this case; this is not meant to imply that this is restricted to medical or health professionals.  This is a manifestation of what is sometimes described as the rule of optimism that is referred to in a later chapter of this report.  95. Other people missed the potential significance of injuries to Baby H; this was probably the product of insufficient induction, training and oversight. There were also gaps highlighted by the health overview report in regard to how information is routinely shared between midwifes and health visiting services for example.    96. The injuries that with hindsight may have indicated potential abuse occurred in Cumbria and in Lancashire on two different occasions17. In the opinion of the panel, an important factor in missing both injuries was the possible                                          17 The injured shoulder in Cumbria was not diagnosed as being the result of abusive or neglectful handling and care. In Lancashire, when the injury to Baby H’s brain was becoming apparent although abuse was acknowledge to be one of the possible options it did not result in medical staff invoking protocols to consult other professionals and to begin formal enquiries.       Overview Report Baby H redacted published version Page 21 of 106 preoccupation with the positive behaviour of a parent rather than focussing on what had happened to the child.   97. Put plainly, the parent and her partner were seen as people incapable of causing harm to their baby. A benign acceptance predominated rather than the respectful, inquiring and informed sceptism that should be exhibited by qualified professional staff dealing with children especially when they are presented for health assessments and treatment.  98. The first occasion was before the family moved to Lancashire. This involved an injury to his shoulder. The second occurred some two months before Baby H was injured and died. This injury was not observed by a health professional but by a Children’s Centre worker who had only just begun her first job in such a setting.   99. The injury to the shoulder was the subject of good quality and sensitive medical treatment. However it was an unusual injury in a child so young and not yet independently mobile and as such should have been the subject of further enquiry and assessment under the safeguarding procedures.   100. A very important point of learning for the panel is the extent to which several different professionals all failed to understand the significance of this injury and therefore to invoke the appropriate procedures for sharing information and making further enquiries which may or may not have revealed further indicators of concern. Good safeguarding rests on professionals having the capacity to make balanced judgments and working effectively together. This means having the capacity to challenge and to cause better reflection with each other.   101. When professionals are busy, or feel under pressure, or are prioritising immediate tasks such as responding to illness or injury, it is important for them to have the support of others who can stand back and provide critical and sceptical perspective that does not accept events or information at face value.   102. Several medical professionals had not considered it unusual that a four week old baby could grab a strap or hold on to injure his shoulder and had been satisfied with the history provided by mother.   103. On the second occasion when a healing injury to Baby H’s head was observed by an early year’s worker who had just begun working at a Children’s Centre, the injury was not reported to anybody else. The significance of any form of injury to the head of such a young baby and the need to seek advice from a more qualified professional went unrecognised; this was the result of insufficient induction. Information about the injury only emerged as a result of the work on this serious case review and it is of credit to the early year’s worker and her managers that they realised with hindsight     Overview Report Baby H redacted published version Page 22 of 106 the significance of this information. They acknowledge that training and oversight has to be in place and backed up by simple but effective systems such as recording when an injury is observed.  104. In the opinion of the panel, even if the safeguarding procedures had been applied on these occasions, it would not be possible to say that the tragic death of Baby H would have been prevented. On the basis of what is known about the family there would not have been sufficient concern to cause either Baby H or his brother to have been removed from his mother’s care without her consent.   105. It is highly likely that a more informed assessment of the family’s circumstances would have been completed; this would have explored the extent to which mother and her partner were meeting the needs of the children. This assessment could have been undertaken under the common assessment framework (CAF) before the first injury occurred. If the shoulder injury had been recognised as unusual it should have resulted in coordinated enquiry and assessment using the local safeguarding protocols.   106. Either of the assessments would have explored in a more informed way the quality of support and perhaps most significantly it would have analysed in better detail the degree of vulnerability arising from the age of the parents and the specific needs of two very young children.  107. It is quite possible that the result of an assessment would have resulted in more coordinated action between the different services. If the assessments had resulted in a child protection conference this would have ensured comprehensive information being shared and in all likelihood a child in need plan would have been agreed as a minimum outcome and more possibly a child protection plan; if a child protection plan had been agreed this would certainly have made a difference to how professionals were viewing the needs of Baby H and his brother.   108. The extent to which the family were vulnerable was recognised by some professionals; however this did not result in a sufficiently consistent or informed response to that vulnerability. There was a reliance on mother presenting as a capable and caring parent even when physical injuries were apparent. The focus was on the behaviour of the parent rather than what had happened to Baby H; this is a phenomenon that is regularly observed in serious case reviews. The majority of serious case reviews examine serious injury or death to young children who had not been recognised as being in need or at risk until their injury occurred.   109. The circumstances under which the children’s father played no part in the family and presence of a male partner who was not the biological father prior to the children’s birth were significant factors that were largely unrecognised or ignored. There were assumptions about how well the family     Overview Report Baby H redacted published version Page 23 of 106 were supported. This is also a feature of serious case reviews and of wider research relating to children in need. There is particular research evidence relating to the additional risks of injury to very young children living in households where the male partner is not the biological father. In this case, few people realised that the partner was in fact not the children’s father.  110. The panel have identified aspects of information recording and communication that could have been handled more effectively. These are features often highlighted by serious case reviews.   111. The panel are concerned that when Baby H was presented at hospital late in the evening in November 2010 it was apparent that he was seriously ill; in the opinion of the panel and guided by expert medical knowledge, the possibility that he had been injured as a result of shaking should have been one of the most probable diagnosis and as such have resulted in discussion with other services under the safeguarding procedures. This did not happen for several hours and only after Baby H had been transferred to a specialist regional hospital.   112. This caused difficulties to the police in particular in coordinating the initial stages of their enquiries and investigation. It also meant that there was delay in bringing the matters before a court to ensure that the local authority shared parental responsibility for Baby H’s sibling and had appropriate powers regarding arrangements for him. He was kept in hospital from the point at which his brother had been admitted and remained there until he was the subject of an interim care order. Until the ICO was made he could have been removed at any time by his mother18.  113. The review includes recommendations to the LSCB regarding the future support given to teenage parents and to young parents and carers of young children. It supports the action being taken by individual services as result of their own management reviews. It is hoped that publication of this review will reinforce the serious risk to very young babies from inappropriate or rough handling. The learning from the review will be used to inform further training and development provided through the LSCB training programmes.  1.15 The family and other significant people  114. A genogram showing membership of the family is included as appendix I of this report.    Ethnicity                                          18 Only mother had legal parental responsibility given her partner was not the biological father; he would have had to acquire parental responsibility by application to a relevant court.     Overview Report Baby H redacted published version Page 24 of 106 Father White British Mother White British Mother’s partner White British Baby H White British Baby H’s sibling White British   115. At the time of Baby H’s death, his parents had separated and mother had a different partner19. A family genogram provided for the review includes details of the maternal grandparents and maternal great grandparents. This information was not available for partner’s family.    116. Some of mother’s family are based in Cumbria; others are in Lancashire. The partner’s family are in Lancashire.  117. Mother became pregnant whilst living in the West Midlands in 2009; although both parents lived in the same area it appears they never lived with each other. Mother had a relationship with her partner (not the father) before the birth of Baby H.   118. The family were evicted from their flat as result of ‘rowdy behaviour’ and moved to live with the maternal grandmother and her partner in Cumbria in February 2010. Baby H was born in July 2010.  119. Mother and her sons lived for a two or three week period in the West Midlands where Baby H had ‘a fall’ from his pram.   120. At the beginning of September 2010, mother and her sons had moved to Lancashire to live with her great grandmother.   1.16 Cultural, ethnic, linguistic and religious identity of the family  121. Baby H’s maternal and paternal families are white British. There is little information regarding any religious or cultural affiliations of the mother, father or partner. Baby H was living with his mother, partner and brother in private rented accommodation at the time of his death. There is little recorded information about the home circumstances; one of the IMRs states that the family was living in a more prosperous part of the city.                                            19 Prior to the relationship when Baby H was conceived, mother and partner were boyfriend and girlfriend. After mother had split with the father and in the early months of pregnancy, she and partner resumed their relationship with him accepting and taking on the responsibility of the baby when born.     Overview Report Baby H redacted published version Page 25 of 106 122. Mother was a fulltime mother caring for her son. Her partner worked in the family business; there is no recorded detail about what this was or the working arrangements.   123. Prior to the family moving to Lancashire, they had lived in one of the larger market towns in Cumbria. That town has a diverse population that includes wealthy land owning families as well as having a significant population of those who are much less well off. The town is generally populated by white British residents although in recent years there has been an influx of economic migrants from Eastern Europe.  124. Lancashire has a population of 1.16 million, which is projected to grow by almost eight per cent to 1.23 million by 2028. The county comprises a mixture of urban, rural and coastal communities and covers twelve district councils four of which (Burnley, Hyndburn, Pendle and Preston) rank in the top 30 most deprived districts in the country (Index of Multiple Deprivation 2007).   125. Five per cent of the population are from minority ethnic backgrounds, predominantly Pakistani and Indian, clustered mainly in parts of the east of the county and in Preston. More recently, small but growing numbers of people from Eastern Europe have begun to settle across the county, with concentrations in Lancaster and Preston.   126. A total of 20 per cent of children across the county are income deprived according to the Index of Multiple Deprivation 2007. Six areas (three in Burnley, two in Preston and one in West Lancashire) are ranked in the two per cent of the most deprived in England for child poverty and 9.5 per cent of children in Lancashire live in Super Output Areas ranked among the 10 per cent worst nationally for income deprivation. The area in which baby H live is not in an area of high deprivation.      Overview Report Baby H redacted published version Page 26 of 106 2 Overview of agency involvement   127. This chapter provides the narrative summary of professional contact with Baby H and is taken from the chronology of agency involvement with the family and from the individual management reviews. It provides an account of the most significant events and decisions from the different services involved with Baby H during the timeframe established for the review.   128. For example there are more contacts and visits with health visitors and the GP as well as at the Children’s Centres20 than are described in this summary. The two Children’s Centres were involved between September 2010 and November 2010. Other information including the work by children’s social care and other services is covered in more detail in the summary of analysis from the agency IMRs in chapter five.  129. The review has had IMRs provided by health services from Cumbria where the family lived immediately prior to moving to Lancashire after Baby H had been born.   130. This chapter also includes information from services outside Lancashire when relevant; for example the initial antenatal contact was with the community health services in the West Midlands where mother was living when she became pregnant although an IMR was not been requested given their very short involvement21.  131. This summary, and indeed the whole overview report, has to strike a balance between protecting the confidentiality of the children, their family and the various people who were in contact with them whilst providing a sufficiently detailed account of events in order to draw out the points for learning and development in the later chapters.  132. In early January 2010 mother had her initial antenatal contact; at that stage it was noted that she had been ‘feeling down, depressed or hopeless and also had little interest or pleasure in doing things’22.   133. Mother had moved to live with the children’s maternal grandmother by the following month. She initially attended at the hospital in that area in order to receive treatment for a urinary infection. At that stage she had not registered with a GP.                                          20 There are 79 Children’s Centres across the county.  21 These are the services that have provided information in the form of letters or short reports to assist this serious case review. 22 There is no documentation to show that this was followed up although the community midwife was aware; the fact that mother was feeling low could have just been reflecting some of the emotional vulnerability that can accompany pregnancy.     Overview Report Baby H redacted published version Page 27 of 106  134. Mother registered with a GP practice within a week and attended the surgery; she was 22 weeks into her pregnancy. No information was recorded about the birth father or about mother’s domestic circumstances23.   135.  There is evidence that a referral was made to Connexions by the health ante natal clinic; Connexions operate a support service for teenagers who are pregnant24.   136. Towards the end of March 2010 mother was experiencing considerable pain and was prescribed antibiotics. She also had a respiratory infection. She continued to feel unwell during April and May. By June her health had apparently improved and she was described as looking ‘really well’.  137. In June 2010 DS attended an out of hours GP service describing a shortness of breath; he acknowledged having some anxiety about the imminent arrival of the baby25.  138. At the end of June 2010 there was a plan to induce the Baby's birth if he had not been born by July 2010. In July 2010 the baby was born by caesarean section at 37 weeks gestation because of mother’s pre-eclampsia26.                                             23 The fact that she was a young person expecting a baby was also not apparently recognised; several other services did not recognise that the partner was not the children’s biological father; it is also apparent that the pregnancy had not been planned. The extent to which different services recognised potential indicators of need and vulnerability are analysed in later chapters. It highlights the important role played by people such as GPs in helping to support vulnerable parents and keeping children safe. 24 Although this looks to be good practice, there is no copy of the referral and no information about how this was followed up or whether mother and partner took up any of the offers of support; this is an example of the lower level activity that is important to effective safeguarding services that can become vulnerable if people and services feel overwhelmed by workload. 25 There is no recorded evidence that the GP recognised the potential vulnerability of both parents due to their age or that the partner was not the biological father; given the presentation with symptoms of anxiety there were indicators to suggest this was a couple who probably needed additional support. 26 Mother presented with symptoms the day before and despite advice to remain in hospital for observation she discharged herself at 23.45. Pre-eclampsia is a condition that only occurs during pregnancy. It causes high blood pressure and it also causes protein to leak from the mother’s kidneys into their urine and is detected by testing the urine for protein. Other symptoms may also develop such as severe headaches that do not go away, blurred vision, flashing lights or spots in front of the eyes and abdominal pain.  Pre-eclampsia usually comes on sometime after the 20th week of pregnancy and gets better within six weeks of giving birth. The severity can vary. Pre-eclampsia can cause complications for the mother, for the baby, or for both. The more severe the condition becomes, the greater the risk that complications will develop. Somewhere between 2 and 8 in 100 pregnant women develop pre-eclampsia.     Overview Report Baby H redacted published version Page 28 of 106 139. Two days later DS presented at the out of hours service (CHOC)27 describing symptoms of nausea, vomiting, acid reflux and gastric discomfort. He was advised to see his GP28.   140. A visit by the community midwife on the same day provided an opportunity for her to enquire about what support mother had available to her; she was told by mother that the support she had was good and midwife felt that the couple had ‘gelled’29.  141. Two days later the Obstetrician1 offered a follow up consultation to mother to ‘discuss any issues arising from the birth. This offer was not taken up30.  142. The day after, the partner attended at the GP surgery; this was the third occasion in a very short period. He was still complaining of vomiting and gastric discomfort. He was prescribed Domperidone and Lansoprazole31. He was advised to make a further appointment if the symptoms persisted. There is no evidence that enquiries were made regarding the family’s social circumstances or follow up consultation with the midwifery or health visiting service.    143. Three days later, the midwife transferred responsibility for Baby H to the community health visiting service. The health visitor made a home visit four days later. The visit included an examination of the baby without his                                          27 Cumbria Health On Call 28 The out of hours service would not have had access to any information about his home circumstances that would have been crowded or acknowledgement about the stress he was apparently under due to the birth and his role as a teenaged ‘parent’.  29 This exploration of how new parents in particular will be supported is an important aspect of community health services; they are highly reliant on what parents tell them and how they present in terms of their overall emotional condition; in this case it is not clear to what extent the midwife was taking account of the information about vulnerability; the age of the parents, unplanned pregnancy, the partner not being the biological father, not having a home of their own, the partner’s anxiety requiring attendance at the GP. This comment is not meant to single out one professional or to be critical; it reinforces the importance of all relevant professionals being well informed about the circumstances of a very young child and of sharing information effectively between different services; only health care services were involved with the family. Serious case reviews time and again highlight how professionals make important judgements on the basis of limited or incomplete information.  30 This letter was included in the hospital records but does not appear to have been copied to the GP. Although this information in itself is not especially significant, given the evidence about the couple’s vulnerability, it would have been good practice to have ensured that community health professionals had this information; it signified an unwillingness of the couple to acknowledge a need for information and support. Little pieces of information such as this help professionals to collectively build a better informed picture about a child’s circumstances; it helps complete the jigsaw. 31 Lansoprazole is a proton-pump inhibitor (PPI) which prevents the stomach from producing gastric acid. Domperidone is generally used for disorders of the gastrointestinal tract (the gut) for the relief of sickness. This indicates that the symptoms were being treated primarily as physiological rather than possibly reflecting the stressful circumstances in which the partner was living. These were not discussed with the partner.      Overview Report Baby H redacted published version Page 29 of 106 clothes; there is nothing unusual in the health visitor examining a baby without their clothes; it provides an opportunity to check routine issues such as weight and important physical development such as the baby’s head. Both children were ‘healthy and well’. The health visitor provided other advice; for example in relation to cot deaths.   144. This is expected practice designed to help prevent accidents to very young and vulnerable children32.  The children were examined a week later and again were found to be healthy and well. There was some evidence of the sibling faltering slightly33; the health visitor, arranged for an early assessment by the GP; this is also good practice. This was followed up the following day by the health visitor; this is also good practice. There was a further follow up two days later; the sibling was gaining weight34.   145. In early August 2010 Baby H was presented at the walk in treatment centre of the local hospital in Cumbria. He was examined by a nurse and a nurse practitioner.  Information was given that Baby H had pulled his left shoulder when he had ‘grabbed’ the pushchair strap as he was being lifted out. A ‘popping’ noise had been heard and Baby H had screamed and was ‘letting’ his arm hang by his side.  146. Baby H was also examined at the A&E department.  He was seen to feed normally when in the unit and noted to be otherwise well. He was unhappy to move his shoulder; he had slight bruising emerging on the outside of his upper left arm; he let his left arm hang down to his side; he became distressed when the arm was moved35. He was examined by a doctor who referred him to an orthopaedic specialist in the fracture clinic. This was good practice although the failure to recognise the unusual nature of the injury and the reported history was not good practice36. He was not                                          32 It is not clear whether this routine advice includes information about the dangers of shaking babies. 33 According to the health review, the evidence could be a technical difference since different scales had been used. To ensure good evidence of infant growth it is best practice to use the same scales to measure weight. 34 Baby H was not examined on that occasion as he was making good progress and was asleep.  35 The cause of the injury to Baby H was accepted as being a simple trauma. It is unclear if consideration was given to the possibility that the history was realistic at the initial stages although during interviews for the review it was more apparent that specialist medical staff had considered but ruled out NAI based on how mother presented; this is explored in further detail in later chapters.  The records do not indicate consideration of non accidental injury; the health review highlights that Baby H was four weeks old and there should have been a query regarding his ability to hold on to a strap. However the IMR describes in some detail the nurse’s careful recording of the circumstances of the injury that included observing mother’s use of the pushchair; she noted there were many straps to catch a limb; she also noted that mother was ‘skilful and gentle’ in her handling of her baby. This is explored further in later chapters that analyse learning from the case.   36 A letter was sent to the GP after the examination but this was not shared with the health visitor; this meant that when the health visitor spoke with the health visitor in Lancashire she did not have     Overview Report Baby H redacted published version Page 30 of 106 presented for that appointment. A GP examination in mid August confirmed that Baby H had regained normal movement.   147. The GP received information electronically about the attendance at the walk in treatment centre. Nobody was told37 by anyone other than the parents who mentioned the information during a routine home visit38.   148. Six days after the injury, mother told the health visitor that the family planned to visit relatives in Birmingham. Four days after this mother attended a teenage parents group to show her children.   149. Baby H was not presented for his follow up orthopaedic appointment. He was not brought to the GP for his first immunisation. The GP sent a letter stating the importance of immunisations. This was followed up by the health visitor who left a voicemail message on mother’s mobile phone. Baby H was not presented for a rearranged further orthopaedic follow up. The GP was informed in writing; this is expected practice that is enshrined in service standards39.  150. After trying to make contact again by mobile phone, the health visitor made an ‘opportunistic’ visit to the home; she was told that the family had left the area for Birmingham but had not liked it and had gone to Lancashire40. The health visitor made further follow calls and established that the family were registered with a GP in the city.   151. The health visitor spoke with the health visitor in Lancashire; information was shared with the health visitor about the children and the family; this included the sibling's slow weight gain and the immunisation                                                                                                                   updated information about the injury being more serious than initially thought and possibly queried the nature of the pushchair injury. 37 This is another example of how information needs to be shared effectively with relevant personnel in building up the jigsaw of information; an injury to a four week child is both relevant and significant and was especially important for all the professionals in direct contact with the child and his family. Hospitals and GPs are all handling large numbers of patient episodes; this has implications for both instigating appropriate communication as well as managing the receipt of information. 38 At this stage it was Baby H’s sibling who appeared to attract a greater degree of ‘concern’ due to the slow weight gain.  39 The review panel include examples of good practice in later chapters; this highlights practice that goes beyond legal requirements or procedural standards; as such it does not capture the examples of good practice such as this which reflects professionals routinely doing their job well in accordance with their professional and agency standards.  40 According to information provided by Birmingham, mother and partner had presented as being homeless in September 2010. They reported that maternal grandmother had told them not to return to Cumbria. An initial assessment was planned but the family left Birmingham before this started. The family are recorded as having their first contact with the health visiting service in Lancashire the same day.      Overview Report Baby H redacted published version Page 31 of 106 status of the children, the parents' young age, that the mother’s partner was not the birth father and accommodation issues for the family41.  152. Five days later, mother attended at a Children’s Centre42 with both her sons. She explained to staff she was new to the area and wanted to get to know other mothers. She said that her “fella’s” dad lived in the area and told her about the centre. During the session mother asked an outreach support worker if she could assist with bottle feeding. On holding the child the worker noted an old injury to the baby's head.  153. When asked how the injury had been sustained mother gave an explanation of having purchased a faulty pram. While out with the children in the pram it had collapsed and a passerby advised her that one of her children had fallen from the pram. Mother asserted to the worker that her Baby H had been examined by a doctor following the incident and no concern had been noted43; there is no evidence that Baby H was examined by a doctor or other health practitioner.  154. A further contact at the health clinic in mid September 2010 provided an opportunity for the children to be weighed; the sibling was still ‘a small                                          41 There was a delay in summarising the children's’ records at the GP practice due an influx of new patients. It is normal practice for patients not to be seen by a GP or member of the nursing when they register with a practice.  A GP or nurse would have only been asked to see a child if there was a cause for concern. According to the health review, the paediatric registration procedure within the practice was not as detailed as that laid out in NHS Lancashire Safeguarding Procedure. Baby H was presented for his first immunisations in September 2010; they saw a nurse and not a GP; this is normal and routine practice. The health visitor would have had information about the family based on the contact with the family’s first health visitor; the health visitor in Lancashire had been told there were no concerns over and above the age of the parents. This is theme examined in more detail later; the purpose of information being provided; whether those receiving the information are provided with information that is the most significant and relevant; distinguishing between reporting concerns of harm from identifying indicators of need and vulnerability.   42 There are more than 3,600 Children’s Centres in England. They bring all the different support agencies together to offer a range of services to meet parents and their child’s needs, all in one place. They’re somewhere for the child to make friends and learn as they play. Parents can get professional advice on health and family matters, learn about training and job opportunities or just socialise with other people. The services are available to parents from pregnancy right through to when the child goes into their reception class at primary school.   43 The worker did not discuss this information with the other worker in the group and leader of the Group nor was the information recorded anywhere. There is no evidence that the injury had ever been examined by a doctor or nurse. This information is analysed in further detail in the analysis presented in later chapters. The extent to which information is taken at face value and is not verified by professionals is a frequent feature of serious case reviews. In this case, the worker was new to her role and there was insufficient information about the family’s background that may have given the injury greater significance at the time. The reference to a child falling from a pram should have been an additional source of concern; it seems implausible and is in any event indicative of inattentive care.      Overview Report Baby H redacted published version Page 32 of 106 baby’; Baby H was between the 2nd and 4th centile44. During the same session mother was encouraged to complete the Edinburgh Postnatal Depression Scale; she scored five on the scale45.   155. Later in September 2010 mother attended a baby massage session at a second Children’s Centre; she told staff that although she had been to Children’s Centre 1, this centre was more local for her46.   156. In late September Baby H’s brother was taken to the GP’s with vomiting, had a chesty cough and was not gaining weight. The GP provided antibiotic treatment. During an opportunistic visit by the health visitor mother discussed her concerns about the sibling’s slow growth and weight gain; she was keen for a paediatrician to review his progress. He was feeding well; mother had no concerns about Baby H.   157. At the beginning of October 2010, mother attended the GP’s for eczema treatment; the GP subsequently mentioned to the health visitor how well he thought mother was ‘managing considering her young age’.    158. During visits to the Children’s Centre staff observed mother ‘positively interacting’ with both her children. Mother was also one of the youngest parents in a group of five.                                             44 A centile chart is a size for age chart that is used to decide whether the size of a child falls within the normal (average) range or whether the child is larger or smaller than normal. Centile charts show the position of a measured parameter within a statistical distribution. They do not show if that parameter is normal or abnormal. They merely show how it compares with that measurement in other individuals. If a parameter such as weight is on the 3rd centile, this means that for every 100 children of that age, three per cent would be expected to be lighter and 97 heavier. On the 75th centile, 75 would be lighter and 25 heavier.  45 The Edinburgh Postnatal Depression Scale (EPNS) is a simple self assessment questionnaire that health visitors frequently use to help identify mothers who may be depressed. A score of ten or more is indicative of depression.  Postpartum depression (PPD), also called postnatal depression, is a form of clinical depression which can affect women, and less frequently men, after childbirth. Studies report prevalence rates among women from 5 to 25 per cent, but methodological differences among the studies make the actual prevalence rate unclear. According to the health review the EPNS complied with the National Institute of Clinical Excellence (NICE, 2007) and the antenatal and postnatal mental health (Clinical guidelines 45) and the NHS Lancashire Teaching PCT Internal Procedure for the Detection of Post Natal Illness. The IMR noted that the NICE guidelines recommends that the EPNS is completed between 6-8 weeks post natal; there was a delay in this case as mother and her family had been in the process of moving from Cumbria to Lancashire.    46 Mother continued to access services at both Children’s Centres over the following weeks. As with the previous centre, it was assumed that the partner was the father. The family completed a further registration for service; this was a duplication of process; the Children’s Centre’s management information system (CCMIS) did not highlight that the family were known to the service. This is explored further in later chapters; it again emphasises the importance of accurate and efficient information systems that support professionals in communicating and recording information.      Overview Report Baby H redacted published version Page 33 of 106 159. In the first week of October 2010, mother telephoned the health visitor47 to discuss her concerns about Baby H; he was crying and feeling hot, was refusing his feeds and had developed a rash throughout his body.  Mother requested a home visit.  The health visitor discussed what support mother had.  She said she felt she well supported by her partner and family and that she attended groups at the Children’s Centre.   160. The health visitor who took the call made a home visit mid morning and found Baby H more settled having been given Paracetamol.  Baby H had taken a small amount of feed, was smiling and cooing. Baby H’s rash was observed to be almost clear.  Mother was advised by the health visitor that it was possibly a viral rash and to contact the health visitor if she had any further concerns.  161. Both children were seen in the clinic the following day. Baby H’s rash had been resolved and his temperature was normal for the previous 24 hours.  His brother was wheezing and coughing at night. Mother agreed that baby H would have his next routine immunisation; this second immunisation was four days later.  162. The same day mother and her sons attended the Children’s Centre where staff thought she looked tired; mother confirmed she was OK but was tired looking after her children. She attended a health clinic two days later when she confirmed that she had enough support at home. No concerns were noted about the demeanour or presentation of either child on this or previous contacts48.   163. In the third week of October 2010 the children were weighed during a routine clinic visit; Baby H was 5.38kg, (2nd Centile). At the end of October 2010 mother forgot a health visitor appointment; this was followed up by the health visitor.  164. By the beginning of November 2010 Baby H’s sibling had lost some weight. He had developed thrush. He was weaning and had a good appetite. A visit to the Children’s Centre drop in the following day caused staff to note the babies dummy was ‘grubby’; however the subsequent session recorded no concern49.                                           47 This was not the family’s usual health visitor; it is not clear why the contact was not with that health visitor although this is not especially unusual; it shows a good response to a parent who wanted advice when the family’s health visitor was not available.   48 Mother cancelled a health visitor appointment on the following day saying that she had been to the clinic the previous day. 49 It is apparent from the overall records of visits to the Children’s Centres that mother was generally well equipped and well prepared with equipment for her son’s needs.      Overview Report Baby H redacted published version Page 34 of 106 165. The health visitor discussed the early weaning. Mother was encouraged to complete the EPNS for a second time and again provided a score of five; mother confirmed this was in line with her overall mood and emotions in meeting the demands of her sons; in other words no significant concerns were being indicated50.  166. In mid November 2010 mother’s partner was observed dropping mother and the babies at the Children’s Centre in the car park; this was the only time he was seen at either a Children’s Centre or clinic51.   167. Baby H received his third and routine immunisation as planned in mid November 2010. The sibling had made better weight gain.   168. On the day of Baby H’s admission to hospital he had attended the health clinic’s drop in session with his sibling and mother. They had attended a baby massage session. No injuries or concerns had been noted.   169. Baby H was initially admitted to the Lancashire Hospital on an evening in November 201052. He initially presented with no sign of life; the intervention by the medical team was successful in re-establishing his pulse at 23.20. He was subsequently transferred at 04.00 to AHCFT (where he would die) having sustained an injury to his brain53. Although there were no visible external injuries to Baby H a differential diagnosis about possible causes for Baby H’s symptoms included a shaking injury; greater attention was focussed on a severe infection. Initial examination of Baby H revealed no physical evidence of injury.                                           50 The author of the Lancashire PCT IMR notes that although the EPNS score was low the health visitor still made a point of discussing mother’s emotional well being and how she was adapting to being a mother; it is a good practical example of how tools can be helpful to assessment but are not to be relied upon to define or restrict a professional’s enquiries or judgements. It appeared to be an acknowledgement on the part of the health visitor that mother was a vulnerable parent although had not ‘triggered’ any thresholds for allocating additional support over and above the increased health visitor contacts.  51 The extent to which father’s and/or male partners and carers are absent from assessments and planning is a frequent and much reported feature in serious case reviews and in research literature; the invisibility of both the birth father and the partner is explored further in later chapters. Involving men more requires even more thought about how services can encourage such involvement; it also requires professionals to give more attention to the significance of why men are reluctant to engage with professionals.  52 Upon admission there was no cardiac output; the cardiac output represents the volume of blood that is delivered to the body, and is therefore an important factor in the determination of the effectiveness of the heart to deliver blood to the rest of the body, (i.e., determining heart failure, inadequate circulation, etc). Baby H required life support until it was switched off three days later.  53 This type of injury is a frequent cause of injury or death for children aged less than 12 months of age and is one of the largest types of injuries to children whose death becomes subject to a serious case review. It is therefore a significant issue for public health and accident prevention across the country. The next chapter provides a summary of information about shaken babies.       Overview Report Baby H redacted published version Page 35 of 106 170. He was transferred by ambulance to AHCFT in the early hours and arrived at that hospital at 05.30.  The written referral to AHCFT specifically stated that there were ‘no safeguarding concerns’54. He was admitted to the Paediatric Intensive care Unit (PICU) at 06.31. The first history was taken from mother and DS at 08.00 when they arrived at AHCFT55.  171. After Baby H had been admitted to AHCFT paediatric intensive care unit (PICU), the consultant who examined him had concerns about the nature of his injuries. It was at 10.00 that the consultant began invoking specific procedures56. This included consultation with the named nurse for safeguarding children and referring Baby H to the named doctor for safeguarding (a senior paediatrician) in the hospital57.  The Lancashire Hospital was advised at the same time to invoke their ‘child protection pathway’; AHCFT had invoked their Acute Life Threatening Event (ALTE) protocol58. This reference to ALTE and safeguarding pathways introduced a degree of ambiguity although did not delay a response from children’s social care services.  172. The completion of CT scans and discussions with specialist neurosurgeons had concluded that the prognosis for achieving any improvement in Baby H’s condition through surgery or any other procedures was very poor. Baby H was baptised in the hospital59.   173. Children’s social care services were informed of Baby H’s admission and the hospital’s decision to invoke the safeguarding procedures at 11.26. A                                          54 This is analysed in greater detail in later chapters; the exclusion of safeguarding concerns was in spite of a ‘differential diagnosis’ in Lancashire that had not ruled out trauma following a shaking injury. 55 The number of occasions that mother and DS were asked for information about the circumstances leading up to admission is analysed in later sections and had implications for the management of the formal enquiries and investigation by police and social care services when a safeguarding referral was made later that morning.  56 The procedures were the LSCB safeguarding arrangements that include agency specific arrangements; in this case this included the sudden and unexpected death in infancy (SUDI) protocols. These are linked into wider procedures that should ensure lead services such as the police and children’s social work services are notified quickly to allow prompt consultation and discussion. This is especially important if an injured child with unusual or suspect injuries has siblings. The speed with which these procedures were invoked are analysed in further detail in later sections of the report.   57 These are specific roles described in national guidance for designated professionals with specialist knowledge and training to provide advice and guidance when there are concerns that a Baby Has or may be at risk of significant harm as a result of abuse.  58 ALTE is a pan Merseyside SUDI (sudden unexpected death in infancy) procedure; it is apparent that the procedure was not a protocol known about in Lancashire and in any event Baby H was alive; further analysis in later sections explores the significance for the initial handling of information and referral as well as why the SUDI protocol in Lancashire had not been invoked when Baby H was first presented on the evening.   59 There was a great deal of very sensitive work being undertaken by medical staff with Baby H’s family; it is inappropriate to go into further detail in a public report other than to acknowledge some very difficult discussions had to be completed with mother and DS.      Overview Report Baby H redacted published version Page 36 of 106 referral was faxed through at 12.18. Children’s social care was also contacted by the nurse at 12.00 to inform them of the admission to AHCFT the previous evening; this does not appear to have been a referral.   174. The police were informed by the social worker at 13.57.   175. At 13.45 the consultant paediatrician at the Lancashire Hospital telephoned the PICU to inform them that they were organising child protection investigation for Baby H’s sibling60.  176. The first strategy meeting took place at 14.35 at the Lancashire Hospital. This involved the police, children’s social care services, the Consultant Paediatrician and ward staff from Lancashire but did not include AHCFT who had initiated the safeguarding procedures by their referral. A telephone discussion between the consultant paediatrician at AHCFT and the social worker took place prior to the meeting. The same paediatrician was contacted after the meeting for further detail about Baby H’s condition and family history. The meeting was told that Baby H’s injury’s (retinal damage and brain injury) were consistent with a significant trauma.   177. A meeting at AHCFT involving mother, DS and medical staff in the late afternoon took a detailed history from the parents. This discussion took place after decisions to invoke a formal enquiry had been agreed by the strategy meeting in Lancashire that had not involved AHCFT. This is analysed in greater detail in later sections of the report61.   178. A meeting took place at AHCFT Hospital later the same day. Baby H had been transferred to the hospital. This meeting was told that Baby H was unlikely to survive. The meeting made clear that joint enquiries were being undertaken under s47 of the Children Act 1989. Baby H’s sibling had been admitted to the Lancashire Hospital the same day and was medically examined. He was also subject of a skeletal survey and CT scan62.                                            60 The sibling had been admitted to hospital in Lancashire as a precautionary measure and with the consent of mother. 61 An important point of learning is associated with this; the strategy meeting is the vehicle for deciding how enquiries will be managed and importantly, how information is sought from family members. The fact that AHCFT had not been included in the discussion meant that they were making judgments outside of the overall management of strategy and enquiries and having to respond to very distressed family members. For a period of a few hours on the 18th it is apparent that there were effectively two parallel processes at work.  62 Baby H’s sibling was admitted to hospital. This admission was the result of medical concerns rather than safeguarding concerns. He was made the subject of an Interim Care Order. Until the ICO was granted following the local authority’s application, the local authority had no formal controls over the arrangements for Baby H’s sibling. The arrangements relied on the parents continuing to agree to leave their son in hospital. Given he was uninjured; this was a long stay in a hospital setting especially for such a young child. Further analysis is provided in later sections of this report.      Overview Report Baby H redacted published version Page 37 of 106 179. The mother and partner were interviewed by the named doctor at AHCFT. During this interview, the mother and her partner were told that the condition of baby H was being considered as a non-accidental injury63.     180. At 16.30 children’s social care services spoke with the children’s ward at the Lancashire Hospital to request that no member of the family should have unsupervised contact with Baby H’s sibling. The hospital said they were unable to comply with the request; they agreed to prevent any family member visiting the sibling and to refer any family member to children’s social care services.   181. At 18.00 the police made contact with AHCFT to confirm their intention to travel to AHCFT to begin their formal interviewing of mother and DS and to have access to hospital records. There was a disagreement about the handling of the interviews and releasing records. The consultant paediatrician was concerned about the parents being ‘removed’ from the hospital when Baby H was so poorly and likely to die.   182. The police agreed to postpone the interviews until the following day64. The police were not aware that as part of the discussion with the parents earlier in the afternoon, the diagnosis of shaken baby had been raised with mother and DS; this had implications for the subsequent police enquiries.  183. A second strategy meeting met the day after the first meeting. This meeting involved the relevant professionals from AHCFT hospital, police and children’s social care services65.                                           63 Further analysis is provided in later sections of the report. Each of the services have distinct and inter-related functions and responsibilities to perform in what are often complex and very emotional circumstances; the procedures are based on best practice and lessons learnt previously at national and local levels and are designed to ensure that enquiries and assessments are undertaken as sensitively and as effectively as possible; it is for this reason that procedures are important and that relevant people know and understand their purpose and how to apply them to get the best out of the respective expertise and skills of the various professionals involved. In this case, the police in particular had to play ‘catch up’ from the outset.; by the time they undertook their first interview with mother and her partner they had already begun using the internet to identify other reasons for the symptoms displayed by Baby H.  64 This is analysed in later sections; the formal enquiries required the police to arrest the mother and DS; this is usual practice and is designed to ensure that they have access to legal advice if they want it. The fact that AHCFT had been excluded from the strategy meeting earlier in the day meant that they had not been involved in the agreement of a plan. Once the police are undertaking a criminal investigation there can be serious consequences if anyone is deemed to be obstructive to those enquiries.  65 This is the meeting that should happen at the very outset when a professional identifies concerns about a child; the meeting has specific functions and purpose described in national and local guidance and procedures; it is a meeting to discuss information known at that stage, determine what further enquiries and assessments are needed, and agree which professionals will undertake particular tasks. This includes considering whether any action is needed in relation to any other children; in this case     Overview Report Baby H redacted published version Page 38 of 106  184. Mother and DS were arrested and interviewed by the police.   185. Baby H died in November 2010.                                                                                                                             the sibling of Baby H.  Without this level of planning, action can become disorganised and disjointed from the outset.      Overview Report Baby H redacted published version Page 39 of 106 3 Procedures and legislation  186. Agencies have a responsibility to ensure that their staff have an awareness and knowledge of the policies and relevant legislation within which they need to operate. This means ensuring that all staff are appropriately trained, have access to supervision and management guidance, and know how to access and apply the policies, procedures and legislation appropriately.   187. The responsibility of all staff employed in public agencies is to apply sufficiently good professional, managerial and practice skills to ensure that statutory functions are properly and effectively carried out. In some agencies the statutory requirements may be couched in general terms; in those agencies that have responsibilities concerning vulnerable children the statutory functions are detailed and comprehensive.   188. Procedures and protocols are underpinned by and intended to ensure that the statutory functions are properly performed. The following chart devised by David Spicer66 illustrates this principle.  Government Formulates Policy ▼ Legislation to Implement Policy ▼ Guidance to Assist Implementation of Legislation ▼ Procedures/Protocols ▼ Practice   189. Appendix 4 describes in detail the legislation, policies, procedures and guidance that are relevant to the circumstances examined in this review. This includes reference to legislation designed to control anti-social behaviour. There is also a summary of relevant national guidance and relevant reports.   190. For policies and procedures to be effective it requires practitioners to have a well informed understanding about the purpose of different procedures. It also requires an understanding as to the degree to which they provide a framework for the checks and balances; this ensures intervention with vulnerable children is based on evidentially sound judgements that lead to clear well executed decisions aimed at achieving improved outcomes for the child. They should not be regarded as bureaucratic requirements that can be                                          66 David Spicer is a barrister and a former County Council Legal Officer in the east midlands; in that capacity he was legal adviser to the LSCB in that area. His guidance was used in a Wales Assembly Government circular.     Overview Report Baby H redacted published version Page 40 of 106 dispensed with unless the circumstances dictate that compelling action to safeguard a child is required.   191. Lord Laming’s progress report67 in March 2008 emphasised the importance of professionals having a good understanding of their legal responsibilities and the particular responsibility of the Local Safeguarding Children Board and Children’s Trusts in ensuring the proper functioning of safeguarding services in their local areas.  This has been further reinforced in the revised national guidance set out in the latest version of Working Together to Safeguard Children published in March 2010.   192. Chapter two and chapter four provide examples of where practice does not comply with procedures and legal duties.   193. Compliance with procedures is regarded by some people as being an administrative or bureaucratic issue. It is not the compliance with policies and procedures that keep children safe.   194. It is the informed decision and actions that are the result of sharing information effectively; the procedures provide the frameworks for ensuring that relevant professionals and information are brought together and are coordinated. It also requires people recognising signs and symptoms of abuse in order to invoke the procedures.   195. It is an important function of the Local Safeguarding Children Board to ensure that local practice complies with and is consistent with legal requirements and standards of good practice. This is explored further in the last chapter that includes the recommendations relating to the significant points of learning identified by the serious case review.   196. The Munro Review calls for local areas across England to have more autonomy in setting the standards and frameworks and working to empower and free up the professionals working directly with children and families to make decisions.                                           67 The Protection of Children in England: A Progress Report; March 2009      Overview Report Baby H redacted published version Page 41 of 106 4 The critical reflection and analysis from the individual management reviews.  4.1 Summary  197. All of the individual management reviews were completed using Working Together to Safeguard Children (2010) which was also supported with additional local guidance provided on behalf of the LSCB. All of the IMRs include the terms of reference provided for the serious case review. The IMRs include action plans for implementing recommendations. All the IMRs are countersigned by the senior manager for the individual commissioning agency.   198. All of the authors were provided with a template for the completion of the IMR from the LSCB.  A briefing meeting was held with the authors and the agency commissioners of the IMRs and training was provided. These arrangements were in hand at the time the independent chair and independent author of the overview report were appointed and prior to their first meeting with the panel in February 2011. The IMR from children’s social care services was commissioned after two meetings of the panel when it became apparent that there were areas of practice that required analysis. This meant that for that service they had a significantly shorter period of time to collate information, arrange interviews and provide their IMR.   199. Some of the authors have undertaken the training that was offered and some had previous experience of providing an IMR. For others this was a new task for which they have had little preparation.   200. All of the IMR authors examined their agency records and procedures and completed structured discussions with relevant staff able to assist in the clarification regarding narrative and contributing to the analysis of learning.   201. Writing an IMR is a significant piece of work. The majority of authors provided their IMRs within timescales and have undertaken redrafting following discussion at the panel68. The panel undertook a detailed critical reading of each IMR and through the relevant agency representatives, provided comments to each of the authors.   202. For some of the authors, they were simultaneously working on other IMRs for other serious case reviews. All of the authors were also undertaking their usual range of professional roles and responsibilities. All of the organisations                                          68 For two of the services providing an IMR they had relatively short notice completed to other services; this arose because the requirement for an IMR was only identified when the first chronology could be examined in detail by the panel; AHCFT and in particular children’s social care services had short timescales within which to complete their work.      Overview Report Baby H redacted published version Page 42 of 106 were involved in responding to the budget savings required as part of the national deficit reduction programme.   203. Although recognising these challenges confronting organisations, the duty to conduct a serious case review should be well understood in particular by the statutory services.  The conduct of a serious case review is an opportunity to examine in detail the systems and professional practice and is also a litmus test for the capacity of the individual organisations to understand both the quality and the quantity of the services for which they are responsible.   204. The skills required to undertake an effective IMR are the skills that a good manager should want to develop and have the capacity to deploy in their day to day role; the work involves collating relevant information, understanding what the experience of children and families are when they come into contact with their service, be confident that staff have appropriate skills and experience and are making balanced judgements and be able to analyse how to improve practice and service further. In the most simple of terms the objective should be on encouraging and ensuring people are making the right judgments that lead to the right action and making it more difficult to make poor judgments and to take the wrong action.   205. This means that serious case reviews are essentially about trying to understand how events looked to key people at the time and understanding what frameworks and information were being used to help them make their judgments. Hindsight always identifies the other options that may have been available; the effective learning comes through understanding why things happen. It is for these reasons that IMRs are so vital to the quality of learning that can be achieved.   206. For some of the organisations it is apparent that they have both a deficit in meeting the sorts of obligations imposed when a serious case review is commissioned and from the quality of their IMRs also have shortfalls in their capacity to evaluate and analyse the extent to which complex systems such as children’s safeguarding is operating.   207. This has serious implications especially as the whole of health and social care services are likely to be the subject of important changes in commissioning and delivery of services over the forthcoming years. Further analysis and comment is made in the final chapter. This includes comment about the possible implications arising from the Munro Review.  208. The panel have worked hard to achieve sufficiently good quality analysis in the IMRs to support an appropriate depth of learning from the case. Although the IMRs have generally identified where with the benefit of hindsight improvements could be made there remains for some of the organisations an insufficient clarity about why some aspects of decision making or procedure did not work as well as they should have.     Overview Report Baby H redacted published version Page 43 of 106  209. The panel acknowledge that there remain significant areas of weakness in some of the analysis provided on behalf of a minority of the services. Those weaknesses are particularly evident in one IMR submitted from Cumbria and another from within Lancashire.  210. The significance is that opportunities are missed in the agency analysis to understand why some of the indicators that Baby H may have suffered unexplained injuries on earlier occasions were not identified. This occurred in regard to the shoulder injury that should have been seen to be unusual and deserving of further enquiry at the time and the apparent priority given to investigating a serious viral infection but not giving an equal weight to the possibility that Baby H had suffered a physical trauma when he was presented at the A&E service in Lancashire.   211. For example, one of the most helpful IMRs identifies that one of the occasions when an injury was not reported related to the inexperience of a worker and will contribute to improvements in the induction and supervision arrangements operating more appropriately in that service.  212. The most significant areas of learning that are not sufficiently clear relate to the shoulder injury and the apparent delay in recognising that Baby H had possibly sustained a suspicious injury when he was initially admitted to hospital. The fact that the possibility of Baby H having suffered abuse was both missed and even with hindsight the reasons for it are not sufficiently clear to the relevant services. This is analysed in further detail in later sections and is the subject of agency specific recommendations.  213. In general the IMRs provide a sufficiently clear account of what happened; they provide the narrative. With some notable exceptions there is generally a good description of where practice or decision making can be improved with the benefit of hindsight. Many have already taken action or initiated action in response to improvements or areas of development identified through their individual review. They all provide information about staff involved with the families and several give good analysis about their organisational context and provide coherent analysis about intervention.  214. The clarity of judgements about the appropriateness of services, the quality of practice and decision making vary in the individual agency reviews. The health overview report provides additional analysis and comment in relation to the learning for the health communities in both areas that have contributed to the SCR.   215. Several of the IMRs provide information about the training given to staff and several make explicit reference to agency procedures. Some also provide comment about the expected standards of practice within their service. All     Overview Report Baby H redacted published version Page 44 of 106 have included recommendations. Considerable effort has been made by the panel to develop SMART69 recommendations.   4.2 Significant themes for learning that emerge from examining the IMRs  216. The agency reviews identify themes that have implications for policy development and staff training that applies to all services working with children. In the summary of the review’s finding provided in chapter one there is acknowledgement that some of the issues to come out of this review are reflected in the finding of national evaluation and research. Important messages for learning from this review include:   Helping professionals to see children and their family within their social context; although primary health care services in Cumbria understood at the outset some of the vulnerabilities facing the family and responded, this information became less clear as the family moved to another area; significant information such as the injury to Baby H’s shoulder was not clearly reported;  Ensuring that all health professionals who see children in hospital and clinic settings have sufficient training, professional support and the capacity to recognise the indicators for unusual or abusive injuries and the implications for further enquiry; this has to include how people have opportunity to reflect upon what they are observing or hearing about;   The recognition of parents who by virtue of their age, social circumstances and parenting task need additional support and may be reluctant to acknowledge or accept their need for help; this has implications for how systems such as CAF are set up in local areas as well as encouraging a greater level of sceptical assertiveness on the part of practitioners to probe and check;  The importance of primary health care services having the capacity to provide or arrange additional advice and support when it is required for vulnerable parents and their children; there was a high reliance on mother and partner following up their own appointments or finding their own support;  The importance of recording, communicating and using information effectively between different health providers and especially when it involved families who transfer between different areas; communication between key primary health providers such as GPs and health visitors was inconsistent;  The recognition that bruising or other forms of injury deserve particular scrutiny and enquiry when observed in very young and non mobile children;   Importance of having an adequate social and family history that also clearly identifies the identity of both parents and the status and identity                                          69 Specific, manageable and measurable, achievable, realistic and timely.     Overview Report Baby H redacted published version Page 45 of 106 of other adults related or sharing the household and information about learning disability; using information gathered from such history taking to anticipate the likely need for additional support; the age of mother and her partner, the fact that the partner was not the biological father, the demands of young children, the apparent absence of a settled home and social isolation were all factors that could have been understood more clearly;   The importance of not taking at face value the information either received or presented; a great deal of confidence was placed on how mother presented to various services that in hindsight resulted in overly optimistic conclusions being reached; the shoulder injury was an important example of focussing on what parents say rather than understanding the significance of what has happened to the baby;  The value of open access forms of support such as Children’s Centres for parents and young children being staffed by empathetic and trained staff who are appropriately inducted and supervised;  The challenge for co-ordinating strategy meetings that involve professionals across more than one county or area.  217. It is important that constructive feedback and reflection is provided to all the practitioners involved in this case. In particular, it will be important to support practitioners who are at a relatively early stage of their career to give them the appropriate positive encouragement for their continued professional development and retention in the workforce. It is of great credit that the early year’s worker in particular provided information for the review when the records within the service would not have revealed it.  218. The remainder of this chapter summarises key evidence relating to the terms of reference established for the IMRs.  4.3 Good practice identified through the review  219. To support the learning from the review the panel looked for examples of good practice. To constitute good practice, the panel looked for action or decision making that went beyond compliance with local and national policy, procedures and guidance.   220. Examples of good practice identified by the review include;   The extra responsibilities and demands that the birth created were recognised by the health visitor in Cumbria who ensured that the postnatal contacts for the family were both frequent and made at home.  This enabled the teenage mum to develop baby management and parenting skills in the safety of the home instead of having to organise the children to take them to a clinic appointment;     Overview Report Baby H redacted published version Page 46 of 106  After the initial booking at the  Hospital in Cumbria the community midwife (CMW) made a referral to the teenage pregnancy group (TPG) that is run in partnership with Connexions;  As well as giving reassurance to young and inexperienced parents the health visitor recognised the health needs of Baby H’s sibling for an early assessment by the GP and this was followed up.   When Baby H and his mother attended for his first GP appointment they were late; having examined Baby H the GP made a further appointment to ensure that sufficient time was given to mother’s post natal check; when this and a further appointment was missed the GP made the health visitor aware who then made efforts to contact mother; this was good follow up;  Baby H was examined by a doctor for the injury to his shoulder on the day of his attendance, who discharged him with a referral to an orthopaedic specialist although neither of the doctor’s apparently recognised the highly unusual nature of the injury in such a young non mobile child;  When it became apparent that the family had moved from Cumbria, the health visitor was thorough in following up where the family had moved and spoke with the health visitor in Lancashire;  The Lancashire health visiting service provided enhanced contact with the family;  When it became apparent that there was a second Children’s Centre closer to mother’s home and more convenient to use, information and advice was given to use that centre;   Good contact was kept up by the Children’s Centre worker to provide information about specific sessions or activities and to encourage attendance; the worker also ensured that mother had her contact details to call her if necessary;  After Baby H’s injuries were referred (albeit several hours late) prompt action was then co-ordinated through a strategy meeting included bringing his sibling into hospital and ensuring full and thorough examinations including a skeletal survey and CT scan were completed; medical staff did not rely on physical observations that the sibling was a fit and healthy child;  Ensuring the family’s wish to have Baby H baptised at AHCFT and having access to a priest;  When it became apparent how ill Baby H was and the imminence of his death there was sensitive practice in regard to managing the competing demands of allowing the family time with Baby H and the police and children’s social care having to begin their enquiries; there was good evidence of communication and coordination between these two services and AHCFT in that regard;  The Police appointed a Family Liaison Officer (FLO) when investigating the death of Baby H; this is at the discretion of the senior investigating officer (SIO) as there was a potential suspect within the family;  221. It is noted that the IMR author for the Lancashire PCT undertook a further audit of records having identified shortcomings in the quality of record keeping arrangements.     Overview Report Baby H redacted published version Page 47 of 106  222. The remaining sections of this chapter summarise the most significant learning from the IMRs against each of the case specific terms of reference.  4.4 Did all agencies and professionals give due and proper consideration to all diversity issues, including ethnicity, religion, language, disability, culture, social background and integration?   223. Collecting information about families is an essential pre-requisite to the provision of services that are both sensitive to matters such as religion and family culture as well as being relevant to the family’s circumstances. An effective social history will help with the early identification of need in families like Baby H’s. It is a part of professional practice that is frequently overlooked as evidence from inspections of services and serious case reviews demonstrate.   224. In this case the extent to which different professionals and services had knowledge about the family was inconsistent and often incomplete. When they recognised support might be required it was often not followed up; great reliance was given to family members providing support or mother seeking it out. This is not intended to suggest that people should not be encouraged to be independent; professionals have to balance not being unduly intrusive.   225. Baby H’s immediate and extended family is white British. For many services his mother appeared to be articulate and apparently able to express herself confidently when she was in contact with various professionals. None of the services involved prior to  the hospital admission had identified that either mother or DS had any known disabilities or learning difficulties; this only emerged when the consultant paediatrician at the AHCFT identified that this was an area of need and it was taken into account by the police and social care services thereafter.   226. For several of the services, they did not pay sufficient attention to finding out about the family and their history; most of the services describe their systems for collecting information although most were not completed with sufficient detail. This is a factor that emerges on a regular basis in many serious case reviews or inspections of a service. Taking a clear family history is the first step in understanding and recognising potential vulnerability of a child. Too often, the collation of such information is regarded as an administrative requirement.   227. Baby H was presented on more than one occasion for medical treatment. For most, there was a high reliance on looking at the immediate presentation of the family and the parental account; if for example medical staff had recognised that DS was not the father, had known about the age of the     Overview Report Baby H redacted published version Page 48 of 106 parents, had understood how much they had moved in recent times, and an injury had occurred, it would probably have caused them to be more skeptically alert and enquiring into the family’s circumstances.   228. Arguably, this initial presentation masked the factors that made LJ and DS a couple who had additional needs; they had been a particularly mobile family having lived fairly recently in the West Midlands, before moving to live in the far north of England and moving again within three months to Lancashire. They were more socially isolated than many other young parents. The circumstances of the children’s conception and the adult’s relationships were more complex than was apparent to many people.   229. The amount of social information available to the GP services in both areas was limited. This was compounded by the time taken to transfer information when patients move to new areas and change their GP; this appears to be a national rather than locally confined problem although the uploading and indexing of patient details once they arrive at the GP practice is a matter for the GPs to manage effectively.  230. The police IMR author describes a large and by all accounts a close knit family that works hard to support themselves. The physical standards in Baby H’s home prior to his death were good and it was located in a semi rural area with low levels of deprivation or crime. It is apparent that members of the family had been instrumental in helping mother and her partner to find both accommodation and employment.    231. The author of the Children’s Centre IMR describes some of the potential difficulty for securing comprehensive information that can apply to all services; for example the Children’s Centres’ registration form relies on the extent of information that a parent is willing to provide; they choose how much information they are willing to share.   232. This reinforces the value of having trained staff to explain the purpose of the information and encouraging as much disclosure as possible to ensure that people working with the family are sufficiently informed about the family’s circumstances and can provide appropriate advice and help. It is apparent that there were important gaps in information that all the services had; for example not all staff working with mother appreciated that the partner was not the father of Baby H and his brother70.                                           70 There is other information that none of the services appear to have; for example the source and amount of income the family had; this is not to suggest that health professionals or Children’s Centres are expected to provide specialist advice on complex areas such as employment, training and entitlement to income but they can play an important role in signposting to sources of help and support. The IMR from the Children’s Centres explains that there is no requirement to keep records for families using the universal services provided through the centre; universal is the term applied to     Overview Report Baby H redacted published version Page 49 of 106  233. A further contributing factor is that the collation of information can be regarded solely as a routine administrative or clerical task whereas in reality even a relatively short but well structured enquiry can reveal important indications of a family’s vulnerability. This applied across several services that came into contact with Baby H including health visiting and GP services after they moved to Lancashire. High reliance was given to a young mother presenting herself as being very competent.    234. The consequences were that when indicators of vulnerability were visible, the default or mindset position was to treat injuries as accidents and rely on mother in particular to seek out further assistance or help for example in relation to support for the family.   235. The IMR on behalf of the Cumbria PCT includes a description of good practice standards that would have contributed to much more effective management of a vulnerable family. This includes ensuring teenagers who are registered as being pregnant are offered follow up with a health professional; this represents a stark contrast to the approach that was taken generally in this case where services were generally in response to mother presenting herself and Baby H.  236. The Children’s Centre IMR author comments that data is used to help analyse information about the range of need and identity represented in families using the service to assist in planning. The author also describes the importance of analysing how the service can reach families who may not yet be participating in activities71.   237. Baby H and his sibling demonstrated no disability from the various examinations conducted on them whilst resident in the area covered by Cumbria PCT and then subsequently when they moved to Lancashire.    238. The language and ethnicity of the family was not routinely recorded by all services with some exceptions. For example the health visitor records in Cumbria did include details of language and ethnicity but was not recorded by the GP or the CHOC service. Mother is described as articulate and able to express herself by the Cumbria PCT IMR and to that extent was no different to how other teenage peers in the area were seen.   239. The IMR author highlights factors that differentiated mother from other young people using health services. This included the fact that she had not been living with her mother (maternal grandmother) until her pregnancy was established; health professionals did not know how long she had been living                                                                                                                   open access services that do not require a referral from other services or professionals. This point about record keeping is analysed further in later paragraphs. 71 There is however limited commentary on how the information is being used to develop services.     Overview Report Baby H redacted published version Page 50 of 106 away or with whom; her father (maternal grandfather) was separated from her mother and living outside the local area; she was a teenager who was pregnant (and then mother).  240. According to the PCT IMR from Cumbria it is not clear that mother’s additional vulnerability was recognised. There were other factors, including the fact that her partner was not the father, that were not apparently recognised by all of the health services and was especially pronounced after they moved to Lancashire.   241. The health visitor recognised the extra responsibilities and demands created and ensured that the postnatal contacts for the family were frequent and made at home.  This enabled the mother to develop baby management and parenting skills in the safety of the home instead of having to organise the babies to take them to a clinic appointment.  242. When mother had her first contact with the Hospital in Cumbria, it was clearly recorded that mother’s partner was not the biological father. After the initial booking the community midwife (CMW) made a referral to the teenage pregnancy group (TPG) that is run in partnership with Connexions72. This provides evidence that there was a degree of recognition about vulnerability although the analysis in paragraph 137 queries the extent to which its significance was properly appreciated; in other words this could be the action of professionals going through the procedures73.   243. The IMR on behalf of the Cumbria Hospital describes how a social assessment section is incorporated into the initial Family Origin Questionnaire; faith and religion, the understanding of English and difficulties in reading should be identified. The IMR does not clarify the extent to which the documentation was completed or the extent to which it provided sufficient quality of information for example in regard to learning difficulties that were identified by other people in November 2010.   244. The person taking the initial patient information should identify are whether they need help to complete forms and identify if they are entitled to claim any benefits.  The support that is available is also documented.  This information is used to give an individual picture of the circumstances of the pregnant woman. The IMR does not comment specifically on how well the                                          72 There was only one record of attendance at this group that is included in the narrative in chapter 2 although the CMW thought that mother was a regular attendee at the group. The offer of support from the TPG did not require a CAF; this is explored in later chapters.  73 This should not be read as a personal criticism of the individual staff; she may well have had a very good appreciation about why mother needed support but her records do not include this; this could in itself be a reflection of a busy professional prioritising her contact with her patient and giving less time to the routine administrative task of recording. Recording, reflection and analysis are all professional skills that need to be encouraged and protected in busy work environments.     Overview Report Baby H redacted published version Page 51 of 106 questionnaire was recorded in this case or the degree to which it assists medical staff to have sufficient social information to support their medical assessments, diagnosis and treatment.   245. The IMR author highlights examples of where staff made assumptions about the degree of support available to the mother in particular. For example there is little documentary evidence that midwifery staff did take into sufficient account the age of the couple and the fact that they had recently moved into the area.    246. The initial referral to the TPG had been made but there is no documentation to confirm that the couple took up the support offered; an assumption was made that the support was accepted.  It was also assumed that maternal grandmother was offering significant support when in fact both she and her partner were working and therefore had limited time to offer support.  247. The partner’s details and status were not known by all the various health services that had contact with the family. The fact that he was not the biological father but had taken responsibility for the children was significant information and the fact that he had no family or friendship networks locally.   248. After the family moved to Lancashire in September 2010 there were 14 contacts with the health visiting service over the ten weeks up to Baby H’s death. The IMR author points out that this is more frequent contact than is required by national and local standards.   249. Mother told the health visitor at their second meeting that her partner was not the father of the children. The computer generated record and the demographic template that the health visitor completes requires them to include ethnicity, main language, gender and religion. In this case only the main language and gender information were completed74.   250. The health visitor in Lancashire, like her counterpart in Cumbria, recognised some of the potential vulnerability of the family and provided an enhanced level of contact with them. In addition to the factors already identified whilst the family were in Cumbria, Baby H’s sibling was slow in gaining weight. The family were living in a privately rented house that was located in a more affluent part of the town. The health visitor described the house as ‘clean and tidy’. Before the health visitor had made her first contact mother had already been in contact with a local Children’s Centre.                                           74 The Lancashire PCT IMR points out that there is no requirement within the Trust’s Record Keeping Policy to record race, culture, disability, sexuality or economic deprivation. As part of her work on the IMR the author for the Lancashire PCT undertook a dip sample of 100 records; she found that ethnic origin was recorded in 92 cases, none had information about religion, main language in 31 cases, none of the case linked to a male adult and only 36 were linked to a female.      Overview Report Baby H redacted published version Page 52 of 106  251. The author of the GP IMR conceded that the ‘registration procedure was not entirely consistent with as required by the Lancashire Primary Care Trust Safeguarding Children Procedure’. No further detail is provided on this specific point although the author highlights several issues relating to the quality and processing of information that is referred to in later paragraphs.  252. The later draft of the IMR on behalf of the Lancashire Hospital acknowledges that there were missed opportunities in the consideration of the family’s background; for example they were unaware of DS not being the birth father until they were informed by AHCFT. The author also acknowledges that with better information about the family’s history and circumstances, there may have been more informed and balanced judgments made. Although it is not made explicit, it seems that the differential diagnosis of a shaking injury may have been given greater consideration.   253. It is not clear what prevented better collation of information; the author describes how training is provided although the extent to which people comply with this and other procedures appear to rely on attendance at training events.   254. The AHCFT IMR describes a good level of information being recorded from the various discussions that took place in November 2010. It is apparent that they recognised early on that DS was not the biological father. When the extent of Baby H’s injuries were apparent there was good attention to responding to the whole families emotional and spiritual needs; the arrangements to baptise Baby H and to provide access to a priest were all examples of sensitive practice.   255. The first contact that CSC had with the family followed the referral in November 2010. The initial recording of the referral did not establish that DS was not the birth father; this information was established at the strategy meeting. The IMR author confirms that although the service was efficient in checking whether there was any previous history or contact with the family the initial referral did not check on whether the hospital had any relevant information such domestic abuse, mental or physical health or disabilities.   256. The IMR author highlights it as a point of learning for customer services (ACORN) and the children’s referral and assessment team (CART). It became apparent during later discussions particularly at the strategy meeting that mother had a ‘degree of learning disability’.   257. The identification of mother’s learning disability emerged after several contacts with other services. When it was discussed at the strategy meeting the extent to which it reflected a learning difficulty or a disability or the degree of the difficulty was not well understood. The author of the CSC IMR     Overview Report Baby H redacted published version Page 53 of 106 believes that once the information was known the implications were considered in respect of interviews and advice provided to mother and DS.   258. The second strategy meeting had further information about the family’s history from AHCFT.   259. The fact that several services had contact with the family over a short period of time prior to November 2010 but had not identified important information such as the learning difficulty is significant.  People working in services have to be sensitised to the importance of this type of information and its relevance for parental comprehension and understanding when being offered advice. At the time of the strategy meeting there was still little information about the nature and extent of mother’s difficulty was not known sufficiently well.   260. Similarly assumptions were made about the extent and nature of support without a great deal of informed enquiry. It is also notable that even at the point of Baby H’s death when he had been baptised as a Catholic there was no information recorded about the faith of the family by CSC.   261. Recording such information should not be regarded as simply a procedural requirement. Faith is important for many families and is one aspect of exploring the value systems and cultural standards operating in a family.  It is one of the reference points that can be used to help develop an insight as to how the family view external help from services such as health and social care.   4.5 Did all agencies keep the child and his experiences at the centre of their assessments of and interventions with the family?   262. The serious case review provides several good examples of different professionals and services working together to keep Baby H at the centre of the assessments and interventions after it became apparent that he had suffered a brain injury. At that stage the services were balancing their responsibilities to conduct proper enquiries into why Baby H had become so ill and remaining sensitive to Baby H’s needs as well as other members of his family.   263. There are other examples of how professionals tried to help and provide support. In the interest of getting as much learning from the review as possible, the panel have been challenging about several aspects of how this help was delivered.   264. A theme that comes up in national evaluations of serious case reviews is the extent to which the needs or behaviour of parents and carers become the overriding preoccupation for professionals working with the family. They     Overview Report Baby H redacted published version Page 54 of 106 concentrate too much on what parents say or how they present themselves rather than focusing on what is happening to a child.   265. This can have particular consequences when dealing with very young children who do not have speech or are unable to communicate clear feelings or wishes. In this case there was a mindset that saw mother in particular as coping very well and apparently was well supported and was not resistant to professional contact or advice.   266. However it meant that assumptions were made by almost everybody until the brain injury became a clear diagnosis in November 2010. The GP commented on how well mother was coping on the basis of very little contact. The health overview author refers to the recommendation made by Lord Laming that children are offered a GP consultation and examination as a matter of routine upon their initial registration with a GP practice75.   267. The same author points out that if he had been examined the GP would have seen a graze to Baby H’s face; an injury that was unknown to health at the time. Mother and her partner’s visible concern and demeanor influenced professionals at key points that included the shoulder injury, the observation of healing scabs and when Baby H was presented in a collapsed state in November 2010; it also allowed the acceptance of the highly unusual account of the baby’s fall from a pram. They apparently researched shaking injury before the police interviewed them when they became aware that the police and children’s social care were working on a hypothesis that Baby H might have suffered a shaking injury.   268. When LJ first registered as a patient with the GP practice she was still legally a child as well as being pregnant. The author of the Cumbria PCT IMR comments that it would have been good practice for her to have been seen and assessed in the first instance by a clinician in the practice in order that and her social and emotional status and any risks to the unborn baby could have been considered within the GP Practice.   269. The same author also explores the extent to which the development of specialism’s between GP and midwives for example has led to GP’s to feel their role in the care and management of pregnant women has been taken over by midwives. Delays in communication between the midwives and the health visiting service further reduced the opportunity for managing support and help more effectively.                                             75 This is not a national service requirement and is not included in the national GP contract.      Overview Report Baby H redacted published version Page 55 of 106 270. The fact that the family, and mother in particular were regarded as coping well, also contributed to some routine tasks such as using relevant tools to assess vulnerability76.   271. The IMRs identify differences between how well individual health professionals were able to keep Baby H and his sibling central to their assessment. For example, the GP provided good care and attention to the health needs of mother prior to the birth; in doing this they also ensured that the unborn baby's well being was being addressed.   272. However there was less regard to the social circumstances of the family. The absence of information about the father or the circumstances of the relationship with the partner were not recorded.   273. By contrast, the health visitors had more comprehensive records. The health visitor was not alerted by midwifery services that mother was expecting.  274. The faltering growth of Baby H’s sibling was picked up quickly as part of the routine contact with the health visitor in Cumbria; appropriate checks and advice were provided.  This included reprioritising the family under the PCT’s framework77. The health visitor was aware that the problems with the baby were possibly simple but she was conscious that the faltering sibling could have underlying illness and subsequently requested a medical opinion.   275. The health visitor considered that the faltering growth could have an organic cause but she did not consider that the weight loss could also be linked to parenting issues and risk. With hindsight it is possible to see that this may have been the first indication that the teenage parents were struggling to cope and this should also have been considered as a possible cause.                                           76 The IMR author explains that the health visitor in Cumbria chose not to use the specialist assessment tool to assist her in formulating a full picture of the family situation. The reason for this was that the initial primary visit made to any new baby is long and very comprehensive and does allow for a great deal of health and social information to be gathered regardless of the tool used. With the benefit of hindsight this risk assessment failed to fully take into account the lack of maturity of the parents and their ability to cope when the babies made regular demands on them. In this case a clearer and more detailed assessment should have more fully considered the levels of stress that the two teenagers were coping with over extended daytime periods and should have further considered if these inexperienced young people could in fact deal with the demands of 2 young infants with no other hands on support. 77 The IMR explains that risk assessment in the Cumbria PCT health visiting service is done routinely at contacts.  The needs of the children and the parents can be categorized as being Green – routine interventions; Amber – families need a slightly higher level of input when they have other health or social needs; Red – families assessed as needing high levels of input for serious health, social or child protection purposes.     Overview Report Baby H redacted published version Page 56 of 106 276. When Baby H was injured in his push chair the nurse who examined him identified faint bruising and accepted the history given. The IMR author is clear in her analysis that although the nurse took a careful history and examination, the fact that a bruise was identified on a baby not yet mobile should have been the subject of a referral under the LSCB procedures.   277. The nurse had attended training but had minimised the chance that the injury was a possible consequence of inappropriate handling or care. The nurse was experienced and was probably using her personal knowledge, experience and intuition. Whilst services rely on the deployment of these sorts of skills, there is inherent danger when individuals choose to disregard guidance and procedure78.   278. A nurse practitioner who was asked to provide a second opinion also made the same conclusions as the nurse; they had both worked together for many years and were both very experienced. This can represent further risk in the process of achieving sufficiently balanced judgments79; colleagues who have developed great trust in each other’s judgment and decisions can inadvertently begin to cut corners especially if they are working in busy and unpredictable surroundings such as a walk in treatment centre; rather than testing the basis of each other’s judgements there can be a tendency to endorse and support a trusted colleague’s judgment80.    279. All of the professionals relied almost exclusively on their observation about how mother behaved; comments such as skilled, sensitive and caring are all adjectives used to confirm that mother was seen to be responsive and attentive to her son. There is nothing wrong in using such information and it an important part of the evidence to be analysed critically.   280. However, when dealing with an unusual injury, it requires a heightened level of sceptical enquiry that does not accept information at face value. It needs to factor in that little information was known about either father or                                          78 The IMR author comments that little recording is made regarding the reasons for the judgements and decision making; this is of additional significance given the staff should have recognised that the injury was highly unusual given the need for the baby to have grabbed and held on until injury occurred; it leaves ambiguity as to whether the decisions reflected insufficient training, was the product of tired decision making or reflected undue reliance on the presentation of the parent rather than focussing on what has happened to the child and that it was highly unusual. This lack of clarity undermines the opportunity for achieving a good enough level of learning on this specific issue.  79 The term balance judgment has been used by David Spicer to describe a range of factors to be considered; the discipline is especially important when significant harm to a Baby Has been proven (which it had not in this case). David Spicer is a barrister and former local authority Legal Officer (not Lancashire) and in that capacity was legal adviser to that LSCB. His guidance was used in a Wales Assembly Government circular. 80 There is academic research that describes the tendency of groups to stop thinking critically with each other and can be described as ‘Groupthink’, the term applied by Janis (1982) to the tendency of groups to avoid dissension. .     Overview Report Baby H redacted published version Page 57 of 106 the partner; it needs to acknowledge that the behaviour observed in a clinical setting can be different from the behaviour of a parent when they become overtired or are stressed. It should recognise when an injury is unusual especially in a very young child not yet mobile.   281. Academic research discusses the struggle that professionals have when challenged when values held conflict with the rights of the child and ‘thinking the unthinkable’81.   282. Research and training shows that bruising in very young non mobile children is very rare and as such deserves further relevant enquiry by appropriately trained and experienced professionals who include paediatric and social work practitioners. Needless to say, the conduct of such enquiries has to be done with considerable skill, sensitivity and informed knowledge.  283. The arrangements for x-raying the injury were made quickly and included arranging transport; this was sensitive and child focussed; it prevented delay and further distress for either Baby H or his mother in respect of immediate treatment.   284. The assessment at the Cumbria Hospital following the referral for further orthopaedic expert opinion was completed thoroughly; a refreshed history was taken rather than relying on third party accounts. The referral was both a reassurance for mother in particular but also demonstrated a clear focus on ensuring Baby H’s health and injury was fully understood.   285. Although doctors considered the possibility of an undiagnosed birth injury (which was apparently given a lesser significance to a severe infection) it is not evident that they seriously considered whether the injury was accidental given the rarity of such an injury in a non mobile child. The IMR from the Cumbria Hospital does not provide any further analysis or information about this including the degree of training and development provided to the specific doctors who examined and treated Baby H who were not paediatric specialists82.   286. After the family moved to Lancashire, the children's weight and physical development was routinely monitored. Mother had expressed her concerns                                          81 Webb (2009) also suggests an “absolutist approach to the diagnosis and recognition of maltreatment with the experience and impact on the child, not the intent of the perpetrators as a primary focus”.  This clearly means that professionals should view the situation from the perspective of the rights of the child rather than the circumstances and behaviour of the parents. An unusual injury deserves a further level of critical enquiry; was the injury the result of careless handling, a result of stress? Webb E, Moynihan S (2009).  An Ethical Approach to resolving value conflicts in Child Protection.  Archives of Disease in Childhood 20th October 2009. pp 55-58. 82 The IMR does state that 81 per cent of nursing staff have received internal training and three of the five doctors had been trained.     Overview Report Baby H redacted published version Page 58 of 106 about the slow weight gain by the sibling and the health visitor followed this up with the GP.  However the IMR author is critical about the lack of ‘effective action’ taken as a result of the follow up.  287. The Children’s Centre IMR reveals that there was information that suggested the family were not coping as well as was assumed from other observations. On the first visit to the Children’s Centre 1 at the beginning of September 2010, a healing and scabbed injury to the baby's head should have been followed up and discussed with a line manager83. The age of the baby and the nature of the injury should have given cause for concern. Expected policies and procedures were not followed. The reason was that the worker was new to her role, had not received specific training that would have clarified expectation and arrangements for reporting or recording information about the session.   288. The explanation of the injury should have aroused further enquiry and advice from a more experienced member of staff; mother had described how Baby H had fallen from the push chair and had not noticed until a passer by had pointed it out. The explanation is credulous; it suggests at best a lack of attentive supervision that could be symptomatic of a stressed and tired parent not coping that deserved further attention. The purpose of safeguarding procedures is to prevent significant harm happening to a child as much as to investigate allegations or concerns84.   289. Mother’s partner never attended either of the Children’s Centres and there was little and inaccurate information about him; the staff therefore did not have a complete picture of the children’s circumstances and environment. They did not have an opportunity to observe how the children responded to him85.   290. The IMR from the Children’s Centre points out that the age of the children meant that they were not yet verbal and could not express their wishes and feelings. Although clearly the statement is factually correct, it does not give sufficient regard to the other signs that might be available to suitably trained and observant staff that could indicate emotional distress or physical pain.   291. Very young children are undergoing some of the most profound development in their early years; recognising non verbal or developmental                                          83 The vulnerability of a baby to any form of head injury is outlined in chapter three. 84 Mother attended 17 sessions with her sons at the two centres; this was the only occasion when an injury was observed although there was reference to mother using a ‘grubby dummy’ on another visit. At times staff saw the boys without clothes as part of the normal activity.  85 This should not be read as an implied accusation that the partner was doing anything to harm the children; only to point out that the gaps that were apparent; if the injury had been picked up it would have been an opportunity to enquire further.      Overview Report Baby H redacted published version Page 59 of 106 needs is the basis of responding quickly to a child’s developing needs and identifying possible causes for concern.   292. In hindsight, the fact that mother was seeking a lot of contact and support from the Children’s Centre could have been explored with her; it is a difficult balancing act where a Children’s Centre does not want to create barriers or anxiety for parents; the point being made is that a parent who is keen to have a lot of contact may have unrecognised needs that require sensitive discussion and follow up.    293. Baby H’s admission to the Lancashire Hospital in November 2010 resulted in effective immediate medical treatment being provided to Baby H. There was sensitive practice in allocating a nurse to LJ and DS when Baby H was the subject of resuscitation; this can be very distressing for families to witness. Although there was an acknowledgment that the symptoms could be evidence of a shaking injury there was no apparent consideration of either invoking the information sharing protocols or consulting with a safeguarding specialist.    294. After Baby H was admitted to the tertiary hospital AHCFT and the safeguarding procedures were invoked and the police became involved there was sensitive attention given to the timing of strategy meetings.  295. The AHCFT IMR also highlights particular examples of how Baby H’s needs were paramount both in terms of invoking the necessary SUDI procedures as well as the emotional care and sensitivity displayed to both baby H and mother in his last hours.   296. There is less information provided in regard to Baby H’s sibling. Although it is apparent that prompt action was taken to arrange for the sibling to be admitted to hospital this initially was to investigate possible medical conditions including sepsis rather than being an explicit safeguarding strategy. There is a contrast in how AHCFT were able to ensure appropriate and sensitive supervision of family contact with Baby H compared to the response from the hospital in Lancashire that was unable to provide a similar assurance.   297. When AHCFT had initiated the safeguarding procedures a request was made by CSC to the Lancashire Hospital to supervise any family contact; the hospital said they were unable to do this and as a result social care services instructed the hospital that no contact should take place between the sibling and family. This is analysed further in later chapters; this includes the legal basis of refusing contact and the extent to which decision making by services were sufficiently sensitive to the needs of a very young child who had been separated from his sibling and family.       Overview Report Baby H redacted published version Page 60 of 106 298. CSC had no direct contact with either child during the time examined by this review. It is evident that information was being provided on both children principally from the two hospitals. When CSC were made aware of the extent and natures of injury to Baby H there was consultation with a senior manger regarding legal action to support plans to keep both children safe. That manager initially decided that an emergency protection order (EPO) would be sought although subsequently amended this to care proceedings by notice rather than seeking an EPO. Both children were in hospitals and mother (as the parent with parental responsibility) had agreed to her children remaining there.   299. There is an argument that can be made that the local authority had no parental responsibility until the interim care order (ICO) was granted and therefore had no power to control family contact or prevent the sibling in particular being removed by a family member. In this case both children were in separate hospitals, there was clear agreement that the children would remain there and the police would have powers to exercise their powers of police protection (PPOP) in the event of any attempt to remove the child.   300. The fact that the local authority initiated the public law outline (PLO) protocol and gave notice of their intention to apply for interim care orders and ensuring that mother was advised of this and was encouraged to find legal representation are all evidence that there was clarity about the arrangements and the reliance on voluntary agreement covered the immediate period after the diagnosis of the injury.   301. Although Baby H died in hospital it is clear that the local authority identified a foster carer who could have cared for both children. There was also good evidence according to the CSC IMR author that mother was consulted in detail about daily care routines and that this was recorded in relevant documentation for the foster carer.   302. The decision to withdraw life support from Baby H was done with a great deal of sensitivity and discussion between the different services and with mother and DS. Good attention was paid to coordinating action to prevent for example police interviews clashing with the last hours of Baby H’s life.   4.6 Were information sharing and communication systems within and between agencies and across boundaries effective?   303. The serious case review has revealed a number of problems in the way that information is collated and shared across different health providers; this is a problem that has been highlighted in national evaluations of services and is not restricted to serious case reviews although of course has particular implications when working with vulnerable families and children.       Overview Report Baby H redacted published version Page 61 of 106 304. There were problems in transferring information between different counties, in the management of information within community health teams and between GP and health visitor. The health overview author points out the discrepancy between the Lancashire IMR that says the records were requested in September 2010 and the date recorded in the Cumbria IMR being October 2010.   305. When the information was transferred to the GP practice in Lancashire there was a delay before it was inputted into the electronic computer system. The computer records at the time were not linked to the Read codes referred to in chapter one although is being introduced. The extent to which this is being implemented across the health trust or the detail in regard to how the coding will help to identify vulnerable children registered to individual GP practices is not entirely clear.   306. The review also highlights the limitations of being able to access information on a 24/7 basis; when Baby H was presented at the Lancashire Hospital it was outside office hours and therefore there was no access to GP or health visitor information; this was compounded when nobody followed up that information the next working day and after Baby H had transferred to AHCFT.   307. Problems in the quality of information sharing occurred at an early stage. For example transferring information from midwifery services to the GP and health visiting records did not occur. This apparently reflected a belief that this was a family who would have no additional needs or vulnerabilities despite the information that would have been available from before the birth.   308. The review highlights gaps in the way information was transferred between the different areas, was shared between the different professionals and delays in recognising the signs that Baby H had been injured and was missed entirely on two other occasions. The review raises important questions about how services such as GPs both receive and then manage their child patient information.   309. The health overview author highlights the absence of information sharing processes and arrangements within the walk in treatment centre and the accident and emergency units in Cumbria although this has been addressed.   310. The review has shown what can happen when important information sharing systems such as strategy meetings do not work as effectively as they could. Perhaps most importantly, the case shows how professionals who are not sufficiently alert to the importance of identifying signs and symptoms of abuse will undermine the best of protocols for the communication and sharing of information about a child.       Overview Report Baby H redacted published version Page 62 of 106 311. The fact that many of the people who came into contact did not have sufficient basic information about vulnerability or previous histories of contact especially with health services undermined their capacity to make sufficiently informed and balanced judgements; instead they relied too much on what was presented to them.   312. A significant piece of information that was not shared between the various services was the fact that mother’s partner was not the father. The assumption was made that he was and neither mother nor he challenged that view.  313. There were gaps in information recorded about the family. Information that was on the records could, with the benefit of hindsight, have been analysed more effectively. However that relies on information getting onto local systems quickly and busy health professionals having the capacity as well as the motivation to look at the information.  314. The information about the family’s contact with health professionals was routinely processed and shared between the relevant people such as GP and health visitors. However, this reliance on routine systems meant that the health visitor who became involved with the family after the birth did not have prior knowledge about the various indicators of potential vulnerability. This has implications for busy practitioners such as health visitors who often have caseloads of 350-400 families86.   315. The absence of prior information meant that the health visitor had to begin her assessment from the start of her involvement with the family. The health visitor was not told about the contact with the walk in treatment centre until she was informed by the mother and did not include information about how disabled the arm had been or about the bruising87.   316. When the health visitor was told of Baby H’s presentation at the minor injury clinic with a shoulder injury she was not told about the extent of the injury. She did not make any enquiries to clarify. When the parents were asked to describe it they did not convey the extent of the injury.                                            86 The coalition government have announced an increase in the number of health visitors.  87 There are all sorts of reasons for why the family did not tell the health visitor about the full extent of the injury from the pushchair; this can range from just forgetting how painful the injury had been through to feeling guilty or it could have been just wanting to keep information away from a health professional in regular contact with the family who has good knowledge about child development and welfare. Serious case reviews regularly identify families who are unwilling to work with professionals and try to undermine or control information to prevent the detection of harm to children. This does not suggest this family were trying to control information or were abusing their son, but is included to illustrate the importance of professionals ensuring information is shared effectively with each other and especially with professionals who are in regular and close contact with very young children in their home and elsewhere.      Overview Report Baby H redacted published version Page 63 of 106 317. Information was shared appropriately and was documented between the emergency department and orthopaedic staff at the Cumbria Hospital.  Outside agencies were not involved during any of these emergency medical contacts with the family.  The GP was informed electronically on discharge but there was no system in place to inform the health visitor. The IMR author does not clarify whether this reflects shortcomings in the policies and standards of the Trust or not88.  318. The Lancashire PCT IMR identifies some issues regarding information sharing between Cumbria and Lancashire. The family's previous health visitor in Cumbria had contacted the Lancashire health visitor to inform her that the family had moved into Lancashire.  The Lancashire health visitor recalled that the previous health visitor had not reported any concerns about the family and was only informing the Lancashire service because of the young parents, who were late in having their first routine vaccinations and eight week medical assessment.   319. This information was not included in the records, neither was the name of the Cumbria health visitor. The health visitor was not informed that the partner was not the biological father of the children. She was also not aware of the injury to Baby H’s shoulder; she became aware when reading the records that were transferred from Cumbria. She did not follow this up in spite of some difficulty in deciphering some aspects of the recording89.   320. The author of the IMR on behalf of the Children’s Centres’ highlights several learning points. The second Children’s Centre did not identify a duplicate registration on the system when mother began to use a Children’s Centre closer to her home; the IMR author has identified the need for clearer advice to be given to Children’s Centres to identify and deal with duplicate records in the future.   321. This review and the evidence from national evaluations of serious case reviews demonstrate the importance of recording and tracking information effectively. The IMR is unable to identify why the system could not identify something as elementary as a duplicate record90 and whether this was the result of an error of inputting or was a technical problem.   322. Mother first contacted the Children’s Centre before she had registered with a GP and therefore there was no formal communication between Children’s Centre staff and the family health visitor; the centre did not have details of                                          88 This contrasts with the recording systems in Lancashire where for example PCT recording can be accessed by the health visiting and school nursing service.  89 When professionals feel under pressure this type of routine contact can become down graded and not followed up.  90 This reinforces the importance of front line staff being supported with adequate systems that include electronic recording systems.      Overview Report Baby H redacted published version Page 64 of 106 who the children’s health visitor was. The author explains that this is usual practice where families are accessing only universal services and where additional needs have not been highlighted or referrals received for additional support.   323. However this case illustrates how the Children’s Centre staff will on occasions be the people identifying potential areas of concern or indicators of need; having information about key people such as health visitors should be an essential part of being able to access and consult other people to check information91. Children can become unwell or have specific conditions that a consultation with a health is helpful. For families where there is a concern, who leave the area, information ‘is passed on as appropriate’. There are no protocols in place for families that move into the area. This appears to be a potential area of vulnerability that is addressed by the IMR.   324. The inability of the new member of staff to understand the significance of information about the head injury, the absence of systems to record such information to alert a manager who could have acted, and the incomplete set of information about the extent of the family’s vulnerability all contributed to information not being shared sufficiently well or the appropriate referrals being made. The injury observed in the Children’s Centre was the second occasion when a referral opportunity was not recognised92. These points of learning are addressed in recommendations.  325. After Baby H was admitted to hospital in November 2010, there was a delay in the invoking of the safeguarding procedures, and these were initiated by AHCFT where Baby H had been transferred in the early hours of the day following his initial presentation at the hospital in Lancashire.   326. The Lancashire Hospital state that the possibility of a ‘non accidental injury’ was highlighted as a possibility; however this had neither resulted in any sharing of further information and was not the understanding given to AHCFT upon admission of Baby H. On that basis the information was not effectively communicated.   327. A non accidental cause for the injury was being discussed as part of a differential diagnosis but it was only after transfer to AHCFT that the SUDI                                          91 There is national and local guidance about how professionals can and should share information. This is summarised in Information Sharing: Guidance for practitioners and managers. It describes seven ‘golden rules’ for information sharing. Fundamental to effective information sharing is knowing who the relevant people are who have contact and knowledge with a family; the people who between them have small items of information that are the pieces of a jigsaw that can build a different picture when seen as a whole.  92 Making  a referral to children’s services provides the opportunity for a qualified and appropriately experienced social worker to make enquiries into a child’s circumstances; information about an injury will require examination but it is equally an opportunity to assess whether the parent or their child need further advice or help.      Overview Report Baby H redacted published version Page 65 of 106 (ALTE) protocol was formally invoked the following day at 10.00 it was not until 13.30 that contact was made with children’s social care services and the police. The police were notified over three hours after a formal investigation had started.   328. Although a strategy meeting was arranged promptly there were further complications. AHCFT had made the referral but was not invited to the strategy meeting that took place in Lancashire. For a period of about five hours there were separate processes at work in AHCFT and in Lancashire.   329. It is not entirely clear why the inclusion of AHCFT had not been seen at the time as a key component for an effective strategy meeting to take place; they had identified that abuse had to be a possibility and also continued to have care of Baby H and were managing contact with LJ and DS. There was a discussion between the consultant paediatrician at AHCFT and the social worker about two hours before the first strategy meeting and there was a further telephone discussion after the meeting.   330. The difficulties of coordinating attendance at crucial meetings especially at short notice when the participants are dispersed over a relatively large area does represent a logistical challenge. Further reflection and analysis is provided in the final chapter.   331. It became apparent to the police when they formally interviewed mother and her partner that they had already been made aware of the concerns that Baby H had been shaken and that this had led to his injuries. This had significant implications for the police in managing their enquiries.  The circumstances for this are explored in the AHCFT review and further work on clarifying guidance for all professionals speaking with families will be developed.   332. There was a delay in making the referral to CSC who in turn made contact with the police. The delay in making the formal referral compounded the difficulties in planning and undertaking enquiries between the two services.   333. The CSC author highlights that although there is good evidence of appropriate enquires and action being taken, the recording of important discussions such as the strategy meeting decisions were insufficiently detailed and were not circulated quickly enough to the various professionals. However the same author is satisfied that there was clarity regarding the arrangements. Events were moving quickly in November 2010 and people had to respond to emerging information. It reinforces the importance of starting the process as early as possible in order to help alleviate the inevitable pressures that will be operating on the various professionals involved in coordinating information and action.       Overview Report Baby H redacted published version Page 66 of 106 4.7 Was historical information given appropriate emphasis within assessments and interventions?   334. The extent to which many of the people who came into contact with the family had very little historical information is remarked upon by several of the IMR authors. If more had been known about risk factors within the family when Baby H was presented particularly after the shoulder injury and again after the brain injury it should have been a stronger prompt to medical staff to have considered abuse as a factor; it is because nobody regarded Baby H as being at risk until the diagnosis of brain injury was made at AHCFT that neither sibling was ever the subject of formal information sharing arrangements that could have looked at the significance of historical information.   335. The CSC IMR author summarises the evidence from research and serious case review evaluations that show how several aspects of this family’s circumstances are shared by families who injure or kill their children. This in no way suggests that a family with those features will injure their child; it is not a predictor of abuse but it should act as an early warning if and when the child is presented in unusual circumstances.   336. The injuries required a referral under the LSCB procedures but there were other occasions when a CAF would have given better opportunity to see the family in the round and co-ordinate support more effectively.   337. The GP in Cumbria had little historical information about the family and it was not sought. There was a high reliance on the midwifery service taking a full history. However, the lack of information within the GP practice meant that other clinic staff were not sufficiently aware of the family’s circumstances. It is not clear that a full assessment was completed by the midwife or any other health professional.   338. The implications and consequences were that when the partner presented with symptoms of stress, the GP and other clinicians were insufficiently aware of the full circumstances of the family or about the capacity of this teenager to take on responsibility for children that he had not fathered.  339. The health visiting service in Lancashire had virtually no historical information apart from what was provided by Cumbria on the transferred records. There is no information about the birth father. The health visitor acknowledged that she did not take opportunities to pursue further information about the family.   340. The GP practice in Lancashire did not have information about the injury to Baby H’s shoulder in their electronic practice records. The IMR author does not believe, even with the benefit of hindsight, that this made any difference to the management of Baby H and his sibling.      Overview Report Baby H redacted published version Page 67 of 106  341. Neither of the Children’s Centres had any historical information about the family. It is quite possible that if for example there had been knowledge about a previous pushchair related injury, there may have been less credulity about the second incident. The health service IMRs do not refer to the head injury and therefore it seems that mother did not seek medical advice and treatment for her son; this also meant that nobody had full information about the injuries.   342. The Lancashire Hospital acknowledge that they had no historical information given they were responding during out of hours. If they had that information the IMR author concludes that a diagnosis of a shaking injury may have been considered more strongly and urgently.   343. Although there is an acknowledgement that if it had been during core office hours there may have been contact with the GP or health visitor it is apparent that this was not followed up after Baby H had been transferred to AHCFT. It remains a mute point in this case given the apparent problems in the GP practice regarding the patient records.  344. The joint enquiries between CSC and the police included seeking a social history which included information from the consultant paediatrician. The CSC author refers to the evidence from research and national evaluations that babies who become injured as a result of shaking injuries are more likely to come from families that are experiencing ‘volatility’ and where there is little contact with services such as CSC. The family had not been subject of referrals and indeed had been generally viewed as a family that was managing with the support from services such as the Children’s Centre.   345. Evidence is provided through this review that more attention and recognition of the family’s vulnerability could have been given from the birth of the children. Information collated by CSC during the core assessment that has been completed after the timescale covered by the review that there was a degree of domestic difficulty and abuse that had not been visible to services.   346. The same author is also aware that for many babies with a shaking injury there is also a prior history of accidents and attendances at A&E or surgeries as well as illness. These were features in this case.   347. It is apparent that this contextual knowledge was not known to many of the people who came into contact with the family. This is not to suggest the shaking injury could have been predicted but it could have made people more alert and enquiring about this family. This could for example have included using the common assessment framework to coordinate information and support.       Overview Report Baby H redacted published version Page 68 of 106 4.8 Was the parents/carer's young age appropriately considered and did it have any impact on services delivered or needed?   348. Midwifery staff had been aware of historical information relating to this young couple.  An attempt was made to address this by referral to the TPG but because it was assumed that they were attending this group, the IMR author for the Cumbria Hospital comments that an opportunity may have been missed to offer more support.  349. The author of the Cumbria PCT describes the extent to which the rule of optimism93 prevented some key professionals giving clearer consideration to factors such as the parents’ young age. This included the GP consultations with DS.   350. Although the health visitor in Cumbria displayed a clear awareness of the mother’s age and of her partner through the various arrangements that she made, it is not apparent that other health professionals had the same level of awareness.   351. Although the signs of faltering growth were picked up quickly and action taken this was not apparently seen as a potential indicator of young parents struggling to meet the needs of their young children.  352. The Lancashire health visitor undertook enhanced levels of visits and contact with the family. This was an acknowledgement of the mother’s young age. She was also aware of the contact with Children’s Centres. Twelve of the fourteen contacts were at a clinic and two at home; this was seen as evidence that mother was open to having contact and support from her health visitor and was making good use of other local services.                                            93 In 1983, Dingwall, Eekelaar Dingwall and Murray, (The Protection of Children: State Intervention and Family Life, Blackwell, Oxford) investigated professional decision making in an English child protection system. They developed the 'rule of optimism' to explain how health and social workers were screening or filtering out many of the cases with which they were involved. These researchers asserted that under the 'rule of optimism' workers applied a heuristic or routine method of practice which was used to reduce, minimise, or remove the concerns for the child's welfare or safety. This was done via the workers applying overly positive interpretations to the cases that they were assessing. The same research suggested that the 'rule of optimism' was only discounted when parents refused to cooperate with workers and rejected help (a 'failure to cooperate'), or when there was a 'failure of containment' where a number of workers became involved with the case and the pressure for protective action became too great. Child death inquiries and serious case reviews have continued to comment on the phenomenon and Lord Laming has also referred to the same rule of optimism.       Overview Report Baby H redacted published version Page 69 of 106 353. The GP commented to the health visitor that mother was coping well with the demands of the children. There was nothing observed or recorded that indicated concern about how mother cared for her sons.   354. The Children’s Centre 1 was not aware of mother’s age until she completed the registration form. Interestingly, mother asked about the availability of a young parents group (she had attended the TPG in Cumbria).  Neither of the centres operates such a group. Although there is little recorded and documentary evidence about either centre knowing about and acknowledging all the potential vulnerability of the family, it is apparent that the worker at Children’s Centre 2 made a particular point of keeping regular contact with mother by mobile phone.   355. The AHCFT IMR presents important information about how a commitment to communicating effectively with parents will present complex dilemmas. The medical team kept LJ and DS very well informed about the seriousness of Baby H’s condition and were both clear and sensitive when it was becoming apparent that Baby H would not recover and helped in the emotional and practical preparation for Baby H’s death.   356. However, the absence of involvement in the strategy meeting and a desire to understand what had happened to Baby H to explain his medical condition (that soon became apparent was a brain injury after the scans and other tests) resulted in discussions that revealed to LJ and DS some of the key hypothesis especially in relation to shaken baby injuries.   357. By the time the police undertook their postponed interviews it became apparent to the officers that the parents had already been researching the subject before they were questioned. The AHCFT author acknowledges the learning that has emerged from the review. The same IMR also anticipates there may be further work in relation to the ALTE SUDI protocol in Merseyside to clarify how information is managed and the underlying principles in regard to keeping parents and children informed.   358. The police gave formal consideration to the age of mother and her partner when interviewing them following the death of Baby H; the IMR author describes the protocols for assessing and deciding whether either was vulnerable within the meaning of legislation or required an appropriate adult. This involved examination and assessment by an appropriate forensic medical examiner.   359. The CSC author describes attention being paid by the social worker to explaining the local authority’s plans with mother and the extent to which this took account of literacy skills.       Overview Report Baby H redacted published version Page 70 of 106 4.9 Did agencies understand the role of the child's father and the extended family, including the role of mother's partner?   360. There is considerable research based evidence that is supported by evidence from serious case reviews at a local and national level that identify the significance of men who are not birth fathers moving into households with very young children. This is not to predict that all men who are not the birth father of a child will abuse the children but it is information that a research aware practitioner will use to frame his or her enquiries with a family.   361. For medical practitioners treating children who have been injured it has additional significance in regard to who has parental and legal authority to give consent for treatment.   362. It does highlight the importance of having clarity about the status and relationship of all adults in relation to children. Other considerations include understanding who actually has parental responsibility as well as the potential significance of adults social and medical histories for children’s health94.  363. At least one of the IMR authors remarks upon how little information and knowledge was known about DS or his extended family. The children’s father is virtually invisible from any record95. In general there was an acceptance that DS was the birth father.   364. Some of the other professionals assumed the partner was the biological father and addressed him as dad. In the absence of any challenge they persisted in their belief that they were dealing with both parents of very young children. The health visitor, AHCFT and the police clearly understood the status of DS very early on in their involvement.  365. The IMR on behalf of the UHT highlights an assumption that maternal grandmother was involved in the support but this was limited because she herself worked.                                           94 Parental Responsibility is defined by the Children Act 1989; it is important for identifying who has legal powers in relation tot a child and can include procedures such as consent for medical treatment or agreeing to services being provided.  95 The invisibility of males in the lives of children who become injured is a recurrent theme in general research and serious case reviews although in this case it appears that the partner was involved in looking after both children but did not attend group activities which apparently took place while he was at work.     Overview Report Baby H redacted published version Page 71 of 106 366. The Lancashire health visitor and GP had no information about father96. The author of GP IMR does not believe this had an adverse effect on the way in which the patients were managed but acknowledge that the family structure that included a non biological father represented an atypical family where there could be increased risk of neglect or abuse.    367. There are several references to the family being well supported. The IMR reminds the review about the national evidence in relation to information about significant men often being missed. The identity of the father was important for professionals to be aware of and also has significance for the children as they get older.   368. The staff at the Children’s Centre did not appreciate that mother’s partner was not the father of Baby H and his sibling. Although mother provided the information in the registration, this information is not made available to the individual workers co-ordinating individual activities. This is a weakness in the system and provides an important point of learning for all early years settings. This is addressed in the IMR’s recommendations.  369. The Lancashire Hospital did not appreciate that DS was not Baby H’s father although this was apparently established at relatively early stage at AHCFT. The IMR author for the Lancashire Hospital describes how training on safeguarding sessions included discussion about the research evidence of non-biological fathers living in households with very young children. The author does not comment on whether any of the people who dealt with Baby H in November had participated in those training sessions. If the staff had been aware of the information it might have caused further reflection in a research aware practitioner.  370. CSC did not establish that DS was not the children’s father at the point at which the referral was taken. This information was revealed through the information supplied by the consultant paediatrician at AHCFT later the same day. Once the strategy meetings had shared initial information, there was attention paid to securing information about the family.    371. The GP made sure that sufficient time was given to examining the brothers although no inquiry was made about their social and family circumstances.                                            96 The IMR author explains that initial contact with families within the PCT an aid memoire is generated with demographic details those details are then transferred onto the computer system and stored in the child’s paper records. This form does not ask for the fathers details, only details of adult member/s of the household and their relationship to the child, consequently a father who did not live within the household would not necessarily be included on this form       Overview Report Baby H redacted published version Page 72 of 106 372. When Baby H attended the small injury unit no information was sought about the family circumstances.   373. AHCFT ensured that information about Baby H’s sibling was known to services in Lancashire and continued to share information with the medical team in Lancashire who were caring for the sibling.  374. CSC and the police checked on the whereabouts of Baby H’s sibling. Arrangements for no family member to have contact were agreed with the hospital due to the hospital not being prepared to supervise contact between any family member and the sibling. The local authority had no legal powers to prevent that contact in the absence of any court order.   375. The IMR author acknowledges this and concurs with the judgment made at the time that seeking an EPO was not necessary or justifiable. Although events showed that the EPO was not necessary, it is a mute point as to whether the action was justifiable. It is apparent that everybody was working in the interests of both children and were managing a quickly unfolding process of information and recognising that Baby H was very seriously ill and likely to die. Having made the decision to use voluntary agreements there was a delay in those arrangements being discussed and communicated with mother in November 2010. This had no impact on the practical arrangements agreed between the various services.   376. The IMR author acknowledges that the arrangements should have been more clearly considered and recorded within the strategy meetings. The point is made elsewhere that procedures are there to guide information sharing and form a framework for informed judgments and clear decision making in what are often confusing or contradictory circumstances. The IMR author is correct to criticise the shortcomings in regard to aspects of the strategy meeting although it is apparent that information was being shared and appropriate decisions were also being made.  The CSC author identifies several points of learning for further action including training for staff who chair such meetings.  4.10 Were any safeguarding and child protection issues identified and dealt with appropriately by agencies? Were agency responses correct and timely?   377. It is important to distinguish between regarding children as vulnerable in contrast to recognising when children are at risk of harm or abuse. The recognition of children’s vulnerability is an important part of good safeguarding practice and arrangements.   378. In this case there was inconsistent knowledge about the extent of vulnerability and there was evidence of injury missed on two occasions.       Overview Report Baby H redacted published version Page 73 of 106 379. A significant area of learning from this serious case review is the poor recognition of safeguarding and protection issues until after the brain injury to Baby H. This began prior to the birth when mother was not in a permanent home, had separated from the father and was not living close to friends or family; additionally she was a teenage mother. When there were clear indicators for increased concern, these were missed or minimised. The most significant was the injury to Baby H in his pushchair and the observed injury to his head at the Children’s Centre.  380. There was little apparent recognition of vulnerability when mother’s pregnancy was confirmed in the midlands. There was no discussion in the Cumbria GP practice when mother registered as a pregnant teenager about her vulnerability or of her yet to be born.   381. When Baby H was injured in his pushchair, this was not seen as a potential safeguarding issue; no referral was made under the LSCB procedures.  The IMR on behalf of the Cumbria Hospital states that staff considered the possibility but had no concerns regarding the mechanics of the injury fitting the history and interaction between mother and baby.  All staff felt mother was appropriately concerned for the welfare of her baby.   382. It is unclear the extent that Cumbria Hospital staff appreciated how unusual the injury was in such a young child and therefore did not seek specialist advice or consultation with a lead safeguarding professional. It is implied that a significant factor was how mother presented as being concerned and caring towards her son97.   383. No safeguarding concerns were identified by health staff prior to the death of Baby H in Lancashire. The PCT IMR explicitly states that although there were factors such as the couple’s age that were indicators of vulnerability, the family did not meet the threshold for initiating an assessment under the common assessment framework (CAF)98. This is explored in further detail in the later analysis of this report.                                          97 Including this commentary is not intended to provide proof or otherwise of abuse or rough handling of Baby H; however there is considerable evidence from serious case reviews and from academic research about the danger of focussing on how parents present and behave rather than maintaining a focus on the child and what has happened to them; it remains highly unlikely that a four week baby would grasp and hold a strap. Babies are highly vulnerable to physical injury that can arise from careless or stressed behaviour. A clearer appreciation of the research evidence may have prompted a more focussed and sceptically informed discussion; this should have included checking on the quality of support and the physical and emotional health of mother and partner. There is a danger in relying on processes such as the Edinburgh Post Natal Questionnaire will identify clinical symptoms of depression at the expense of using other information and tools to check on the degree of stress affecting new parents in particular.  98 The introduction of CAF was designed to improve the opportunity for co-ordinating information and support with families who presented with additional needs that did not constitute sufficient concerns to indicate either significant harm or impaired development and well being. The CAF relies on     Overview Report Baby H redacted published version Page 74 of 106  384. The Children’s Centre had observed an injury to Baby H’s head in September 2010. This information was not discussed with a manager or other senior colleague in the centre and was therefore not referred on under the LSCB procedures. The information only came to light after the death of Baby H and the serious case review was commissioned99.   385. The Children’s Centre staff also became aware that Baby H and his brother shared a cot. This information was not discussed with the health visitor. It is unclear if the health visitor was aware of the sleeping arrangement100.   386. The AHCFT IMR provides a detailed account of the procedures that were followed from the point Baby H was admitted to the hospital. It is apparent that Baby H’s critical condition presented the medical team with a challenging range of tasks to stabilise his condition. It was some three hours after his admission to the hospital that the doctor was ruling out sepsis as a possible diagnosis and was paying close attention to other causes. Initial retinal examination was inconclusive and the consultant paediatric radiologist was asked to look at the CT scan from Lancashire; this was also not showing definitive evidence of bleeding.   387. Although the doctors were continuing to look for more definite symptoms, by 10.00 they knew they were dealing with unexplained symptoms that were indicative of a shaking injury. It is arguable that this should have been a stronger possible diagnosis in Lancashire; the fact that one sibling was apparently fit and well compared to baby H was apparently not seen as unduly significant.  At the point of admission AHCFT had been advised there were no safeguarding concerns according to the transfer service who had transported Baby H.                                                                                                                    professionals other than children’s social care services being willing to take on the role of lead professional. There is further analysis in later chapters. 99 It should not be assumed that if a referral had been made that Baby H’s injury and tragic death would have been prevented; on the basis of what is known about the family it would be highly unlikely that action would have been taken to remove either child from their mother’s care unless further information had come to light. The referral would have been an opportunity to have undertaken an initial assessment and to make enquiries; these should then have brought together the disparate pieces of information upon which to then make further judgments and decisions.  100 Cot death is also known as SIDS, which stands for sudden infant death syndrome. Cot death isn't a single illness or disease. Rather, it's a diagnosis, given when an apparently healthy baby dies without warning. When doctors and investigators can't pinpoint a reason for the death after performing a full investigation including a post mortem examination, a search of the place where the baby died and a review of the baby's medical notes, cot death is given as the cause. Around 340 babies death are recorded as SIDS each year. Cot death is uncommon in babies less than a month old. It is most common during the second month and nearly 90 per cent of cot deaths occur in babies under six months old. The risk reduces as the baby grows older; very few cot deaths occur after a year. Being a boy born slightly prematurely and with a low birth weight (less then 2.5 kgs) are factors associated with a higher risk factor. For this reason any information relating to the baby’s sleeping arrangements is important to note and discuss with the health visitor. .      Overview Report Baby H redacted published version Page 75 of 106  388. The invocation of the safeguarding procedures at AHCFT was linked to the ALTE/SUDI protocol and is a procedure that covers all unexplained life threatening events irrespective as to whether it is the result of abuse or loss of control by a carer; the linking of SUDI effectively raises the threshold for invoking safeguarding processes. In this case the protocol was begun when doctors were clearly becoming more convinced that Baby H had been shaken or had suffered a trauma to his head.   389. Baby H had been critically ill from the moment he was admitted to the hospital in Lancashire. He was stabilised and kept alive with intensive life support. Although arguably the delay had little implications for Baby H, it did mean that although his sibling was taken to hospital for tests and assessments these were principally in relation to a possible diagnosis of sepsis. It was not at that stage a protective action.  390. None of this commentary is intended to dismiss or minimise the high level of professional and personal care provided to Baby H by the medical teams. They were focussed on giving him good treatment and trying to understand what had happened. With hindsight, this good quality medical intervention could have been supported with the involvement of other services at an earlier stage.   391. The IMR from the Lancashire Hospital is unable to provide further analysis as to why the senior medical staff were apparently considering a shaking or other traumatic injury but did not seek to share that information or to make further enquiries with other services.   392. The initial delays had consequences for alerting other services to the possibility of a Baby H having been injured as a result of abuse most notably the police and children’s social care. The delay had repercussions for how quickly the police began their forensic and criminal investigation.   393. The late invocation of the safeguarding procedures and involving children’s social care services and the police had some impact on the clarity of accounts given especially by mother and her partner.   394. CSC received a medical report completed in November 2010 from the Lancashire Hospital that confirmed a non accidental injury was included within a differential diagnosis. The report was late being written, and arrived with CSC a week after Baby H had been admitted and transferred to AHCFT. The author of the CSC IMR is justifiably critical of that delay.   395. The CSC author confirms that appropriate procedures were complied with although notes that the ALTE procedures invoked at AHCFT was terminology not previously known in the customer service centre. However it is clear that from the outset there was an understanding about the information being     Overview Report Baby H redacted published version Page 76 of 106 referred. The author highlights that the internal policies had not been updated in respect of 24 decision making by CART although management briefing ensured that staff were aware of the procedures and complied with them; that is good evidence of managers communicating changes in arrangements and that it was complied with.  396. The reason for the strategy meeting being arranged at the Lancashire Hospital is considered by the CSC author who reports that the senior social worker was mindful of Baby H being so poorly to be unable to leave hospital and therefore focussing more urgently on the sibling. The author concludes that this should not have prevented giving clear consideration to involving AHCFT; it would not only have been good practice but would have also complied with LSCB requirements to have staff who have direct involvement in treating an injured child and diagnosing abuse involved in strategy discussions. The same author refers to the ‘guiding principles’ as to whether those have to be meetings or discussions. This is analysed further in the final chapter.  4.11 Did they follow safeguarding procedures when necessary?   397. Safeguarding procedures were not correctly applied when Baby H’s shoulder was injured or when an injury to his head was observed.    398. Safeguarding procedures were invoked in Lancashire following the referral from AHCFT. The earlier injury noticed by the Children’s Centre should have been recognised as a potential safeguarding issue but was not.   399. The procedures were invoked after Baby H had been transferred to AHCFT and was several hours after the initial admission and examination of Baby H.   400. The safeguarding/ALTE procedure was applied when doctors had become more convinced that his symptoms were evidence of an injury and not illness. The AHCFT IMR describes the significant amount of work involved within the hospital to co-ordinate appropriate action following the identification of possible abuse.   401. The sooner such procedures are initiated the greater capacity there is for planning with other services. The same IMR also describes how the hospital had made decisions to recruit an additional consultant to provide more consistent expert advice around the clock.   402. Although a strategy meeting was organised promptly once the police and children’s social care services had been told of Baby H’s admission it is apparent that some aspects of information sharing with mother and her partner went outside the usual arrangements. There were also difficulties regarding the recording of one significant discussion that had not involved the police.      Overview Report Baby H redacted published version Page 77 of 106  403. This indicates some lack of clarity about investigative protocols once the police are conducting a formal enquiry and creating additional difficulties for the officers undertaking the investigation.   404. The CSC author offers no explanation as to why CSC did not chair both strategy meetings; the second was chaired by a police officer. That contravenes a clear expectation that a manager in CSC chairs such a meeting. Although aspects of the strategy meetings are criticised in other sections there is no evidence that the police officer’s chairing had a detrimental impact.   405. The strategy meeting did not involve AHCFT who had initiated the referral. This is a requirement of national and local protocols and is an essential part of conducting an effective discussion at the outset. There was a telephone discussion before and after the meeting; this is not a substitute for participation in the discussion.   4.12 Did agencies have the necessary resources and capacity?   406. The IMRs do not identify any shortfall in resources. However the Lancashire PCT does included information about the health visitor regularly working in excess of her contracted hours; this was also the case for the previous health visitor. The health visiting team is fully staffed. No information is provided regarding case loads. Managers did respond to the issue of working excess hours by implementing a team caseload system that allocates the workload ‘equitably’101.   407. The health visitor had been appointed in August 2010 but did not have any child protection supervision until January 2011. The supervisor had not been ‘available’ for the planned session at the end of November 2010.   408. The Lancashire PCT IMR identifies several issues in relation to contemporaneous record keeping. A significant one relates to the timing of events; staff who enter information on paper records include the time of the event; when the information is loaded into an electronic system the computer generates the time of the record being made which can lead to serious inaccuracies unless a ‘freehand’ note is included in the text. Other issues have been referred to in the previous paragraphs including the recording of details about non-resident fathers.                                            101 No information is provided about the impact of these revised arrangements either for the staff working more controlled hours or for the families who have access to a health visiting service rather than an individual.      Overview Report Baby H redacted published version Page 78 of 106 409. The author of the IMR confirms that although significant issues are highlighted in relation to recording, this did not compromise the care provided to Baby H.  410. The history of a previous shoulder injury was not recorded in the records at the GP surgery. It appears that the records had not been summarised at the time of Baby H’s death ten weeks later.  Baby H had been registered in September 2010.  On average during September the practice registers approximately 1800 new patients.  This inevitably caused a back log of records to be summarised and uploaded that the IMR author described as a relative delay.  411. The Children’s Centre worker who noticed the head injury to Baby H had attended training in her previous job but this had not been updated to take account of the younger age group that she was working with in her new role. She should have been ‘de-briefed’ by the leader of the session.102 This did not happen. The reason is not made clear in the IMR.   412. The police IMR author identified that the use of dolls and film would be useful enhancements for future interviews; both were used in this case to good effect.  4.13 Were professionals working with the family suitably skilled and adequately supervised?  413. The author of the IMR on behalf of the Early Years Services in Lancashire provides important learning regarding how staff are trained and prepared for work. The worker who had observed the injury to Baby H’s head was new to her job. She had been trained as a teacher and had undertaken safeguarding training as part of that professional preparation.   414. An assumption was made that this would apply across different work settings. The IMR author provides good analysis based on her discussion with the staff involved in this case that such an assumption when it is now looked at in hindsight was mistaken. The age group of children, the work being undertaken and the circumstances of involvement with children and families requires staff to have more job specific training.   415. The same IMR also provides clear analysis about the importance of making sure new staff members in particular have clear guidance and debriefing. This has led to changes in the Children’s Centre already.                                           102 The fact that knowledge about the injury did not come to light until the serious case review emphasises the importance of effective induction and supervision arrangements for all organisations appropriate to their role and function.      Overview Report Baby H redacted published version Page 79 of 106 416. The report from the Cumbria Partnership Trust describes a good level of training and experience on the part of the staff in the health visiting or the CHOC service.  The Lancashire PCT also describes health visiting staff as being very experienced and that they had attended relevant training. There was a delay in the health visitor having her first professional supervision session (in January 2011) after coming into post in August 2010. 103  417. The IMR on behalf of the Cumbria Hospital states that the majority of staff have had safeguarding training. However there is no information about what level the training is. There is an acknowledgment that the training and experience of the orthopaedic doctors in particular who examined and treated Baby H for his injured shoulder was limited.    4.14 Is there evidence of management decision-making?  418. None of the IMRs describe arrangements for management oversight. All confirm that this case did not require referral to a manager for specific decision making until the safeguarding procedures were invoked. There is a description of supervision arrangements for health visitors and Children’s Centre staff.   419. After the case became subject of the safeguarding frameworks there was evidence of appropriate oversight and decision making. An example is the consultation with a senior CSC manager in regard to whether legal action should be sought to protect the sibling.                                            103 The IMR author describes the peer supervision system that operates in the PCT; she makes clear that this case would not have been discussed in any event in a supervision session because she had no concerns about the family. There had been a supervision session arranged in November 2010 but when the health visitor attended the supervisor was unavailable; the circumstances are not explained or whether this was an exceptional or regular occurrence in the Trust.      Overview Report Baby H redacted published version Page 80 of 106 5 Analysis of key themes for learning from the case and recommendations  420. There is a risk when undertaking a serious case review that has examined the involvement of several services and from more than one geographical area that it can result in a range of recommendations that overwhelm rather than promote the positive development of services and practice. The overview author also has to take account of the recommendations and action plans that are the outcomes of the IMRs and the health overview report.   421. At the outset of this review the panel were determined to be very challenging in order to bring out as much learning as possible. It is for this reason that a great deal of detail has been reflected upon within many of the individual agency reviews, the health overview report and within the content of the previous chapters to this overview report.   422. The review panel acknowledge the contribution made to the learning from this review by the many people who participated in interviews and discussions with the IMR authors. The Panel also acknowledge the considerable work undertaken by the authors of the agency IMRs and of the health overview report.  423. There is a temptation in thinking that reports such as this will resolve the areas for learning and development identified through the review. It is not the reports that achieve this but rather the dedicated and purposeful work of the managers and practitioners in the different services and of the two LSCBs who will oversee the learning from the review. It is their work with some of the most vulnerable children and young people that can make a difference in continuing to achieve better outcomes for children.   424. This report and all the others that are provided through a serious case review should acknowledge the complexity facing people working in these services. The benefit of the hindsight offered through a review should not over simplify or devalue the skills and knowledge that the combined workforce of education, health, police and social care professionals has developed.   425. In this final chapter of the report, the focus is on the key points of learning to come out of this particular review. The process of undertaking the review has already generated learning across several services and therefore it is of doubtful quality to take an unduly forensic approach of dealing with every detailed aspect; such an approach leads to over complicated and ultimately less effective action plans and strategies. The fact that this overview report is a public document also means that the full content is available for relevant training and development to promote continued learning.   426. A few well chosen recommendations are more likely to be effective than trying to address every micro detail, especially at a time when all     Overview Report Baby H redacted published version Page 81 of 106 organisations are also managing significant change in response to the national challenges. This final chapter’s purpose is to be proportionate in identifying those most important areas for learning that result from this particular serious case review.  427. There is nothing to prevent any organisations or individuals from identifying additional action as a result of their individual management review or the overarching themes highlighted by either the health overview report or in this overview report.  428. A central message from this review that is also reflected in national evaluations and inspections is how to get all of the various professionals who come into contact with vulnerable children to pay sufficient attention to the possibility that a child has or is possibly suffering abuse.   429. In identifying the themes for further action and development as a result of this review, thought is also given to building on rather than repeating any action from earlier serious case reviews. As far as possible, the focus is on how services collectively go forward from this review although there are inevitably some detailed points of action that have to be addressed to specific services.  430. This review provides important learning for local services in identifying and responding to children in need within both counties.  431. These include the use of CAF and early intervention to identify and provide help to vulnerable children; the role of primary health care providers such as GPs and health visitors in safeguarding children; training and access to safeguarding advice in smaller accident and minor injury or walk in centres; access to information out of hours; the value of using hypothesis and balanced judgment; organisational learning and memory to improve the critical evaluation and analysis of services and responding to the Munro Review; the importance of public health promotion around shaking injuries to very young children.  5.1 Learning from previous serious case reviews  432. There have been nine previous serious case reviews in Lancashire. Two of those cases identified themes relevant to this case. These include the use of CAF, recognising that young parents are a vulnerable group, and the importance of collecting and analyzing relevant historical information.   433. Cumbria has published two serious case reviews. Themes relevant to this review include multi-agency training on the use of CAF, the particular vulnerability of children moving between different authorities, management     Overview Report Baby H redacted published version Page 82 of 106 of information within and between different services, and care about relying on how parents present information and behaviour104. The serious case reviews in regard to Child C and E both highlighted the absence of CAF in both cases; one of the children also had a very young mother.   434. Chapter four has summarised the key themes and has provided the detailed analysis from each of the IMRs against the terms of reference and case specific lines of enquiry. The IMRs have included recommendations and action plans intended to address agency learning.  5.2 The use of CAF and coordinating early intervention and help for vulnerable children  435. Throughout this case there was a high reliance on mother in particular self reporting or self referring for advice and help. It was this factor that appeared to cause professionals to either down play evidence for example when injuries were presented or observed, and to minimise the significance in regard to the evidence of vulnerability in both Cumbria and in Lancashire. There was a general reliance on informal advice and arrangements.  436. This highlights the potential value of a CAF based plan that allows for the sharing of information. If that had happened in this case it is highly probable that it could have made much clearer the background information to the family. The use of CAF has been highlighted in previous serious case reviews.   437. The health overview author makes reference to three recent national reports that have all described the benefits of providing early help and intervention. It also forms a central policy recommendation of the Munro Review referred to previously in chapter one of this report.  438. The development of effective early intervention is more likely to occur when local areas have identified it as a strategic priority and have agreed policy commitments in terms of what help and support children and families can expect to have over and above core universal provision. It also requires consideration about how policy commitments are supported; this will become increasingly important if there are fewer nationally agreed priorities set out by central government and a greater reliance on local areas developing their own arrangements. These are proposed within the Munro Review.                                           104 A review that dealt with the injury of a child almost three years old by his parents who ‘were charming and convincing when being interviewed by professionals and had an excellent cover story..’ This reinforces the importance of being focused on evidence to explain what has happened to a child.      Overview Report Baby H redacted published version Page 83 of 106 439. Baby H and his sibling were never formally regarded as being especially vulnerable and were not seen to be at risk of abuse until the brain injury had occurred; even at that stage there was a delay of several hours before a paediatrician recognised the significance of Baby H’s symptoms and it subsequently became a matter for joint safeguarding work primarily in respect of Baby H’s sibling.  440. Some local areas in England have developed early intervention strategies that have included clarifying when for example a CAF should be used. This has the advantage of giving priority to children such as Baby H whose circumstances represent additional need. In some areas including neighbouring authorities to Lancashire there are policy commitments to organise a CAF to develop help for teenaged parents for example. It is important that such support is provided in a non stigmatising way that encourages family participation.   441. Places such as Children’s Centres are an example of such services. One of the IMRs refers to Child H and his sibling not meeting the threshold for the completion of a CAF; it is concerning if a framework such as CAF begins to rely on developing thresholds rather than having a focus on anticipating vulnerability or need. Setting high thresholds is often a response by organisations that feel overwhelmed. It undermines the potential of a CAF system and risks introducing complexity and rules based behaviour and thinking.   442. The absence of a clear reference to the use of CAF or any other early intervention model suggests that an explicit policy framework that articulates the circumstances under which a CAF will be considered would have considerable merit. In this case it would have supported better sharing of information and would have perhaps provided greater resolve in following up how for example support was being used.   443. Using the evidence from this case, a commitment to convene a CAF could be linked to the age of the parents, the likely presence of a learning difficulty for mother, a family that had moved several times, the presence of a non biological father in the household, the evidence of slower weight gain for one child.  Recommendation one  The Directors of Children’s Services in both counties should provide information to their Local Safeguarding Children Boards regarding the current policy frameworks for CAF and early intervention with vulnerable young children. In particular, information should describe what guidance or priority is given in regard to any indicators of additional vulnerability arising from factors such as the age and the circumstances of the children’s     Overview Report Baby H redacted published version Page 84 of 106 parents. This should be completed within three months of publication of the review.  5.3 The role of primary health care providers such as GPs and health visitors in safeguarding children  444. This review has primarily concerned the involvement of several health services with a very young child and his sibling105. The publication of national evaluations of serious case reviews, the requirements of national guidance set out in Working Together and the evidence from inspections of services all highlight the vital importance of primary health care services in particular having the capacity and the ability to identify vulnerable children and sharing significant information appropriately with other relevant services.   445. In this case insufficient inference was given to the indicators of vulnerability. Gaps in information hindered the quality and balance of judgments.  446. The information sharing between maternity and health visiting services in Cumbria have been addressed since the review was commissioned. The effectiveness of these arrangements will require evaluation. The action plans will be the subject of evaluation and monitoring by the LSCB and therefore no additional recommendation is made in this overview report.  447. It took seven weeks to transfer information between Cumbria and Lancashire; this is within national timescales. The challenges of developing national systems for managing patient records have been widely reported and are beyond the remit of local trusts and managers. There was information in those records that remained unknown to the GPs in Lancashire as a result of the delayed inputting of data into the electronic system. These problems do not appear to be wholly resolved.   448. The Quality and Outcomes Framework (QOF) is part of the General Medical Services (GMS) contract for general practices and was introduced on 1 April 2004.  The QOF rewards practices for the provision of 'quality care' and helps to fund further improvements in the delivery of clinical care.   449. Practice participation in QOF is voluntary but most practices on GMS contracts, as well as many on Personal Medical Services (PMS) contracts, take part in QOF.  The QOF has a range of national quality standards, based on the best available, research-based evidence covering four domains.  Each domain                                          105 The involvement of children’s social care only arose after Baby H was transferred to the regional specialist hospital. The review has identified that a referral to children’s social care should have been made on two previous occasions.     Overview Report Baby H redacted published version Page 85 of 106 has measures of achievement, known as indicators, against which practices score points according to their level of achievement.  450. The QOF has been updated to reflect new standards and developments. The fourth revision was issued in April 2011106.   451. The QOF includes quality standards in regard to the management of patient records.   Recommendation two  The Lancashire PCT should provide information to the LSCB on the extent to which GP practices within the county are participating in the Quality Outcome Framework (QOF) and in particular report upon the arrangements for uploading information about vulnerable children into electronic GP practice record systems. This should be provided within three months of publication of the overview report.   5.4 Training and access to safeguarding advice in open access services or smaller accident and minor injury or walk in centres  452. There were two occasions when injuries to Baby H were observed. The first occasion was at the walk in treatment centre when he was presented with the shoulder injury; the second was when an early year’s worker on her first day of working with a much younger group of children than in her previous job and had observed the healing scabs to Baby H’s head. Appendix 4 of this report includes information about why any type of mark or injury to a very young child’s head in particular deserves particular attention.  453.   On both of these occasions’ practitioners and clinicians were content to regard the injuries as accidental and not a cause for concern and therefore further enquiry and sharing of information. A recurring lesson in safeguarding work with children is to inculcate staff with a frame of mind that focuses on what has happened to a child rather than what the parent is trying to persuade the worker to think.   454. The lessons from serious case reviews frequently emphasise the importance for practitioners maintaining a respectful sceptism; in other words having the capacity to listen to accounts about what has happened to children but to treat all information as requiring validation and verification. It was the absence of evidence about sufficient rigour in this process of validation and verification that is highlighted by this review.                                            106 Quality and Outcomes Framework guidance for GMS contract 2011/12 Delivering investment in general practice BMA and NHS employers     Overview Report Baby H redacted published version Page 86 of 106 455. The lessons of serious case reviews often highlight the extent to which a parent or other adult has managed to influence the response to a child’s injury whether consciously and with explicit purpose or has simply engendered misplaced empathy. These behaviours can be reflected in dependency on particular professionals, attempts to secure closure of professional enquiry or involvement, flight from services or disguised compliance. This last behaviour has the consequence of persuading key people that the child is not at risk because the parent is open to the support and help being provided.   456. The point of including such evidence is to reinforce the complexity of judgments that professionals are required to make as part of their routine work. They have to avoid invading a family’s rights to privacy unless they have cause to be concerned for example about the well being or safety of a child.   457. It is an example of how inexperienced or insufficiently trained staff can miss important contextual information. None of this is intended to infer that every parent who presents with an injured child will be accused of abusing their child. It does require staff to retain that possibility in their mind and to therefore have the means to differentiate between what is likely to be abuse and what is more likely to be the consequence of an accident.   458. They would be in a better position to make such informed and balanced judgements if they have taken up training and development opportunities and have the self awareness of when they need to consult other colleagues who may have more experience or specialist knowledge.   459. For staff working in open access services it is particularly important to ensure that they have received basic awareness training as part of their routine induction and that they have opportunities for continuing t update and develop their knowledge and awareness. It is also important that units such a small injuries clinic has access to specialist advice and know when and how to make use of such expertise.   460. The shoulder injury was unusual. Even though this was apparently recognised it did not lead the doctors to seek more specialist advice; if they had a mental framework that had been more focussed on what had happened to the child rather than the mother’s account there would have been more likelihood of seeking further opinion.   461. The health trust and early year’s service have included recommendations to address the specific issues highlighted in their IMRs.   Recommendation three      Overview Report Baby H redacted published version Page 87 of 106 The LSCBs in both counties should ensure that arrangements currently in place are sufficiently comprehensive to apply to organisations providing open access services to children for ensuring that upon appointment of staff and or volunteers, their induction includes child protection awareness training appropriate to their professional roles. The inductions should ensure clear understanding about recording and reporting any injury or mark to a child and the arrangements for consulting specialist staff for advice.   5.5 Access to information out of hours and co-ordinating information 462. The IMR on behalf of the Lancashire Hospital describes how they had no additional information when Baby H was initially presented at their A&E service out of hours. They had no historical information to help inform the differential diagnosis regarding Baby H’s sudden collapse.  463. The IMR acknowledges that no contact was made with any other service whilst they had Baby H at their hospital and neither did they contact any other service after he had been transferred to AHCFT. They also made no referral to either their named doctor or their named nurse within the hospital107.  464. It is clear from the Lancashire hospital IMR that a differential diagnosis that included the possibility of a head trauma was being considered; this should have been sufficient to have prompted consultations within the hospital and with the local social care out of hour’s team.   465. Although the panel acknowledge that the primary focus of the medical team was upon stabilising Baby H who was very poorly, the failure to follow up additional lines of professional enquiry and interagency information resulted in a significant delay before either social care or the police were made aware of Baby H’s admission to hospital.   466. The significance of the delay was that his sibling was not subject of any agency enquiry or oversight and it caused delay to convening a strategy discussion and meeting to discuss the information and agree action between the different services. This delay coupled with the disclosure to the parents                                          107 National guidance in Working Together refers to designated and named professionals who have specific roles and responsibilities for safeguarding children. All Primary Care Trusts must have a designated doctor, and nurse, to take a professional and strategic lead on all aspects of the health service contribution to safeguarding children; these Trusts are due to be abolished under the coalition government’s proposals for reform to health and social care commissioning in England. All NHS Trusts must have a named doctor, and nurse, for safeguarding, who will provide advice and expertise for fellow professionals and promote good practice within their organisation.      Overview Report Baby H redacted published version Page 88 of 106 by medical staff at AHCFT resulted also in delays to securing forensic evidence and caused difficulties for the police interviews of mother and her partner. In view of some particular issues highlighted through the IMR and SCR process a specific recommendation is made for additional information to be made available to the LSCB.   467. The first referral to children’s social care and police was made by AHCFT. This was some ten hours after Baby H had been admitted. There was apparently some initial misunderstanding about what the ‘ALTE’ procedures referred to by AHCFT meant although this did not cause delay in the action taken by CSC or the police. A recommendation is made to encourage the adoption of consistent regional protocols.  468. The decision to convene a strategy meeting was appropriate and consistent with local and national standards and procedures. However the meeting was convened without the attendance of the consultant paediatrician who had diagnosed that Baby H had probably been injured as a result of shaking or other trauma.  469. The guidance set out in Working Together refers only to discussion. It makes clear that ‘the discussion may take place at a meeting or by other means (for example by telephone). In complex types of maltreatment a meeting is likely to be the most effective way of discussing the child’s welfare and planning future action’.  470. The logistics of coordinating at short notice the attendance of several senior professionals for a meeting especially when it involves a specialist facility out of area are considerable. It becomes even more problematic if the expectation is that professionals have to be physically in the same venue in order to have a discussion. The development of video and telephone conferencing facilities provides new opportunities for meetings and discussions to take place between several locations.  471. The nature of the work undertaken by AHCFT inevitably will mean that they are involved in the investigation and management of children injured as a result of abuse or neglectful care. Their contribution to critical discussions throughout an enquiry is vital to ensure that the multidisciplinary team are clear about facts and information and that there is clear agreement about how important matters such as communication with the family will be handled. It is important that there is clarity in regard to the specific tasks and responsibilities of the different services and professionals. It is this level of detail that an effective strategy meeting should help to clarify.  472. In this particular case the consultant paediatrician who made the referral to Lancashire was not informed of, or invited, to participate in the strategy meeting. This contravened national and local guidance and requirements that make clear that those professionals with the responsibility for organising     Overview Report Baby H redacted published version Page 89 of 106 strategy meeting must ensure there is appropriate representation from key agencies; the national guidance in Working Together paragraph 5.56 lays particular emphasis ‘in particular any referring agency’ being included. The CSC author has included a recommendation for ensuring best practice is applied in regard to future strategy meetings.   473. The AHCFT have included a recommendation to amend their internal protocols to ensure that direct communication is also established with the police when the hospital makes referral to children’s social care. This provides a ‘belt and braces’ approach to ensuring information is being shared and is additional to ensuring that future strategy meetings include the professionals making a referral.   474. The capacity of GPs and paediatricians to attend child protection case conferences is a longstanding and national difficulty and will be exacerbated when meetings have to be convened at short notice and may involve significant journeys. The development of facilities and protocols for the use of video and or telephone conferencing could offer better opportunity for these professionals to contribute to essential multiagency discussions. There are currently facilities for conference calls although their use is not apparently promoted in any procedures or protocols. A recommendation is therefore made to support this area of development.  475. Once it had become apparent that Baby H and his sibling would be the subject of formal safeguarding enquiries and action professionals quickly recognised the need to manage contact between Baby H’s sibling and the family. The request for ward staff to prevent any unsupervised contact between the sibling and family members elicited a response from the hospital that they would not supervise contact.   476. Whilst it is understandable that a hospital’s first priority is to provide medical and nursing care there will be circumstances when staff, either as a result of their own observations, or as a result of information from other services, will recognise the need for more careful observance of people visiting a ward. In this case, it seems there could have been more helpful distinction between inappropriately asking hospital staff to closely supervise contact in contrast to making them aware of not allowing children to be removed from the ward without consultation with CSC and the police.  477. The prohibition on contact given the absence of any court order relied on the mother specifically agreeing that no family member would have contact with her child. This permission was given. The reliance on a voluntary agreement has been analysed in a previous chapter; this is not a matter for further procedures.   Recommendation four       Overview Report Baby H redacted published version Page 90 of 106 In view of the difficulties associated with the SCR process and particular IMR the LSCB in Lancashire should receive a report from the chief executive of the Lancashire Hospital regarding the arrangements in place for ensuring that procedures, staff training and their deployment including the use of named safeguarding professionals are overseen by the senior management. This report should be provided within three months.  Recommendation five  The use of telephone and video conferencing facilities should be explored by the LSCBs and the senior management at the health trusts that have contributed to this serious case review to support the effective and efficient participation of key people in professional meetings that include strategy discussions and child protection conferences. This should be provided within three months of publishing this review.  Recommendation six  The chair of the LSCB in Lancashire should write to the regional Strategic Health Authority recommending the adoption of a common protocol across the region for responding to the sudden unexpected death of infants or children. The purpose would be to ensure that the ALTE or SUDI procedures are clearly aligned and communicated to LSCBs and relevant hospital trusts.  5.6 The value of using hypothesis and balanced judgment  478. The health overview author refers to the ‘management of uncertainty’ within a differential diagnosis. This was a feature in the management of the shoulder injury in Cumbria and was also a feature when Baby H was presented at the Lancashire Hospital. The management of uncertainty is crucial to whether people will use policies, procedure and frameworks appropriately and with intelligence. Uncertainty is very real phenomena in safeguarding work. The core purpose of safeguarding processes (as distinct to simply applying procedures) is helping people to think consistently about how they may reduce the extent of their personal uncertainty.   479. Effective safeguarding relies on individuals doing the small, mundane and basic things well and routinely; it is fundamentally about helping share and managing information often across virtual teams. It is not policies and procedures that will keep children safe but rather the better informed judgments, decisions and coordinated action that are more likely to occur.  480. The management of uncertainty reflects the reality described in the Munro Review but also in research and national evaluations of serious case reviews that risk and uncertainty is a reality that people, and especially those working in health settings, have to face on a daily basis. It is the reality that for many health professionals it will be highly probable during their routine work that     Overview Report Baby H redacted published version Page 91 of 106 they will come into contact with a child who has been abused; they have an essential role in often initiating the sharing information with other people and making referrals as appropriate.   481. One of the assumptions highlighted by evaluations of serious case reviews and described within the Munro Review is the false premise that uncertainty can be eradicated. There is a danger that by saying uncertainty and risk is a reality we must accept that professionals are powerless to act with confidence or clarity.  482. If risk and uncertainty is acknowledged to be a daily reality, the focus has to be on ensuring that risk is not weighted towards leaving children to face undue uncertainty and unpredictability. Just as a navigator setting out on an unknown journey has to plot the variables that are known or predictable and to factor them into reducing the extent of their uncertainty about an exact position and course to steer, so too professionals have to acknowledge the extent of their own uncertainty and consider how they can reduce it.   483. This is done through a variety of measures that include using professional knowledge and experience to make balanced judgements about the likelihood of different explanations as should have for example been applied in regard to the shoulder injury. It requires and acknowledgement about what information could help firm up alternative scenarios or hypothesis. It requires a consciousness about the limits of knowledge and expertise and the value of sharing information.   484. If the doctors at the Lancashire Hospital had known the full history of Baby H including the previous injury it is highly probable that they would have considered more seriously the possibility of a trauma or shaking injury to explain Baby H’s sudden collapse. Instead they were faced with a very ill child and an apparently very concerned mother and ‘father’.   485. None of this is intended to blame individual professionals; the review is about refection and development. In this case if professionals had started out with a clearer hypothesis that physical abuse was a possibility it would have been more likely that they would have sought further information to develop or discount that initial hypothesis.   486. The injury to Baby H’s shoulder, the discovery of healing scabs at the Children’s Centre, the story of falling from a pushchair, and the final presentation at A&E are examples of where a clearer hypothesis would have been helpful in managing uncertainty.  487. The use of hypothesis is also valuable in looking at vulnerability and possible neglect. This concept would have worked at the outset in the midlands when mother discovered she was pregnant. Her age and circumstances were highly indicative of a vulnerable girl who would face     Overview Report Baby H redacted published version Page 92 of 106 challenges. It would have worked when the midwifery services were involved and knew about more vulnerability arising from the house moves and presence of a non-biological father.   488. In support of the concept of hypothesis an appendix is included to this report describing the factors that support balanced judgments. This was developed by David Spicer who is referred to in chapter three. Although it reflects a legalistic framework it nonetheless offers a helpful aide memoire when considering how far a judgement can be said to reflect proper balance of various factors. It is not intended to be followed slavishly; it is offered as a framework for use in development and training with any professionals.   489. The LSCB in Lancashire already include the use of hypothesis in multi-agency training within the last twelve months. There is value in extending this to single agency training and applying for example in training for staff that provided specialist advice or are responsible for the supervision of practitioners working with children.  Recommendation seven  The LSCB in Lancashire should encourage relevant agencies to include in their agency training and development events the use of hypothesis and balanced judgments and for this to be incorporated in particular within training for practice supervisors. This should include using evidence and information from this and other SCRs to support that work.  5.7 Organisational learning and memory to improve the critical evaluation and analysis of services and responding to the Munro Review; 490. This serious case review coincided with the publication of the final report of the Munro Review. This makes recommendations for the future development of safeguarding services in England.   491. Although the coalition government has confirmed an intention to act in response to the recommendations there is much detail that has yet to be clarified and will have wide ranging implications for the work of LSCBs and their constituent services.  492. It is apparent that there will be important changes that will have an impact on the way for example that assessments are undertaken, the details of national guidance and requirements and the frameworks for developing policy and evaluating the quality of services. The conduct of future serious case reviews will also change with an emphasis on using systems learning and is likely to change the methodology for completing IMRs for example.  493. At the same time there are already changes taking place in regard to how important services such as health will be commissioned and organised. Again, there is much detail to emerge.     Overview Report Baby H redacted published version Page 93 of 106  494. It is therefore inevitable that there will be significant change confronting the people who manage and are accountable for services as much as for those people who are in daily contact with children and families in many different settings.  495. This review has presented a significant challenge for several of the services contributing to the serious case review. Some of this no doubt reflects the changes that have happened as a result of meeting new resource frameworks including reorganisations as much as responding to other daily service demands.   496. The quality of an IMR in terms of the information presented and the analysis and understanding that is drawn out is a tangible demonstration of an organisation’s capacity to respond to the complex and difficult work in regard to keeping children safe.   497. There has been considerable variation in both the quality and the timeliness of information provided to the review panel. Although future serious case reviews in England may not require the completion IMRs in the same format, there will remain a need for services to have the capacity to look critically and with informed reflection at their own services.   498. The skills of being able to collate relevant information, encouraging people to reflect on the complex work they do and having the capacity to analyse the interplay of different factors and influences and to then be able to use that information to help further improve services will be required in the revised frameworks for serious case reviews. They are also skills that organisations will increasingly need to meet the various challenges they face.   499. The likely publication of further national guidance in response to the Munro Review will no doubt have training and development implications for the LSCBs and for their constituent services. For this reason, no specific recommendations are made in this overview report in regard to the conduct of the serious case review. This will not prevent the LSCBs initiating work with specific services to improve their capacity to oversee and evaluate their arrangements for responding to serious case reviews and routine evaluation.   500. This review has found and reported on several examples of good practice and this is a reflection of the dedicated work carried out by many hundreds of people across the areas that have contributed to the review.   501. It has also found examples of important learning in respect of some individual practice and in terms of how aspects of information systems could work more effectively.      Overview Report Baby H redacted published version Page 94 of 106 502. Both LSCBs will have detailed recommendations or actions either to implement or to reflect upon. These are set out in individual management reviews as well as recommendations made in this overview report.  503. The central challenge provided by the Munro Review is how to ensure that vulnerable children receive help both earlier and more effectively. This case provides important and tangible examples of how with better clarity at the outset services could have more involved with Baby H. This would not have necessarily changed the tragic outcome for Baby H. It is notable that Baby H and his sibling had a mother who sought support from places such as the Children’s Centre. If she had not done this, Baby H and his sibling would have been far more invisible.   504. The Munro Review also encourages less procedure, less protocol and more freedom for practitioners in working with children such as Baby H. This review indicates some of the implications for training and development.   505. The central learning is creating organisational and working conditions where practitioners are more likely to take note of information, they are more likely to seek further information, are more likely to share information. We know this is more likely to occur in organisations that are relatively stable, are adequately resourced in terms of both people and systems, and can offer opportunity for professional learning and reflection.   506. This will be a challenge for several organisations over the forthcoming months. The review panel would have benefitted from having a clearer account of the organisational context within which some people worked; for example there is little detail regarding the overall workload of services and of the individuals whose professional practice has been examined in this review.    507. The role of the LSCBs in both counties will be crucial to overseeing arrangement. It will require strategies that promote new working arrangements that remain rooted within the learning and knowledge that has already been achieved in regard to safeguarding children.     Overview Report Baby H redacted published version Page 95 of 106 5.8 Issues for national policy  508. The delivery of services to children already relies on the work undertaken by many and varied providers are represented by statutory, independent and voluntary sector organisations. Coalition government policy anticipates that there will be increasing participation from organisations from outside the established arrangements.   509. This will include many small organisations providing very specific services. This review has shown the vulnerability that can arise if open access services are not supported with appropriate induction, training and oversight arrangements. This will have implications for how such services are commissioned and procured ad needs to encompass voluntary as well as professional or paid services.   510. The plans for the abolition of PCTs will remove an important element in local arrangements for the oversight and support of safeguarding arrangements across primary health services such as health visiting and GP services.   511. This case has highlighted that even when national timescales are met in regard for example to the transfer of patient records between GP practices this allows a gap of several weeks.   512. The use of modern communication methods such as telephone and video conferencing represent opportunities to involve professionals in important discussions about vulnerable children. National guidance is largely silent in this regard.  513. The health overview author has highlighted the potential value if young children who transfer in to GP practices are offered a consultation with GP as a matter of routine. In this case the GP would probably have seen a graze on Baby H’s face.   514. The management of care and support for very young mothers is a focus of several reports. This and other serous case reviews at a local and national level have emphasised the value of encouraging health trusts in particular to treat pregnant teenagers differently to other parents.    Peter Maddocks, CQSW, MA. Independent author 19th August 2011  CONFIDENTIAL    Overview Report Baby H redacted published version   Page 96 of 106 6 APPENDICES  6.1 Appendix 1 – the family’s genogram  (removed to preserve anonymity)  CONFIDENTIAL    Overview Report Baby H redacted published version   Page 97 of 106 Appendix 2 - Procedures and guidance relevant to this serious case review Legislation  The Children Act 1989  Section 11 of the Children Act 2004 places a duty on the key people and bodies described in the Act108 to make arrangements to ensure that their functions are discharged with regard to the need to safeguard and promote the welfare of children. The application of this duty varies according to the nature of each agency and its particular functions. The Section 11 duty means that these key people and bodies must make arrangements to ensure that their functions are discharged having regard to the need to safeguard and promote the welfare of children and this includes any services that they contract out to others.  Section 17 imposes a duty upon local authorities to safeguard and promote the welfare of children in need.  Section 47 requires a local authority to make enquiries they consider necessary to decide whether they need to take action to safeguard a child or promote their welfare when they have reasonable cause to suspect that a child is suffering, or is likely to suffer significant harm.  These enquiries should start within 48 hours. The local authority is required to consider whether legal action is required and this includes exercising any powers including those in section 11 of the Crime and Disorder Act 1998 (Child Safety Orders) or when a Baby Has contravened a ban imposed by a Curfew Notice within the meaning of chapter I of Part I of the Crime and Disorder Act 1998.  Section 46 provides the Police with Powers of Protection to take children into police protection where a constable has reasonable cause to believe that a child would otherwise be likely to suffer significant harm.                                           108 Local Authorities, including District Councils, the Police,  National Offender Management Service, NHS bodies, Youth Offending Teams, Governors/Directors of Prisons and Young Offenders Institution, Directors of Secure Training CONFIDENTIAL    Overview Report Baby H redacted published version   Page 98 of 106 The Children Act 2004  Section 10 requires each local authority to make arrangements to promote co-operation between it, each of its relevant partners and such other persons or bodies, working with children in the authority’s area, as the authority consider appropriate.  The arrangements are to be made with a view to improving the wellbeing of children in the authority’s area – which includes protection from harm or neglect alongside other outcomes.  This section is the legislative basis for children’s trusts arrangements.  Section 11 of the Children Act 2004 places a duty on the key people and bodies described in the Act109 to make arrangements to ensure that their functions are discharged with regard to the need to safeguard and promote the welfare of children. The application of this duty varies according to the nature of each agency and its particular functions. The Section 11 duty means that these key people and bodies must make arrangements to ensure that their functions are discharged having regard to the need to safeguard and promote the welfare of children and this includes any services that they contract out to others.  Safeguarding Procedures  The Lancashire Safeguarding Children Procedures  The procedures provide advice and guidance on the recognition and referral arrangements for children suffering abuse. This includes emotional abuse that involves causing children to feel frightened or in danger. The procedures also cover physical abuse of children. The procedures also describe abuse involving the neglect of children that includes failing to protect children from physical harm or danger or the failure to ensure access to appropriate medical care or treatment. This includes describing distinct action to be taken when professionals have concerns about a child, arrangements for making a referral, and the action to be taken. The procedures cover arrangements for the ACPC (now superseded by LSCB) to ensure there are effective arrangements that promote good interagency working and sharing of information and training. The procedures describe specific responsibilities for all agencies contributing to this serious case review.                                           109 Local Authorities, including District Councils, the Police, National Offender Management Service, NHS bodies, Youth Offending Teams, Governors/Directors of Prisons and Young Offenders Institution, Directors of Secure Training Centres. CONFIDENTIAL    Overview Report Baby H redacted published version   Page 99 of 106  National guidance110  Working Together to Safeguard Children (2010)  The national guidance to interagency working to protect children is set out in Working Together to Safeguard Children: A guide to inter-agency working to safeguard and promote the welfare of children. The guidance includes safeguarding and promoting the welfare of children who may be particularly vulnerable.   Framework for the Assessment of Children in Need and their Families 2001  The guidance in respect of the Framework for the Assessment of Children in Need and their Families is issued under section 7 of the Local Authority Social Services Act 1970 and is therefore mandatory.   The framework sets out the framework for ensuring a timely response and effective provision of services to children in need. It makes clear the importance of achieving improved outcomes for children through effective collaboration between practitioners and agencies. The framework sets out clear timescales for key activities. This includes making decisions on referrals within one working day, completing initial assessments within seven working days and core assessments within 35 working days. As part of an initial assessment children should be seen and spoken with to ensure their feelings and wishes contribute to understanding how they are affected. If concerns regarding significant harm are identified they must be subject of a strategy discussion to co-ordinate information and plan enquiries. Child protection procedures must be followed.  Assessments should be centred on the child, be rooted in child development that requires children being assessed within the context of their environment and surroundings. It should be a continuing process and not a single or administrative event or task. They should involve other relevant professionals. The outcome of the assessment should be a clear analysis of the needs of the child and their parents or carers capacity                                          110 The election of a coalition government in May 2010 may result in changes to guidance and policy developed by the previous government. CONFIDENTIAL    Overview Report Baby H redacted published version   Page 100 of 106 to meet their needs and keep them safe. The assessment should identify whether intervention is required to secure the well – being of the child. Such intervention should be described in clear plans that include the services being provided, the people responsible for specific action and describe a process for review.   Common Assessment Framework (CAF) The CAF is a key part of delivering direct services to children that are integrated and focused around the needs of children and young people. The CAF is a standardised approach to conducting assessments of children’s additional needs and deciding how these should be met. It can be used by practitioners across children's services in England. The CAF promotes more effective, earlier identification of additional needs, particularly in universal services. It aims to provide a simple process for a holistic assessment of children's needs and strengths; taking account of the roles of parents, carers and environmental factors on their development. Practitioners are then better placed to agree with children and families about appropriate modes of support. The CAF also aims to improve integrated working by promoting coordinated service provisions. All areas were expected to implement the CAF, along with the lead professional role and information sharing, between April 2006 and March 2008.   CONFIDENTIAL    Overview Report Baby H redacted published version   Page 101 of 106 Appendix 3 Balanced Judgements111 “Reaching sound professional judgements in clarifying just what the law does and does not demand of professionals, it is helpful to consider the means by which the soundness of judgements and conclusions are challenged and undermined in proceedings before the courts.  To be sound the approach must be demonstrably reasonable in the sense that it has been properly reasoned.  The following list sets out the issues commonly explored and against which the forming of judgements or making of diagnoses may be measured.  If integrated into practice these principles will raise the quality of judgements and leave them less exposed to successful challenge:   Demonstrate proper reasoning;  Take account of all relevant factors;  Give each factor appropriate weight;  Consider all the options or alternatives;  Keep an open mind until it is appropriate to close it;  Know and act in accordance with the law;  Know and apply procedures or know why deviated;  Consider human rights implications;  Consider any relevant guidance;  Consult appropriately;  Acknowledge lack of expertise and its impact;  Acknowledge lack of information and its impact;                                          111 David Spicer is a barrister and former Lancashire County Council Legal Officer. His guidance was used in a Wales Assembly Government circular. CONFIDENTIAL    Overview Report Baby H redacted published version   Page 102 of 106  If the position is provisional, identify what is required to make final;  Ensure full and accurate recording of these issues.”     CONFIDENTIAL    Overview Report Baby H redacted published version   Page 103 of 106    Appendix 4 – Shaken Baby Syndrome  The cause of Baby H’s death is yet to be determined by the coroner. It remains a line of enquiry that Baby H was harmed as a result of a shaking injury. It is for that reason that this appendix is included in the spirit of including it in the learning from this particular serious case review.  A baby's head is large and heavy. It constitutes about 25 per cent of the infant's total body weight. The baby’s neck muscles are too weak to support such a disproportionately large head. It is for this reason that babies are especially vulnerable to the sudden and unsupported movement of their head.   Shaken Baby Syndrome is a form of abusive head trauma that occurs when a frustrated caregiver violently shakes, slams, hits, or punches a child’s head, usually to stop them from crying or to get a young child to respond to the expectations of the caregiver.  There are often no outward signs of trauma, but there is injury to the brain and probably to the eyes112.                                             112 Inflicted head injury to the developing brain frequently results in serious disability. The pathogenesis of the neuraxial and ocular findings in infants believed to have suffered inflicted head injury remains the subject of considerable debate; this was the subject of a recent edition of the File on Four programme on BBC Radio 4 in February 2011. Recent neuropathology studies of fatal cases of inflicted head injury and of a foetal/perinatal non-traumatic model have led to a majority 'unified hypothesis' (Geddes et al including the reference below), the essential feature of which is hypoxic brain swelling secondary to cervicomedullary injury. It has been suggested by others that less than violent forces may be involved and even that some cases may not be due to trauma at all. There are some critical reviews (that reflect something of a minority view) of the data upon which these suppositions are based on a background of what is already known and that there are serious flaws in the methodology; the conclusions reached cannot logically be drawn from the data; and the 'unified hypothesis' is not supported by the evidence. On the basis of the data presented, it is also difficult to sustain the secondary hypothesis purporting to describe a minority cohort with 'infantile encephalopathy with subdural and retinal bleeding' of non-traumatic causation. This footnote is included to acknowledge the debate that is continuing and the complexity for enquiry and assessment by the relevant professionals.   CONFIDENTIAL    Overview Report Baby H redacted published version   Page 104 of 106 Shaken Baby Syndrome113 is a form of physical non-accidental injury to infants, characterised by acute encephalopathy114 with subdural and retinal haemorrhages, occurring in a context of inappropriate or inconsistent history and is commonly accompanied by other apparently inflicted injuries. Injuries to the neck and spinal cord  may also be present.   Controversy surrounds the precise causation of the brain injury, the retinal and subdural haemorrhages, as well as the degree of force required and whether impact in addition to whiplash forces is needed. Although most discussion has concerned fatal injuries of this nature, not all are lethal, but they can be associated with subsequent neurological disability of varying severity.  The application of rotational acceleration and deceleration forces to the infant's head causes the brain to rotate in the skull. Abrupt deceleration allows continuing brain rotation until bridging veins are stretched and ruptured, causing a thin layer of subdural haemorrhage on the surface of the brain.   The retinal haemorrhages, which are characteristically extensive, occupy much of the circumference of the globe and extend through all the layers of the retina and similarly result from rotational acceleration and deceleration forces.   Immediate effects include seizures, lethargy, vomiting, and irritability, or in extreme cases, coma or even death.   Infants can also sustain eye injuries, such as detached retinas or retinal bleeding, from the violent shaking. Long-term effects include learning disabilities, physical disabilities, seizures and, in extreme cases, death.   A UK study published in December 1998 found that 75 per cent of babies who suffer brain injuries from shaking will die or suffer permanent disability.                                           113 The evidence base for shaken baby syndrome J F Geddes and J Plunkett, BMJ  2004;328:719-720 (27 March), 114 This is a condition that occurs in the brain and that affects its development. In children, encephalopathy may result in developmental problems. CONFIDENTIAL    Overview Report Baby H redacted published version   Page 105 of 106 Because the anatomy of infants puts them at particular risk for injury from this kind of action, the vast majority of victims are infants younger than one year old. The average age of victims is between three and eight months, although the injuries are occasionally seen in children up to four years old  The perpetrators in these cases are most often parents or caregivers. Adults who were victims of abuse themselves and have low frustration levels may be more likely to shake a baby in an effort to hush or quieten its crying. Typical victims of this abuse are infants with colic115 who will not stop crying.   Common triggers are frustration or stress when the child is crying. Unfortunately, the shaking may have the desired effect: although at first the baby cries more, he or she may stop crying as the brain becomes damaged.  Approximately 60 per cent of identified victims of shaking injury are male. Children of families who live at or below the poverty level are at an increased risk for these injuries as well as any type of child abuse. It is estimated that the perpetrators in 65 per cent to 90 per cent of cases are males; usually either the baby's father or the mother's boyfriend, and is often someone in his early twenties. Some of these factors are present in this case although this does not imply either this child was definitely injured as a result of a shaking or that it is possible to predict an episode of shaking.  The prevention of such injury to very young children represents a significant public health issue. Injuries can become more likely when parents are unable to cope with the emotional and physical demands of responding to very young children. Babies are especially vulnerable to the loss of control by their care giver.                                            115 Colic is the inconsolable crying in a healthy newborn baby with bouts of fussiness and irritability. The condition has no known cause but is harmless, although it can be very distressing for parents or carers. It's very common, affecting up to two out of every 10 babies. Colic usually affects babies in the first few weeks of their lives but generally goes after about four months. Crying can be intense and furious and it may last for several hours a day over a few weeks. Although crying can occur at any time, it usually gets worse in the late afternoon and evening, and can affect the baby's sleep. Mothers who smoked during pregnancy will have a baby that is twice as likely to get colic. CONFIDENTIAL    Overview Report Baby H redacted published version   Page 106 of 106 Understanding the significance of identifying children who may be particularly vulnerable is both a matter for clear policy and strategy at local levels and ensuring that staff across services but especially in primary health and early year’s services is sufficiently trained. Further analysis is included in later chapters of this report.   