Injuries to a 4-week-old infant in 2016. Civil court found that the injuries were caused by Father and that Mother failed to protect Child N. A criminal investigation in respect of Mother, Father and Paternal Uncle concluded with no further action in 2020. Child N lived with their mother, father and older sibling, Sibling 2. Both siblings were subject of a Child in Need plan at the time of the injuries. Another older sibling, Sibling 1, died when aged 5-months-old. Mother was a teenage parent with a history of self-harm, mental health problems and personality disorder, and substance misuse. Father had experienced a difficult childhood and had anger control issues. Ethnicity or nationality not stated. Learning includes: when one parent has mental health issues affecting their ability to care for the children, the assessment and plan needs to consider the impact on the other parent/carer; supervision for professionals needs to ensure they are focused on the child and not on the parent's histories and situations; professionals should seek to understand the nature of parenting relationships from the point of view of both parents/adults and the child, and not focus only on the mother. Uses the Significant Incident Learning Process (SILP) methodology. Recommendations include: confirm if formal pre-birth assessments are being undertaken in cases where a new baby will be the subject of a child in need or child protection plan at birth; consider the benefits and practicalities of requesting that the information that a child is on a child in need plan is shared with all professionals working with the family.
      
    Serious Case Review No:  2020/C8475  Published by the NSPCC On behalf of an unnamed local safeguarding children board      This report was written by an independent author and is owned by the commissioning LSCB.  This report is published by the NSPCC with the agreement of the National Panel of Independent Experts.  Publication of this report by the NSPCC does not constitute endorsement of the contents. Copyright of this report remains with the commissioning LSCB.   1         Serious Case Review  Child N     September 2020      2  CONTENTS   1. Summary of the learning       Page 2 2. The case         Page 3 3. Process         Page 3 4. Background prior to the scoped period     Page 4 5. Key episodes         Page 6 6. Analysis by theme        Page 10 7. Conclusions         Page 23 8. Recommendations        Page 24  1 Summary of the learning from this review 1.1 This Serious Case Review (SCR) is in respect of a 4-week-old child with unexplained injuries.  The baby was known to a number of different agencies prior to the injuries being identified, and was on a child in need plan.    1.2 A number of learning points have been identified for the agencies involved and for the Safeguarding Children Board. Some of the learning requires improvement action and a number of recommendations have been made in section 11 of this report.  Learning was found in the following areas, the detail of which is included in the analysis section of this report: • The impact on the child/ren, parent, other parent/carer and the professionals involved when a parent has a mental health issue.  • The need for information sharing, assessment and services where there are parental anger control issues.  • The importance of considering history when assessing presenting problems.  • Maintaining a focus on the child/ren and their lived experience, including unborn-children.  • The importance of re-assessing parenting capacity and evaluating risk when a new baby is due.  • Identification of superficial or avoidant parental cooperation with agencies.  • The need to assess and provide services regardless of the gender of the parent/carer. • Greater consideration of non-accidental injury as a differential diagnosis when children present at hospital with certain health issues.   2.1 The LSCB agreed that this Serious Case Review (SCR) would be undertaken using the SILP methodology1, which engages frontline staff and their managers in reviewing cases and focuses on why those involved acted as they did at the time2.    1 The Chair of the LSCB agreed the SCR, the lead reviewer was appointed, the terms of reference were agreed, agency reports and a chronology were requested, and two events were held to engage with staff in July and September 2018.  The lead reviewer is Nicki Pettitt, an independent social work manager and safeguarding consultant. She is an experienced chair and author of SCRs and a SILP associate reviewer. She is independent of the LSCB and its partner agencies.  2 Agency reports are completed where agencies have the opportunity to consider and analyse their practice and any systemic issues. They provide details of the learning from the case within their agency. Then practitioners, managers and agency safeguarding leads come together for a learning event. All agency reports are shared in advance and the perspectives and opinions of all those involved at the time are discussed and valued at the event. The same group then comes together again to study and debate the first draft of the SCR report. Later drafts are also commented on by all of those involved and they make an invaluable contribution to the learning 3  2 The case 2.1 Child N lived with their mother, father and older sibling to be known as Sibling 2. Child N suffered what were thought to be non-accidental injuries3 when 4 weeks old. Child N and the sibling were the subject of a Child in Need plan at the time.  Mother was known to mental health services and the family had been in temporary housing for much of the timeframe of this review.   2.2 Another older sibling died when aged 5 months old and this child will be known as Sibling 1. This report will not specify the genders of the children to protect their identities.  2.3 The children share the same mother.  Sibling 1 had a different father.  This report will refer to the adults caring for the children during the time that is being considered as Mother and Father. Any other family members will be described by their relationship to Child N e.g. Paternal Grandmother.   2.4 The couple originally met in a hostel for homeless young people. They were unemployed and in receipt of benefits.    3 Process 3.1 It was agreed that the scope of this review would be from November 2014 when the child in need began, until 4 May 2016 when the parents were removed from the hospital as a safeguarding measure in respect of Child N.  Relevant information prior to these dates was also considered as required, particularly any agency involvement with an older sibling of Child N, who died in 2014 of natural causes.   3.2 Early family engagement is required as part of the SILP model of review. The Police were not willing for the lead reviewer to meet with the family prior to the conclusion of the criminal investigation.  Both parents were spoken to separately by the lead reviewer prior to publication of this report. It is acknowledged that this was four years after the injuries to Child N.  Their views are included in the report as relevant.   3.3 The Department for Education (DfE) expects full publication of SCR overview reports, unless there are particular serious reasons why this would not be appropriate. Working to that requirement, some confidential historical family information and case detail will not be disclosed in this report. It is written in the anticipation that it will be published, and contains the information that is relevant to the learning established during this review.  The decision was made by prior to publication that the review would be published by the NSPCC anonymously due to concerns about the vulnerabilities of the adults in this case.  6.6 There were on-going parallel proceedings to this review, including care proceedings on Child N and Sibling 2 and a criminal investigation in respect of Mother, Father and Paternal Uncle - who was staying with the family at the time the injuries may have been sustained. A finding was made in the civil courts in December 2016 that the injuries were caused by Father and that Mother failed to protect Child N. The police investigation was completed in 2020 and no further action was taken.  7. The background prior to the scoped period  7.1 The father of Sibling 2 and Child N was known to children’s social care (CSC) as a child initially due to concerns about the parenting he received, and later due to his behaviour,  and conclusions of the review and analysed; and makes use of relevant research and case evidence to inform the findings.   This review has achieved these objectives.  3  The injuries included intracranial haemorrhages, retinal haemorrhaging, two fractured ribs (historic)3 and two fractured femurs (historic).   4  including anti-social behaviour, drug use and criminal behaviour leading to contact with the youth offending service. He was in homeless young person’s accommodation from age 16 - 19.   7.2 Mother’s early years were thought to be neglectful and abusive, due to serious parental drug misuse and domestic abuse. Mother did not live with her birth family from the age of around six years old. It is believed she lived with a family friend in a private fostering arrangement that became a Residence Order4 when Mother was aged eight.  She remained there until the placement broke down when Mother was around 16 years old.  7.3 Prior to the birth of Sibling 1, when Mother was 18 years old, she was in a violent relationship with the baby’s father and in temporary housing.  Early in the pregnancy Mother was admitted to a psychiatric hospital, which resulted in a diagnosis of Emotionally Unstable Personality Disorder and Mental and Behavioural Disorder. The latter was thought to be due to multiple drug use.  She has been supported by the Mental Health Recovery Team5  ever since.   7.4 An Initial Assessment followed by a Core Assessment6 was undertaken by Children’s Social Care (CSC) prior to the birth of Sibling 1 (although the recommendation of the Children’s Access Point had been for a pre-birth assessment). As Mother’s mental health was then stable, she had separated from the baby’s father and there was no evidence of on-going drug use, it was agreed that the baby’s needs would be met if the child were subject to a Child in Need Plan7 from birth.  This involved the allocation of a social worker, a high level of support from the health visitor, an agreed plan and regular meetings between professionals and Mother, including Mother’s mental health worker. Communication between professionals at the time was good.  This did not include the GP as they were not contacted.  Mother engaged with the plan and was felt to be providing good care to Sibling 1 and the attachment was described as positive.  The main focus of the child in need plan was housing, planning contact for Sibling 1 with the child’s birth father, and supporting Mother with her parenting. A referral was made to an independent service that supports people affected by domestic abuse by the allocated social worker but Mother did not engage with the services they offered. Health and social care professionals reported observing a positive and appropriate attachment between Mother and Sibling 1.  7.6 Sibling 1 died at five months old. The death was from natural causes, the result of an infection that Mother had probably contracted during her pregnancy, and which Sibling 1 had contracted antenatally8.  Following the baby’s death Mother’s engagement with professionals declined and she refused counseling. She had a further period of housing instability and was misusing drugs and alcohol for what was described by her mental health worker as a ‘short time’.   8. Key Episodes 8.1 The time under review has been divided into 4 Key Episodes, which are periods of intervention that are judged to be significant to understanding the work undertaken with a child and their families.  They are key from a practice perspective rather than to the history  4 S8 Children Act 1989 5 This involved the support of an allocated care coordinator for emotional and social support and access to medication reviews as required.  6 At the time children’s social workers undertook these assessments of children in need. Initial Assessments would take place within 10 working days of a referral and Core Assessments within 35 working days. 7 Where an assessment by CSC has concluded that a package of family support is required to meet the child's needs under Section 17 of the Children Act 1989.  8 The death of Sibling 1 was fully examined and investigated at the time.  5  of the child. They do not form a complete history of the case but summarise the key activities that occurred, and include the information that is thought to be most helpful in informing the review.  8.2 The key episodes in this review are:  1.  Pregnancy and birth of Sibling 2.  2.  CFIS9 involvement and the pregnancy with Child N.  3.  Birth of Child N and the continued child in need plan.  4.  Child N in hospital and suspected non-accidental injuries identified.  Key Episode 1: (Pregnancy and birth of Sibling 2. October 2014 until May 2015.) 8.3 Housing initially alerted CSC to Mother’s pregnancy with Sibling 2.  No action was taken at the time, as it was early in the pregnancy and the recording of the contact made no reference to Sibling 1.   Mother’s midwife made a later referral to the health visiting service as they noted that concerns previously identified for Sibling 1 remained at the time of the pregnancy with Sibling 2, and that these concerns were exacerbated by Mother’s recent bereavement. The referral also referred to Mother and Father sharing that they were using cannabis regularly.  The health visitor made a referral to CSC, which included the information shared by the midwife.    8.4 The information known at this time was that Mother had relapsed into drug and alcohol misuse following Sibling 1’s death, but claimed she had stopped using drugs, including cannabis, due to her pregnancy.  Mother and Father had known each other for a while, but their relationship was new and it was known that the police had been called due to their arguments.  Mother was living in unsuitable temporary accommodation and was facing eviction.  Following assessment CSC agreed with Mother that at birth Sibling 2 would be subject to a child in need plan, to support her with the practical issues she faced. These included housing, benefits, isolation and parenting.   Both parents were thought to have stopped using drugs and Father was advised to seek help from his GP regarding his anger. Both parents said they were keen to receive the help and support to be provided by the child in need plan.   8.5 There is evidence that Father attended his GP surgery in both December 2014 and then May 2015, firstly seeing the practice nurse in December and then a GP in both January and May 2015. He shared his anger issues, stating he had issues since childhood and wanted help now he was a father.  He stated he was not a drug user but that he had been injecting steroids until recently. A blood test was undertaken and it showed high levels of testosterone. Father was referred for anger management by the GP, but the referral was not successful as there was no commissioned service.  The GP was advised that he could speak to CSC if there were safeguarding concerns. There is no evidence that this happened or that the GP spoke to Father again about his anger or his use of steroids. The mental health service that the GP referred father to for anger management did not link this information to Mother’s case.   8.6 Child in need meetings were held, starting prior to the birth of Sibling 2 in January 2015.   Information sharing took place, and concerns were shared and discussed. For example after her visit in April 2015 the health visitor noted Mother’s high Edinburgh postnatal  9 Child and Family Intervention Service, which is targeted at the most challenging families with multiple needs. They support families using a formal support plan and intensive key working. 6  depression score10 and the information was shared with the GP, mental health services and the social worker, along with the concern that mother’s mental health appeared to be impacting on her ability to provide ’emotional care’ to Sibling 2.   Key Episode 2: (CFIS involvement and the pregnancy with Child N. June 2015 until March 2016.) 8.7 Mother and Sibling 2 initially lived in bed and breakfast accommodation, they then moved to temporary housing prior to a move to a permanent tenancy in June 2015. Father was officially not living with the family, although he was effectively permanently staying with them.  The housing moves had an impact on the provision of both health visiting and GP services for Mother and Sibling 2, because of their geographical bases. Positive systems to handover between health visitors at the time were reported however. Shortly after the birth of Sibling 2 the health visitor and GP liaised with mental health services to ensure Mother received her medication as she had stopped taking them during her pregnancy.  8.8 The professionals involved identified factors regarding the impact of Mother's own attachment issues, her bereavement, and the impact on her parenting of and bonding with Sibling 2.  A referral was made to the Child and Family Intervention Service (CFIS) in May 2015 to address this.  The intensive work undertaken led to concerns about how well Mother was coping and the CFIS staff were concerned about Mother’s relationship with Sibling 2.  Mother herself also shared her concerns about the difficulties of bonding with her child. 8.9 Father appears to have undertaken the majority of the childcare for Sibling 2. He was included in the child in need plan and the work being undertaken by CFIS, but was reluctant to become involved.  Mother reported to her mental health worker that due to episodes of anxiety she could sometimes not leave the house. Her medication also had an impact on her ability to provide 24 hour care to children. Father was thought to be supportive and to have a good relationship with Sibling 2. The focus of the work was on Mother. Father often attended but in the role of supporting his partner. Mother reported to the social worker in August 2015 that Sibling 2 had staying contact with Parental Grandmother, but she was not contacted at the time to provide information about the children and her role or to engage her in the child in need plan. The parents were asked to provide details of family members so that a family network meeting could be held, but the parents choose not to engage with this process.  8.10 Police information was available in July 2015. They had attended following concerns from neighbours that Mother was shouting at Sibling 2 and that there was cannabis use in the home.  Further police information was available in September 2015 when it was reported that Father was outside the premises shouting and banging at the door. Again the officers smelt cannabis and raised this with Mother who alleged Father had smoked it.  Both incidents were notified to CSC.  The concerns were discussed with the parents at meetings but they denied using cannabis in the home. Mother has since told the lead reviewer that they did smoke occasionally, and that she used cannabis to manage her anxiety at this time.  8.11 Due to the on-going concerns, a meeting was held in August 2015 between CFIS, the social worker and relevant managers and the decision was made to have a strategy discussion with the police and to recommend an initial child protection conference (ICPC). The police agreed with the plan but the conference did not happen and it was agreed after Section  10 The Edinburgh Postnatal Depression Scale (EPDS) is a 10-item questionnaire that was developed to identify women who have postpartum depression.  7  4711 enquires were completed that a continued child in need was the best response to the issues identified.  The extent of the S47 was limited however as the GP was not consulted. The change of plan appears to be because Mother’s mental health diagnosis had previously been thought to be bi-polar disorder and when it was confirmed that this was not the case the threshold for a child protection response was no longer thought to be met.  This decision was made by the social work team, with both the team manager and service manager involved in this decision. Neither CFIS nor any other agency challenged the decision. When Mother’s pregnancy with Child N was confirmed the following month, this decision was not reconsidered.   8.12 The child in need plan for Sibling 2 continued throughout Mother’s pregnancy with Child N. Mother had some pregnancy related health issues. When she visited on the 15 October 2015 the health visitor noted a smell of cannabis in the property. Mother disputed this but the information was shared with the social worker. Mother also appeared to have less support at this time from mental health team as she had cancelled a number of appointments and had difficulties with her mobile phone reception. This led to some difficulties in managing her medication. A newly allocated social worker noted that Sibling 2 spent a lot of time in a chair or car seat, and that mother was reluctant to let the child play on the floor. The health visitor had shared that there was no developmental delay so the social worker did not feel it was problematic.  Key Episode 3:  (Birth of Child N and the continued child in need plan. March – April 2016.) 8.13 Prior to the birth of Child N, following a child and family assessment (not a specific pre-birth assessment) by the social worker, it was agreed that Child N would also be subject of a child in need plan at birth. Mother was also referred to a peri-natal mental health consultant. When Child N was born Mother showed continuing signs of anxiety relating to the death of Sibling 1 and the safeguarding lead at the hospital shared concerns with the health visitor that Mother was struggling to bond with Child N. The social worker reported during this review that they were aware that S47 enquiries had been completed by the previous social worker in August 2015 and thought that the decision to maintain supporting the family on a child in need basis was the mandate she was required to continue. The family continued to state their need for support and willingness to engage with the plan, so no consideration was given to this being an issue that required a child protection response.  8.14 Child N returned to hospital a week after birth having been referred by the GP due to an infected umbilicus.  Father stayed with Child N on the ward. There was no record of Mother visiting and it was noted that Father reported that his partner found it difficult being on the ward. When Child N was 3 weeks old (20 April 2016) they were again referred to the hospital by the GP following ‘multiple presentations in the days before with projectile vomiting, weight loss, crying/unsettled and general concern about the vulnerability of the family.’12  Colic was diagnosed and Child N was discharged the next day.    Key Episode 4: (Child N in hospital and suspected non-accidental injuries identified. 25 April to 4 May 2016.) 8.15 On 25 April 2016 Child N was admitted to hospital, having been taken there by Father who reported that Child N had a 'floppy episode' at home.  Child N was at the time correctly  11 Section 47 of the Children Act 1989 places a duty on Local Authorities to investigate and  make inquiries into the circumstances of children considered to be at risk of ‘significant harm’ and to decide what action it may need to take to safeguard and promote the child’s welfare. 12 Primary Care agency report.  8  treated for a presumed infection and gastro-oesophageal reflux on the ward. During the admission it was observed that the head circumference had increased which led to further investigations which showed intracranial bleeding and retinal haemorrhages. As a result of this scan the child was transferred to a specialist neuro-surgical centre for on-going medical and surgical treatment. Whilst at this hospital further x-rays and scans discovered healing rib fractures, healing leg fractures and 2 types of brain haemorrhage (bleeding).   8.16 It was recorded by ward staff on 29 April 2016 that Child N woke for a feed and was crying. Father was offered help and the nurse ‘witnessed dad raising his voice at Child N and swearing telling Child N “It’s too early”. He declined the help offered.’   8.17 The Police were informed on 1 May 2016 about the child’s injuries and a strategy meeting13 was held that day. Contact between Child N and the parents was discussed and a medical of Sibling 2 was agreed and undertaken the same day. No safeguarding concerns were identified.  Sibling 2 was placed with a family member.   8.18  It was established that Father’s brother had been staying with the family for a period of time prior to Child N’s injuries. Both the health visitor and midwife were told he was staying to support the family for 2 weeks following Child N’s birth, and that he had done the same when Sibling 2 was born. Professionals at the learning events stated that it is not unusual for family members to be present at this time. Very little was known about Paternal Uncle prior to Child N’s admission to hospital.  It has since been established that he had been in prison and has a history of drug misuse.    9 Analysis by Theme  9.1 From the information deduced from the agency reports, from the discussions at the learning events, and from the meeting with the family, several key themes have emerged.  These can be summarised as: • Mental health  • Substance misuse and domestic abuse • ‘Care’ history of Mother • Homelessness/temporary housing  • Assessment • Child in Need planning • Parental engagement and focus  • Gender • Response to Child N’s injury 9.2 Each theme will be considered below, with any learning clearly identified.        Mental health: 9.3 Mother was diagnosed with Emotionally Unstable Personality Disorder (EUPD). Mother’s history of childhood neglect, self-harm and drug misuse were typical of those with this mental health condition. Working with patients diagnosed with EUPD can be a challenge for professionals. The best outcomes are achieved when there has been the opportunity to build consistent relationships with service providers and the availability of psychological therapy. Mother’s immaturity, life-style and the stress of being a mother did not enable the  13 Whenever there is reasonable cause to suspect that a child is suffering, or is likely to suffer Significant Harm, there should be a Strategy Discussion/Meeting involving Children's Social Care, the Police, Health and other professional as appropriate.   9  required help to be provided consistently and Mother’s symptoms were largely managed by medication. The mental health team providing a service to her did remain involved throughout the time frame of this review however, and she saw her psychiatrist periodically for reviews of medication. There were a number of staff changes of support worker, but handovers took place.  9.4 Mother was prescribed with anti-depressants, diazepam and sleeping tablets. As the pregnancies were unplanned there were some issues with what drugs she was able to take which complicated the consistency of her medication regime. Mother reported being very confused at the time regarding what prescribed drugs it was safe to take during her pregnancy.  Some inconsistent advice was also given to Mother by the mental health professionals involved at the time.  Mother’s frequent changes of address meant that she was not able to build a relationship with her GP surgery and GP’s were often having to see her without her notes, as these can take time to be transferred from one surgery to another. In a complex case this systemic delay can be problematic.  9.5 There were a number of mistakes regarding the recording of Mother’s mental health issues in agency records, probably due to professionals taking Mother’s word on what her diagnosis was and not checking with mental health professionals. Mother appears to have misrepresented her diagnosis on occasion.  It is not clear if this was due to her own confusion, or if she was intentionally not telling the truth. She had stated she had schizophrenia and this was recorded in the health visitor and midwifery notes.  The CSC records stated she was bi-polar. Neither is correct.  It is the symptoms rather than the diagnosis that was important in this case however, particularly when considering the impact of Mother’s mental health on her parenting.  When the decision was made to hold an ICPC in this case, when Sibling 2 was around 6 months old, the discovery that mother was not bi-polar but had EUPD led to a change in the plan and it was decided not to hold an initial child protection conference.  This appears to have been agreed without due consideration of the impact of Mother’s behaviour on her care of Sibling 2.  There was no risk assessment completed in regards to the impact of her anxiety and lack of bonding with Sibling 2, and no discussion with other agencies.  9.6 It was clear to those working with her that Mother presented as a person with a complex trauma. Mother reported to her Midwife after the birth of Child N that she felt the children did not respond to her in the way that they did to their father, and she had shared similar feelings with CFIS. They believed at the time that this had an impact on her care of her children and her ability to build a positive relationship with them. She was willing to work on practical parenting skills with the CFIS team but was very reluctant to consider the emotional impact of either her childhood experiences or the death of Sibling 1.  CFIS shared their concerns with the professionals involved and the family at child in need meetings.  However the children were always said to be clean, well dressed, and cared for physically. The mental health workers who were involved prior to the birth of Sibling 2 had no concerns about Mother’s parenting and this reassured the CFIS staff and the social worker.  Mother appeared to be up-front and honest and she shared her concerns that she would be unable to bond with Sibling 2 due to her experience of losing Sibling 1.  Mother was said to be more positive prior to the birth of Child N due to the child being a different gender to the older siblings. But it was noted that she did not visit the baby in hospital when they were admitted with the umbilical infection when one week old.   9.7 Father, at the request of the child in need meeting, attended his GP to ask for anger control help. He had been able to acknowledge he needed some help and was referred on to 10  mental health services.  There appears to have been a gap in services however as no suitable anger control groups or one to one work was being commissioned at the time. Those present at the SCR meetings felt that there is a demand for these services but no current local resource is available to meet the need.  This issue was not pursued with Father at later child in need meetings, as an assumption was made that the wait for support is often many months, and the unmet need was not identified.   9.8 Father admitted at the time that he found Mother’s mental health issues difficult to deal with.  He asked professionals not to speak to Mother about the death of Sibling 1 as it made her so upset.  On occasion she would be disabled by her anxiety and grief and he was effectively a carer for her as well and the children. This was acknowledged at the time, and Father was offered support but he refused help.  As Father was effectively the primary carer for the children, the need to ensure he received support with his anger and with the strain of caring for Mother needed to be included in the children’s plans.   9.9 There is little doubt that the shock and pain of losing her first baby had an impact on Mother’s mental health and her relationship with Sibling 2 and Child N. To suffer such bereavement is devastating for the most capable, supported and emotionally stable parents.  Mother, who was so vulnerable and young, was inevitably going to struggle to cope with the loss.  The professionals involved during the timeframe being considered by this review understood the effect of the loss on Mother and on her ability to parent her children, but on occasion.  The same can also be said for Father, who preferred to avoid discussion of Sibling 1’s death to ensure Mother didn’t get upset. It is difficult for professionals to make demands on a young woman who appears to be doing her best and who struggles due to her difficult history and a recent bereavement. The so-called ‘human factors’14 which effect professional practice came into play here and had an impact on the management of the case following the birth of Sibling 2.  The professionals involved at the time had sympathy with Mother and while they tried hard to gain her engagement, this was not successful. Without the clear mandate that a child protection plan brings, professionals can often feel unable to push parents to partake in the work they know is required. As this was a case that was seen as ‘child in need’ without the identified risk present when a child is on a child protection plan, there was no final push for further engagement with the services offered by the likes of CFIS.    9.10 Sibling 2 was the same gender as Sibling 1 and was born just a year after Sibling 1 died. Mother had not received support with the bereavement and probably held some guilt that Sibling 1 had died from a condition Mother had passed on during child birth. Bowlby15 states that parents who have experienced the death of a child are often consumed with feelings of anger, guilt and self-blame.  Mother was offered bereavement support a number of times but always refused it. Father was not the parent of Sibling 1 and this could have been a complicating factor in their relationship and in his understanding on the impact on Mother. Without work being undertaken to look at these issues, it would have been hard to understand the impact on Sibling 2 and Child N.  Mother told the lead reviewer that she was very anxious about passing an infection to Sibling 2 and that this had an impact on her ability to bond with the baby, but that when she was told the baby was infection free, she was able to bond appropriately.  Learning:  14 Serious Case Review Quality Markers. 2016. (SCIE / NSPCC.)  15 John Bowlby. Loss, Sadness and Depression. 1980.   11  • When considering the impact of a mental health issue on parenting, it is the symptoms and impact of the treatment of the condition, and not the diagnosis itself that should be considered when assessing the needs of/risk to a child.  • When one parent has mental health issues which affect their ability to care for the children, the assessment and plan needs to consider this and the impact on the other parent/carer.   • The impact on professionals of working with parents with complex and emotionally powerful issues needs to be acknowledged in supervision and when professionals discuss the case.  Those involved with the family softened their approach to Mother which had an impact on decision making and professional judgments.  • A service for parents with anger control issues needs to be available in the area.  • There is a need for consistent practice on the use of prescribed mental health medication during pregnancy. The decisions made about medication, with the rational, need to be communicated to the health professionals involved and the service user.  Substance misuse and domestic abuse: 9.11 Mother seriously misused both drugs and alcohol immediately prior to her pregnancies with both Sibling 1 and Sibling 2. She was also previously in at least two domestically abusive relationships. During her pregnancies she was reportedly able to give up her use of drugs and alcohol, and she successfully separated from her abusive partner while pregnant with Sibling 1.  9.12 Domestic abuse was not believed to be an issue in her relationship with Father, although the police had attended their home on a number of occasions due to verbal arguments. The significance of these events was not thoroughly explored with either parent, and it appears Mother minimised them when incidents were discussed, describing them as one-off verbal altercations.   9.13 There is limited evidence but it seems that that both parents may have continued to use cannabis while caring for the children. The health visitor for Sibling 2 noted the smell of cannabis in the home on one occasion, and both parents had admitted to smoking cannabis during the early pregnancy with Sibling 2.  Police notifications also reported the smell of cannabis in the home. Mother confirmed to the lead reviewer that there had been on-going cannabis use.  9.14 Father approached his GP both in 2012 and in 2015 and shared the information that he had misused steroids. There is evidence that this can have a negative impact on anger control, with people reportedly acting aggressively when injecting anabolic steroids regularly16.  Father told this review that he had anger issues prior to this behaviour however. Adult mental health services were aware of Father’s reported misuse of steroids, but as they did not link his records with Mother’s they did not consider if there was an issue for Mother or the children. The GP was told by Father that he had a child, but there was no attempt to share the information with other professionals such as the health visitor. It appears Father was seen in isolation and that there was a lack of professional curiosity.  Learning: • Consideration should be given to the potential misuse of steroids by parents who report anger control issues, as this may be a safeguarding concern.   16 https://www.drugabuse.gov/publications/drugfacts/anabolic-steroids 12  • Professionals must understand that service users will not always disclose domestic abuse or coercion/control in their relationships while it is happening.  • It is important that when families move or new professionals become involved with a family, that the questions about drug and alcohol use and domestic abuse should be asked regularly.  ‘Care’ history of Mother: 9.15 As far as Mother was concerned she had been in foster care as a child and believed she was a care leaver. She was happy to share this information with professionals. She presented as a ‘care leaver’ to those involved, who had no reason to dispute Mother’s stated history. It appears that the placement with her ‘foster mother’ was an informal placement made by the family and the Local Authority had no role in Mother’s life or in the placement at the time.  This made Mother particularly vulnerable as she did not have any of the support or supervision that should be available when a child is in the care system. At the time in the area (around 15 years ago), as well as elsewhere in the UK, there was not always an adequate awareness of private fostering. Those privately fostering children and other agencies such as schools did not always respond to their legal responsibility to alert the local authority to such situations17.  Private fostering is when a child or young person under 16 years old (or 18 if they are registered disabled) is cared for and provided with accommodation for 28 days or more by someone who is not a close relative.  All councils are legally required to make sure children who are privately fostered are being cared for by a suitable carer in an appropriate environment, and an assessment is undertaken by a social worker in such instances.   9.16 Despite the informal and unclear status of the placement, Mother had a degree of on-going support from her ‘foster mother’ throughout the timeframe of this review, which shows that their relationship did not just end when Mother moved out. There was very little confirmation however of Mother’s reported history, despite this being important in order to understand the impact of her own experiences on her parenting.  9.17 What was known was that Mother became a parent when she was little more than a child herself, that she had reported a traumatic childhood history, and that she had not lived with her birth family from a young age. The foster mother stated she had taken Mother in when she was young due to concerns of poor care from her mother. There is little evidence that this was checked out and explored in detail by those working with Mother regarding concerns about her own children.  There is a current view that she may have lived in another Local Authority, but there was no attempt at any point prior to the injuries on Child N to establish the precise details of her history.   9.18 The most recent social worker was clear at the learning events that she had tried to read the files available about Father as a child, but that the historic files were hard to understand and capacity issues had made it impossible to complete the task. As she had worked in a previous role with both parents in a hostel for homeless young people, she often relied on her previous knowledge of them when considering their histories. While this was helpful information, it was not as comprehensive as was required in this case. It is difficult for professionals who knew parents as children or young adults to have the required focus on their children when they become parents. There is a need for supervision to provide reflection on this issue to ensure that there is no bias or issues with professional judgements.  Learning:  17 The Children (Private Arrangements for Fostering) Regulations 2005.   13  • In order to ensure that a thorough assessment is undertaken, knowledge of a parent’s own experiences in childhood is essential. Any information self-reported by parents should be checked, historic records should be sought and read, and the relevant information should be shared with other professionals and considered when reflecting on the risks this may pose for the children.   • Supervision for professionals needs to challenge those working with families to ensure they are focused on the child and not distracted and swayed by the parent’s histories and situations. This is particularly crucial where the parents are young, have a care history, and /or require a lot of personal support.  Homelessness/temporary housing: 9.19 To quote the Primary Care agency report, ‘with the benefit of hindsight it would seem that the disruption from moving areas just after the birth of Sibling 2 was quite significant’. This would have been an extremely difficult time for Mother and Father. There were concerns about delays in Mother’s medication being restarted after the birth, her anxiety that the new baby looked very much like the baby who had died, her expressed difficulties in bonding with Sibling 2, and her move to an area away from where she wanted to be and away from the support she had from her ‘foster mother’ and from Father’s relatives. Father was not officially living with Mother and the baby, which could have provided additional stress when he was living with them ‘unofficially’.   Father had to adjust to being a parent for the first time, with a partner who was grieving for her first child and who was on medication that effected her functioning, and without help to manage his anger.  9.20 While they made time to try to get to know Mother, despite initially working without the records being transferred in the case of the GP, professionals needed to quickly understand a lot of background history and consider the impact on the current situation. It is noted that when complicated high risk patients move areas, it increases the vulnerability and risk for the children.  It is at this time that good information sharing is crucial.  In this case there was good practice identified with the GP contacting the mental health team, and the health visitors undertaking a handover visit.  Also the previous mental health team and social work team remained involved.  9.21 Father’s brother not known to local agencies and those working with the family. As Child N and Sibling 2 were ‘children in need’ there would not have been the same degree of scrutiny regarding who was living in the house as there would have been if the children were on a child protection plan. It is not known how long Father’s brother had been staying with the family and what impact this had on the children and on the parents.   Learning: • Robust information sharing and the swift transfer of records is essential when a child in need and their family move home. It should also be acknowledged that there is likely to be an increased risk at this time due to changes of professionals involved in services that work geographically.  Assessment: 9.22 Prior to the birth of Sibling 1, Sibling 2, and Child N, both Initial and Core Assessments18 were undertaken, but not a formal Pre-birth Assessment. When the referral for Sibling 2 was accepted by CSC the manager on duty stated it required a Pre-birth Assessment. This would  18 An Initial assessment of a child’s needs is undertaken following a referral and is completed within a maximum of 7 working days. A Core Assessment is a more in depth assessment and should be completed within a maximum of 35 working days.  (Framework for Assessment of Children in Need and their Families (2000). 14  have established both the child’s needs and the risk of harm in view of the impact on Mother’s parenting capacity of; her background history; her mental health difficulties; her history of substance misuse; her own experience of being ‘parented’; her unsettled lifestyle; and her recent bereavement.  Limited information was available about the fathers of the children at the time, and the assessments needed to thoroughly consider their role and histories too.    9.23 It appears that there was confusion at the time in the area about what cases required a Pre-birth Assessment, with a misunderstanding that they were to be used specifically for children who were likely to be subject to a CP plan prior at birth.  The early arrival of Sibling 2, the amount of time spent trying to assist Mother with getting rehoused, the allocation in a busy assessment team, and Mother’s agreement to engage, also had an impact on the type of assessment undertaken. It was acknowledged during the learning events that the pathway for pre-birth assessment work remains unclear, but that a lot of work is underway to improve processes and practice.   9.24 The Ofsted report: ‘Ages of concern: learning lessons from serious case reviews’ provides a thematic analysis of 482 serious case reviews that Ofsted evaluated between 1 April 2007 and 31 March 2011.  They found that improving practice in pre-birth assessment was a key area for improvement.   Developing an effective and evidence-based approach to pre-birth assessments is considered a critical element of this work.  Many of the headline findings of the Ages of Concern research has a correspondence with this case:  • There were shortcomings in the timeliness and quality of pre-birth assessments  • The risks resulting from the parents’ own needs were underestimated • There had been insufficient support for young parents  • The role of the fathers had been marginalised  • There was a need for improved assessment of, and support for, parenting capacity  • Practitioners underestimated the fragility of the baby   9.25 The local procedures for pre-birth assessments state that the overall aim of the pre-birth assessment is to identify and understand:  • Parental and family history;  • Life style and support networks and their likely impact on the child's welfare;  • Risk factors;  • Parental needs;  • Strengths in the family environment;  • Factors likely to change and why;  • Factors that might change, how and why;  • Factors that will not change and why. This would have been a helpful assessment prior to the birth of all the children, considering the circumstances that were known at the time.  9.26 Professionals need to be aware of and understand the enduring impact of abuse and neglect in childhood on parenting.  While there was some understanding of the parent’s backgrounds, this was largely self-reported and limited by lack of evidence.  A full consideration of the significance was not considered at key times, such as the decision making about the type of assessment undertaken and whether an ICPC was required 15  following the S47 prior to the pregnancy with Child N. Information has become available during the later involvement with the family and during this review that it would have been helpful to know when undertaking the assessments both pre and post the birth of the three children in the family.    9.27 Part of the pre-birth assessment for Child N should have included information (not just from the parents themselves) about their backgrounds.  There was also a need for a consideration of Sibling 1’s attachment to the parents, particularly after the difficulties Mother had bonding with Sibling 2 following the death of Sibling 1.  It was recorded that Mother struggled to bond with Sibling 2 who looked so much like Sibling 1, and that Mother would not hold Child N on the day they were born.  Information sharing was evident regarding attachment issues between Mother and Sibling 2, and this needed full consideration due to the probability that the same would be the case for Child N.   9.28 It has been established that there was no re-assessment19 undertaken by social workers following the birth of Child N, which suggests either a lack of focus on the new baby or a decline in concerns about Mother’s ability to cope and an improvement in her feelings towards Sibling 2.  At the learning events professionals involved at the time stated that they did believe there had been an improvement prior to the birth of Child N and that consideration was being given to closing the case after the baby was born. This optimism would have led to less focus on the case and on the event of Child N’s birth.  9.29 The child in need plan was on-going and review meetings were being held regularly and within expected timescales.  The local authority with the support of partner agencies were using a signs of safety mapping tool at this time and they were completed at the child in need reviews in January and March 2016. The mapping tool includes a ‘harm box’ which lists any risks and should demonstrate that the likelihood of harm was addressed. They were empty in this case. It appears this was due to the view that the box should be used to list actual harm rather than risk factors that may lead to harm. There was also a lack of experience in regards to both professionals and managers in completing the forms at the time.   9.30 CFIS planned to undertake direct work with the family, with a view to improving the relationship between Mother and Sibling 2.  They used VIG (Video Interactive Guidance), a method which uses video recordings of interaction between parents and children to encourage positive relationships and improve attachment and bonding. Like a lot of younger women, Mother was reluctant to see herself on film and told the review this was too much pressure for her.  Mother cancelled a number of appointments with CFIS.  She was pregnant for some of the time and had some health issues, she also made a point of cancelling then rearranging appointments, giving the impression she was actively engaged in the process and willing to work on the issues identified. She only attended five appointments in a seven month period, with Father attending fewer than Mother.     9.31 The attachment issues evident between Mother and Sibling 2 were well known at the time.  NICE published attachment guidance in November 2015 titled ‘Children’s attachment: attachment in children and young people who are adopted from care, in care or at high risk of going into care’.  It summarises why a solid attachment is so important for children and why the stakes were high in this case, even without any evidence of a risk of physical harm  19 The children and families assessments (what was previously a core assessment) should be updated on a regular basis, and following any changes of circumstances, for example a new baby or a move of accommodation.  16  to the children at the time20.  The professionals in the CFIS team were aware of this and voiced their concerns about Sibling 2 when they requested a child protection response in Key Episode 2. The decision making following the meeting did not sufficiently consider the impact on Sibling 2 of the limitations in the emotional care they were receiving.    Learning: • Clarity is required regarding the need for a Pre-birth Assessment in cases where there is a child in need and parental risk factors which may impact on the care of the child they are expecting.    Child in Need planning: 9.32 There were clearly recorded plans for the children in this case, with an identified team of professionals who were aware of the plan and who attended meetings. Both parents regularly attended meetings, most of which were held in their home. The plan consisted of clear tasks for the professionals involved and the family, for example that Mother would attend her local family centre and that Father would approach his GP regarding his anger.  Some aspects of the plans were weak; they were not outcome focused, they did not state what needed to be achieved before the plan could stop, and they did not include a contingency plan.  9.33 Part of the learning from this review is in regards to children who are on child in need plans not always being seen as in need of risk assessments like children on child protection plans. It has been stated that some of the professionals thought of the children in this case as ‘only’ being child in need.  Learning from serious case reviews nationally shows that children who die or are seriously harmed are usually well known to professionals but not the subject of a child protection plan. The assessment process and rigour of a child in need plan can therefore be as important to those who are seen as in need as to those who have already been established as suffering or at risk of significant harm21.  In this case the CSC agency report author found that ‘given their CIN status and the lack of any obvious overt crisis or deterioration, the situation was not questioned.  The impact of this kind of thinking has been to limit any kind of wider evaluative thinking and analysis of the children’s situation’.  Due to the limited use of the signs of safety tool the risk factors were not articulated and acknowledged in Key Episode 3.  9.34 In the area there have been concerns identified about the quality of child in need plans and it has been acknowledged that there is a need to ensure that they are more effective, multi-agency, and that drift and delay is avoided. In November 2015 a request was made for an Advanced Practitioner to review this case and the case note of this review says; “Record checked, child seen in a timely manner. No safeguarding issues identified”.  It is the view of the CSC agency report author that ‘this indicates a superficial review and does not evidence that any substantial quality assurance of the situation for the child was achieved’.  An OFSTED inspection undertaken at the time noted the expectation that the Advanced Practitioners would improve the quality of child in need work, but that this was not yet  20 The reports states ‘children whose caregivers respond sensitively to the child's needs at times of distress and fear in infancy and early childhood develop secure attachments to their primary caregivers. These children can also use their caregivers as a secure base from which to explore their environment. They have better outcomes than non-securely attached children in social and emotional development, educational achievement and mental health. Early attachment relations are thought to be crucial for later social relationships and for the development of capacities for emotional and stress regulation, self-control and mentalisation. Children and young people who have experienced insecure attachments are more likely to struggle in these areas and to experience emotional and behavioural difficulties.’ Nice Guidance: Children’s attachment: attachment in children and young people who are adopted from care, in care or at high risk of going into care. 2015.  21 The child protection plan threshold. 17  embedded at the time being considered by this review. It is noted that a recommendation from OFSTED report was that agencies should strengthen the quality of planning for children in need of protection, children looked after and care leavers so that plans are clear about intended outcomes and timescales and clear about who is responsible for actions and have agreed contingency plans. The plan for the Advanced Practitioners to robustly and thoroughly review child in need cases needs to be more effective than was seen on this case.   9.35 At the time that Child N was born and then went into hospital professionals felt that Mother had been making good progress with Sibling 2. Those involved at the time stated they felt the case was moving in the right direction and that Mother and Father looked as though they would be able to parent the children without the need for a child in need plan. This understanding at the time would have led to less focus on the case and less challenge to the parents across agencies, and there was no specific assessment undertaken at this time that considered the impact of another baby on Sibling 2’s care.   Learning: • When a new baby is expected and a sibling is on a child in need plan, there needs to be an assessment in regards to the new baby, but also a reassessment of the older child to consider the impact of a new baby on that child. The plans should reflect the new information.  Parental engagement and focus: 9.36 Mother and Father were not always entirely open about their issues with the agencies involved with them.  They would often give partial information rather than sharing the whole picture. For example Mother told her GP, after the death of Sibling 1, that she had been drinking heavily and had considered returning to drug use, but had not.   Other professionals were aware Mother had been using drugs at this time.  Father accepted he had some anger control issues but did not tell those involved in the child in need plan that he had been injecting anabolic steroids. Without agencies sharing all of the information known to them, no one agency had the whole picture.  9.37 The Victoria Climbe enquiry22 highlighted that professionals must maintain a ‘healthy scepticism’ and ‘respectful uncertainty’ in order to see beyond what is often being presented by parents. A process of ‘checking back’ with professional colleagues may provide opportunities to detect hidden issues and provide mutual support in challenging parents and in protecting children. This is particularly important where the self-report is not in the professional’s area of expertise (e.g. adult mental health or substance misuse).   9.38 It requires skill and experience to keep a healthy scepticism regarding parents while still building and maintaining a trusting relationship. Parents are not necessarily dishonest or deliberately hide what is really happening at home, however professionals need to maintain their professional curiosity and scepticism in all cases, not just those where there are very apparent concerns. These parents were not angry, aggressive or challenging to professionals and both stated regularly that they accepted they needed help. As a consequence workers did not appear to adequately consider the impact on the children of the lack of cooperation and engagement with much of the planned work.  Father told the lead reviewer that both he and Mother would lie to professionals. He added that they also lied to themselves as they knew deep down that they were not managing as parents.     22 Laming, Lord (2003) The Victoria Climbié inquiry. Report of an inquiry by Lord Laming. 18  9.39 The parents were seen as being co-operative by all of the professionals involved.  Mother had a pattern of frequently re-arranging appointments rather than simply cancelling them or not attending.  This practice, along with a high degree of empathy for Mother due to her anxiety, her bereavement, her challenging housing needs, and her ill-health during pregnancy led to professionals not sufficiently challenging missed appointments.  The inconsistent attendance had an influence on the work and interventions provided for the children. As stated in the CSC agency report ‘the local Child Protection Procedures refer to this kind of behaviour which is described as avoidant and a kind of uncooperativeness.  Had this been recognised the focus could have remained more clearly on the children’.   9.40 While the parents appeared to be cooperative with the child in need plans and the services offered, such as the CFIS work, they were insistent they would not give permission for a family network meeting, stating that they wished to be independent and that their families had issues of their own to contend with.  The social worker was persistent with this issue and they eventually agreed but then avoided providing the contact details required.   9.41 The parents did not always follow advice in regards to certain practices, such the need to let Sibling 2 have more time out of their bouncy chair and on the floor.  Both parents needed both practical and emotional help, what is not clear is if consideration was given to how likely it was that they would meaningfully engage.  It has been acknowledged however that the family had a lot of appointments to attend due to the work being undertaken with their insecure housing, the involvement with mental health services and on-going health issues. It may have been helpful to coordinate contacts with the family to limit the demands on them and potentially increase their engagement.  9.42 Service delivery in this case became focused on the parents and their needs, particularly Mother.  Assessments, the child in need plans, and subsequent interventions were based around Mother’s needs and difficulties.  There was limited consideration of the way that her behaviour would impact on the children’s development in the future. Examples of the focus on Mother include the lack of challenge regarding her reluctance to engage with the CFIS work, the decision not to hold an ICPC in order to give Mother more time to engage with the child in need plan (without a full consideration of the children’s timescales) and the professional network’s understanding of how Mother’s grief for Sibling 1 made it hard for her to hold her babies, despite their needs.  The CFIS worker told the learning event that it was acknowledged that professionals had to tread carefully with Mother due to her bereavement issues.  All of the professionals stated it was like they were walking on egg-shells.  9.43 This sensitive and mother-focused approach was over optimistic about Mother’s potential for engagement and therefore potential to change given her mental health issues, her own negative childhood experiences, and her enduring reaction to Sibling 1’s death. This also led to the children’s voices not being heard as much as would be required to aid the planning and interventions required. It is stated in the NICE attachment guidance (2015) that the window for a child to gain a secure attachment is very small, and in the case of Sibling 2 this was a significant issue. The CSC agency report author’s analysis is that ‘Mother’s openness about her own difficulties drew the CSC workers in to her world, and although her issues were thought of in relation to how this would impact on her ability to parent the children, the children did not remain the priority.  This situation led to drift for the children.’ Learning: 19  • Professionals need to identify when parental cooperation with a plan for assessment and support is superficial.  Consideration then needs to be given to the impact of this limited engagement on the child/ren.   Gender:   9.44 There is evidence that the focus of the work in this case was on Mother.  This was over and above the children and sometimes excluded Father.  It was hard to ensure that this SCR did not mirror this, as there were no services specifically involved with Father and few professionals who got to know him well. The general focus on Mother was because she was seen as the person with the issues that were most likely to impact negatively on the care of the children. Father was known to be primary carer to the children much of the time, but despite this he appears to have been on the periphery of the work being undertaken.  Very little was actually known about Father and about the children’s routines in the home and which parent was responsible for them. Father confirmed to the lead reviewer that this was the case.  9.45 Mothers are often seen as the ‘key’ parent for children.  Serious case reviews have shown that professionals often fail to identify, and frequently discount or ignore the men in a child’s life.  The ‘invisible male’ is a key theme in a large number of reviews.  In this case, Father was known, involved, and engaged with to a certain degree, but there were exceptions such as his address not being recorded in health visitor records and clarity about his contact with his wider family not fully pursued.  Research23 shows that professionals often struggle to engage with fathers and that there are limited expectations of fathers. When looking at plans to support or protect children it is often assumed by professionals, and the parents themselves, that ‘parent’ really means ‘mother’.  9.46 The Family Rights Group research argues that social workers tend to see men in a family as either ‘a risk or a resource’ rather than an as equal parent who needs to be assessed, supported and challenged along with the mother. They add that ‘even a father who displays risk factors, such as violence, may display some protective factors. The challenge is to identify interventions that bring forward those protective factors while keeping the risk under control.’  In this case Father undertook a lot of the practical care of the children when Mother was unable to do so. He showed a commitment to the children and their Mother and was said to have a good bond with Sibling 2 and Child N.  Despite an initial reluctance to engage with social workers he requested help for his family when the impact of Mother’s anxiety was evident.  He appeared to be committed to the care of his children and he had a right to be fully involved in any plans to improve the children’s care.  9.47 CFIS acknowledged that they focused their interventions on Mother, and specifically on working with Mother on improving her bond to Sibling 2. The learning for them from this case is that father’s should be offered their own sessions in cases like this.  They were not alone in recognising that services can be focused on women and do not necessarily give appropriate consideration to the importance of the men who are involved in children’s lives.  9.48 The University of Worcester, in collaboration with the Fatherhood Institute, undertook an evaluation of a training programme and toolkit to assist health visitors and community practitioners to engage with fathers as part of the Healthy Child Initiative in 201424.  They found that ‘there is little evidence that the importance of engaging with fathers is reflected  23 Family Rights Group, Fatherhood Institute, Daryl Dugdale (Bristol university), Professor Brigid Featherstone (Open University) 2012 24 http://www.fatherhoodinstitute.org/wp-content/uploads/2014/10/Burdett-Report-Final-Version-June-18-2014.pdf 20  in Health Visitor training or, indeed, that family services are making progress in father-inclusive practice’.  This was due to the culture of organisations and training, the recording and information systems used, attitudes and preconceived ideas about fathers’ parenting abilities and skills and time constraints.    Learning: • Professionals undertaking assessments should seek to understand the nature of parenting relationships from the point of view of both parents/adults and the child.  It is not enough to simply focus on the parenting capacity of the child’s mother.   • All agencies need to ensure that their systems (including recording templates), procedures, practice, ensure engagement with, consideration of and inclusion of, both parents /adults in a family regardless of their gender.25    • Professionals need to challenge their own practice and their organisational cultures to ensure that service provision considers the child’s day to day experience and that the gender of the care giver/s does not exclude them from receiving the required assessments, support and plans.   Response to Child N’s injuries: 9.50 When Child N was taken to hospital by Father there was initially no documented suspicion of non-accidental injuries.  No referral was initially made to the Police or CSC as there were no child protection concerns at this stage.  S47 enquiries were not undertaken until the suspected non-accidental injuries were identified and Child N moved to the specialist hospital around five days after admittance to the local hospital. The move of hospitals was on a Friday and when the matter became a child protection issue it was the weekend. This meant that the S47 enquiries and strategy discussion happened outside of office hours and in a hospital a considerable distance away from local agencies. Despite this there was good attendance at the strategy meeting, which is positive practice.  9.51  In the meantime both parents had been having unlimited contact with Child N on the ward, despite the possibility of the concerns being non-accidental injuries. A differential diagnosis should have been considered by health professionals after Child N was first seen, while still ensuring the child’s medical needs take precedence.  Contact was not stopped and then fully supervised until after the parents were arrested by the Police at the second hospital.  9.51 There was a view at the time that the hospital was a place of safety for the baby. However at one stage when Child N was still in the local hospital, Father was heard speaking crossly to Child N, who could have been at risk even within the hospital environment. A hospital is not a safe place for a child having contact with an adult who may have harmed them as nursing staff cannot provide 24 hours supervision. If there had been an earlier strategy meeting, prior to the move of hospital, the issue of contact could have been discussed and a plan made.   Learning: • Non-accidental injury should be considered as part of a differential diagnosis of vomiting, irritability/colic, apparent life threatening events (ALTE) and floppy episodes, which could have led to an earlier strategy meeting in this case including professionals who knew the family and while the child was in the local hospital.    25 A previous SCR led to changes in the booking form used by midwives in the area; they were not fully embedded at the time being considered by this review however.   21  10 Conclusions   10.1. Mother was a teenage parent with a history of self-harm, mental health crises and personality disorder, drug and alcohol misuse, a poor experience of being parented and living ‘in care.’ She was challenged by insecure housing, domestically abusive relationships, a major bereavement and a new relationship with a man who had a difficult childhood himself and a reported anger control issue. Mother and Father both engaged to a degree with the agencies providing support, but one of the children living with them received what are thought to be non-accidental injuries in circumstances that are unknown, when just 4-weeks-old.   10.2. As stated in the 2016 Triennial Analysis of SCRs, for many of the children considered in an SCR, ‘the harms they suffered occurred not because of, but in spite of, all the work that professionals were doing to support and protect them.’ This was true for Child N.26  This SCR has, however, been able to identify learning which is relevant both to this case and to the wider system. It includes clear statements of learning which were developed from the themes considered above, and recommendations.  10.3. Individual agency learning is significant and the LSCB has ensured that a robust consideration of the concerns identified has been undertaken by each agency involved in this matter.  A number of single agency recommendations have been made which will improve systems and practice in regards to the learning identified in this overview report.  10.4. It is important to learn from the good practice identified during the course of this review. Good practice across a number of agencies has been acknowledged throughout the report, and includes the following:  • The GP surgery Mother registered with shortly after the death of Sibling 1 flagged the following details on Mother’s records. ‘Double appointments always. Sudden death of 4 month old baby. Vulnerable adult with mental health problems’. • GPs referred Child N twice to acute paediatrics and asked for a same day appointment.   • Good relationships were evident and reported between agencies in this case. For example between the children’s social work team and the mental health team.  • A joint handover visit was completed between two health visitors after Mother and child moved.  The health visitor involved when Sibling 2 was born was also contacted. • There was conscientious social work practice in this case, although insufficient focus on risk.  • There were numerous examples of good information sharing between agencies. • Father was involved in much of the work. A health visitor made an additional appointment to visit when Father would be in to get his consent for a referral to CSC.  • The CSC and police response following the confirmation of that Child N had suffered non-accidental injuries were thorough and followed practice expectations. • The transfer of Child N to a tertiary hospital for further tests was entirely appropriate and in line with the neurosurgical pathway.   10.5. There has been a high degree of cooperation and engagement from agencies with the SCR process. There have also been a number of changes within the partner agencies of the LSCB, which the response to this SCR will outline.   26 https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/533826/Triennial_Analysis_of_SCRs_2011-2014_-__Pathways_to_harm_and_protection.pdf  22  11     Recommendations 11.1. It is recognised that actions have already been taken in relation to some of the individual agencies’ identified learning. The agency reports have recommendations which will have largely been completed by the conclusion of the SCR.  Some of the learning identified within this overview report will have been addressed by the single agency actions plans.  11.2. The purpose of providing additional recommendations is to ensure that the LSCB and its partner agencies are confident that any areas identified as being of particular concern, and not included in the single agency plan, or which require an interagency or Board action are addressed.   Recommendation 1: The LSCB to request that Children’s Social Care undertake a specific quality assurance piece of work to confirm if formal pre-birth assessments, including the use of risk assessment tools, are being undertaken in all cases where it is agreed that a new baby will be the subject of a Child and Family Plan (child in need) plan or child protection plan at birth.  CSC should report the result of this piece of work to the LSCB, and provide reassurance of actions to be taken if any issues are identified.   Recommendation 2: The LSCB to consider the benefits and practicalities of requesting that the information that a child is on a child in need plan is shared (with consent) with all professionals working with the family, including the child’s GP and the GP for all adults living in the home.  Recommendation 3: The LSCB should be assured that the multi-agency partnership is delivering robust child in need plans. This should include a multi-agency case file audit on unborn babies and pre-school children on a child in need plan.  To include whether the potential risks/likelihood of harm to the child have been identified and addressed.  Recommendation 4: The LSCB should assure itself that services are available and commissioned to meet the need for anger control support for those who require it across the area.   Recommendation 5: That the LSCB requests a review by all partner agencies of their forms and information recording and sharing systems to ensure they expect professionals to include and involve fathers/adults present in the household.  Recommendation 6: The LSCB to request a review of what advice and support is provided to all new parents regarding coping with babies. This is often delivered alongside safe sleeping advice during the antenatal period27.  Recommendation 7: When assessing housing needs, any issues in relation to children subject to a plan should always be taken into consideration by the housing authority, which has a clear responsibility for safeguarding.  Those working with children on a plan should ensure that the relevant housing professionals are aware of the plan and who is involved.   27 https://www.nspcc.org.uk/services-and-resources/services-for-children-and-families/coping-with-crying  