Death of a 3-month-old boy in September 2017 whils in his mother's care. Child E was taken to hospital in cardiac arrest having been left unchecked for 12 hours overnight in a pram with heavy blankets. Mother had a history of drug misuse. An anonymous referral to children's social care raised concerns about mother's drug use and home environment. A common framework assessment (CAF) meeting was held in relation to Child E's siblings. This was closed as professionals felt mother had worked honestly with the service and was no longer misusing drugs. However, mother later disclosed to the midwife that she had used multiple drugs during the pregnancy of Child E. Criminal investigation is ongoing. Ethnicity and nationality of family not stated. Learning includes: the rationale for closure of CAF should identify trigger points to review necessity for further multi-agency sharing of information; understanding multi-agency referral pathways is crucial to professionals' sharing information with purposeful intent; specialist midwives are best placed to support the pregnancy of women with a known drug history; health agencies need to work together in order to ensure that new born babies are registered with a GP practice. Recommendations include: review guidance ascribed to cessation of CAF to include a risk indicator to support single agency identification of risk to initiate further multi-agency consultation; ensure that the role of specialist midwifes is developed and promoted amongst the wider health economy; use this review as an instructive case scenario to support early help services to understand barriers to best practice.
      
 Title:  Serious case review report: Child E. LSCB: Rochdale Borough Safeguarding Children Board Author: Rochdale Borough Safeguarding Children Board Date of publication: 2018  This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC.  This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above.                              1                         Serious Case Review Report                                             Child E                       2 1. Introduction   1.1 This Serious Case Review (SCR) concerns Child E, a baby who died aged 3 months old whilst in the care of his mother ME. Child E was taken to hospital in cardiac arrest having spent twelve hours unchecked overnight in a pram containing heavy duty blankets.  1.2 Child E is the third born child to ME, he had two older maternal half siblings.  FE, the father of Child E did not live in the family home but remained in a relationship with ME throughout Child E’s life.  1.3 Eight months before the birth of Child E, an anonymous referral was made to Children’s Social Care which raised concern about ME misusing substances and about the adequacy of the home conditions for the children.  A child and family assessment was completed in the Early Help Service and family support services worked with ME for a period of two months within the Common Assessment Framework (CAF). ME was considered to have worked honestly with the service and no longer using substances when the case was closed to CAF.  1.4 Child E was known to universal services only and was never subject to a multi-agency plan.  2.       Scope and Terms of Reference  2.1 The circumstances of the death of Child E clearly met the criteria for Serious Case Review given that a child had died, and abuse or neglect was a suspected factor.  2.2 Once the decision to conduct a review was made by the Chair of the Rochdale Safeguarding Children Board, all partner agencies were asked to provide a chronology of interventions and an analysis on their agency activities between November 2016, the date the pregnancy of Child E became known to agencies, and September 2017, the date of the death of Child E.     3 2.3 A serious case review panel was established with an independent reviewer appointed. The serious case review panel was mindful that Rochdale had two other concomitant Serious Case Reviews that were specifically considering thresholds of intervention and the approach to step up and down through the application of threshold criteria. The panel, supported by the Local Safeguarding Children Board Chair, made a decision to conduct a lighter touch review in respect of Child as the two other cases (Child Z and Child X1 and X2) were addressing similar issues.  Specific to this review, three specific lines of enquiry were identified:   1. To what extent ME was educated in respect of safe sleeping arrangements for babies; 2. The effectiveness of risk assessment by agencies that had single agency contacts with Child E and ME; 3. The extent to which opportunities to share information were taken across the safeguarding partnership.  2.4 Unusually, but within the context of this being a third Serious Case Review with some similarity and in light of the agreement for a lighter touch review,   practitioners were engaged through the agency panel leads and written reports only.    2.5 The review was conducted alongside an ongoing police investigation for neglect, and the potential for practitioners to be called for evidential purposes to a criminal trial also precluded direct involvement in the review in a timely fashion.  2.6 The Review was conducted through three meetings, written reports from agencies and the debate of panel members and the independent author.  2.7 The criminal investigation is ongoing.  3.       Overview of what was known to Agencies 3.1 Prior to the timeframe for this review, in September 2016 ME self-referred to a Rochdale drug service. After an initial assessment, ME missed one and attended four    4 sessions with a keyworker.  ME asked for her contact to be closed in November 2016, shortly after the closure if the child in need plan, at which point she stated that she was no longer using cannabis but was exhausted looking after two children.  3.2 A CAF meeting in respect of Child E’s elder siblings took place in early November 2016 with ME present. This meeting followed a two month period of intervention by the Early Help Service using the graded care profile as a tool to support ME to address the vulnerabilities that were present for the children. A decision was made to close the CAF because it was believed that ME had addressed the issues of concern. The issues of concern included the effects of ME using drugs on her parenting, and specifically the children missing health appointments.    3.3 The CAF meeting outlined the following:   that ME could initiate contact with a nursery parent liaison officer if she required support in the future;  that ME would be referred to the Children’s Centre and Home Start in order for ME to access low level support to get her and the children out of the house;  the health visitor would continue with routine developmental checks ME had already confirmed the pregnancy of Child E with the GP prior to this meeting but did not share this information.  There was no further multi-agency meeting.  3.4 One week after the meeting, ME attended a midwifery booking appointment for her pregnancy with Child E. ME shared a previous history of drug misuse, stating that she had used cocaine in the past and last smoked cannabis six months previously. ME shared with the midwife that she and had recent involvement with Children’s Social Care.  ME told the midwife that she lived alone with her two children and that FE visited the home on his days off work.  3.5 The booking midwife contacted Children’s Social Care MASH Team to verify what ME had told her and this was confirmed as accurate. The midwife completed a special circumstance form for sharing of information with other health professionals and    5 Children’s Social Care. The special circumstances form was received by Children’s Social Care as information only, and although the midwife recommended that further early intervention may be required, this was not clear from the way in which the information was shared because no multi-agency referral form was completed. 3.6 Two weeks later, the health visitor involved in the previous multi-agency meeting undertook a home in relation to Child E’s half sibling and was advised by ME that she was pregnant. FE was present during the visit 3.7 In late January 2017, the health visitor made a home visit to complete an 8-12 month developmental review of Child E’s half sibling.   During this visit, the lounge was noted to be cluttered with toys but safe for playing. FE was present during the visit. Child E’s half sibling was not yet walking and the health visitor planned to visit further in three months’ time.  3.8      The health visitor made a home visit in May. The developmental assessment of Child E’s half siblings was reviewed with a plan to revisit in three months. The lounge was noted again to be cluttered with toys but safe to play.  3.9        Child E was born in June 2017 at 37 weeks. The GP was sent a notification of birth. The midwife in hospital, aware of ME’s history with multi-agency services contacted Children’s Social Care who confirmed that no actions were required before discharge. Prior to leaving hospital, safe sleeping advice was given to ME.  3.10     Nine days after the birth, ME contacted the police for advice and assistance stating that the father of her eldest child was refusing to return Child E’s half sibling to her care. ME stated that the child normally stayed with the father two days per week, but he felt it was too soon for his child to return after the birth of Child E. ME advised that she was not concerned for the welfare of her child as the father was a good father, but also stated that she did not know where he lived.  The police agreed that they could conduct a safe and well check however ME made the decision to manage the situation without police intervention.      6 3.11 The health visitor arranged a visit for twelve days after Child E’s birth, however no one was home to receive the visit. A further visit was made three days later whereby it is recorded that Child E was observed with both ME and FE who were bonding well. Safe sleeping advice was discussed for a second time as was the effects of passive smoking.  The home was seen to be clean, warm and welcoming. No concerns were identified in regards to ME’s emotional health and the health visitor planned for the next visit to be a routine 6 – 8 weeks assessment four weeks later.   3.12 No one was home to receive the next scheduled health visitor appointment nor a subsequent attempt. Calling cards were left re-arranging each missed appointment and it was the third attempted visit when the family were seen at the home. Child E was asleep in a moses basket when the health visitor arrived, lying with a quilt nestled around the sleeping area. ME was advised to remove the quilt as it posed a risk to overheating and suffocation. Safe sleep advice was re-affirmed at length for a third time and written information was also provided. ME reported herself to be physically and emotionally well but finding three young children demanding. ME was encouraged to access the local sure start children’s centre with the children. The health visitor planned a further appointment for a routine 8-12 month development assessment.  3.13     Child E did not attend a pre-appointed GP appointment at two months old for post-natal check and first immunisations.  The appointment was sent alongside a standard letter sent to all new mothers congratulating on the birth of their baby and advising of the requirement to register the baby with a GP and attend for the eight week check and immunisations. Child E was registered with an alternative GP practice three days before death.  3.14 The eldest sibling of Child E commenced full time school in September 2016. The school had been made aware by the nursery that a CAF had been in place, however, the safeguarding file had not transferred to the school as is standard procedure.     7 3.15 Aged three months, Child E was taken to hospital in cardiac arrest mid- morning. Police investigation has revealed that Child E was put to sleep in a pram at 11 pm and was not checked until 11am the following morning. At which point the baby was unresponsive with a blanket over his head. The police investigation established that ME had been using cannabis the night prior to the death, and that she had left the house between 1 and 2 am in the morning to go to a local garage.  4. Analysis 4.1 Child E was born into a family where two children had been parented for three years without being known to children’s services beyond those universally accessed by all children. The referral to Children’s Social Care in 2016 was a first referral and the undertaking of a child and family assessment through the Early Help Service was proportionate to the nature of concern, the age of the children and ME’s willingness to engage.  4.2 When challenged about the content of the anonymous referral, ME admitted that she had used cannabis and other drugs, but advised this was no longer a feature of her life. Over the two months period, ME was considered to have engaged in the assessment and early help process by accepting that continued use of substances was not compatible with her responsibilities as a parent.  ME’s willingness to accept professional advice and level of insight into the impact of cannabis use on her parenting was accepted as an indicator that she was motivated to change her behavior and prioritise parenting her children. Within twelve months however, and with the addition of a third child, it is now known that ME continued to misuse cannabis and that this this was a contributory factor to the neglect of Child E.  4.3 ME disclosed to the midwife that she had used multiple drugs during the pregnancy of child E, this information would confirm that ME had not ceased using drugs as she had stated to the professionals involved in the CAF.  Such information would normally lead the way to a referral to a specialist midwife who works with substance abusing mothers, however this did not happen because ME had indicated her drug    8 use was a past concern.  The information was not accepted at face value by the midwife who did show a degree of caution by checking the facts as told with Children’s Social Care to ensure that ME had given a truthful account.  The fact that the case no longer remained open to Children’s Social Care influenced the subsequent actions, in that there was an acceptance that the issues of concern were no longer present.  In effect, because the CAF had been closed, ME was seen a woman without a current or ongoing substance misuse problem. The information available to the midwife, just one week after the closure of the CAF, was however critical to reviewing the analysis of potential for risk which was supported by the belief that ME was no longer using drugs. 4.4 The multi-agency meeting that took place in November 2016 was attended by the health visitor, nursery and a key worker from the supporting families’ team who had provided a short prior of intervention to address the issues of concern. The meeting was convened prior to ceasing the supporting families’ team involvement which demonstrated good practice with regard to information sharing across the agencies involved at that time.  The outcome of the meeting focused on assisting ME to access local support networks. The CAF did not continue and therefore there was no further plan to continue multi-agency working.  4.5 At the point of closure, no specific risk was perceived to be present. The risks from substance misuse were accepted as resolved and this was supported by the improved attendance of the children at nursery and health appointments which indicated increased stability and organisation within the family. ME did not share that she was pregnant, although had known this. Her actions would suggest therefore that her level of engagement was superficial, and that she was not working in the open manner that professionals had believed. The actions beyond the CAF meeting were designed to increase ME’s support networks but it was ME’s choice whether to participate. Significantly, ME also ceased the drugs counselling after the closure of the CAF, and her engagement with the service lasted only the length of the multi-agency work.     9 4.6 Had ME worked honestly with services, undoubtedly the process of CAF would have continued to ensure a longer period of support to assist ME to address the issues that were impacting on her parenting. Similarly, had the professionals known that ME was pregnant, they may well have continued the support plan under CAF arrangements. Although ME was considered to have a high motivation for change, she had not been willing to participate in parenting groups such as Webster Stratton, and did not want to access options for community support networks beyond nursery care for the children.  Her engagement with drugs services did not result in any sustained change of attitudes or behavior, whilst her attendance alone may have falsely reassured professionals that she was committed to change.  4.7 The information available to the review would suggest that ME had a history of recreational and habitual drug use rather than an addiction. To professionals this implied that ME could and had made a choice to maintain a substance free lifestyle, free from the challenges of addiction. This review therefore begs the question about how well professionals can be reassured that substance misuse that impacts on parenting is ever really resolved or whether some level of risk will always remain.   4.8 MT reported cannabis to be her drug of choice to be cannabis and cocaine less frequently.  It is true that many parent’s use of drugs does not present a risk of harm to their children. It is also true that many parents who use drugs have chaotic and unpredictable lifestyles that do impact on their ability to maintain stability and safe parenting of their children. For child care professionals, the most common drug use leading to problematic parenting is cannabis and cocaine, and less common is heroin. The use of cannabis has become an increasingly common factor when working with families in early help and higher thresholds of need, to the extent that professionals need to mitigate against becoming de-sensitised to the fact that it remains an illegal drug, and one which when used even intermittently can have highly detrimental consequences for family life.  4.9 The time within which professionals were reassured by ME that risk related to substance misuse was reduced may be a significant factor in the accuracy of their    10 probability judgement. Using a model of change to support the analysis of how effectively change is achieved, professionals are reminded of the significance of the maintenance phase as the route to ensure that change is embedded. While there was evidence to support that the children were experiencing improved standards of care, the ability to sustain this was somewhat untested by the CAF ceasing within two months of commencement.   The risk of re-occurrence was not articulated in the cessation of the CAF, and therefore not addressed in a way which facilitated a pathway for single agency identification of risk factors to lead to a further multi-agency communication.  4.10 The opportunity to review how significant the fact that ME had continued to use drugs was to the welfare of the children was lost to the multi-agency partnership. The three barriers to achieving this was the lack of clarity by the midwife about whether the special circumstances form was intended to be a referral for early help, the absence of a decision to refer to the specialist midwife for substance abusing mothers, and the absence of a clear analysis at the point of CAF closure about the risk and potential impact of continued drug misuse.  4.11  The substance misuse by ME contributed to her impaired ability to provide safe care for Child E who was left for twelve hours without checking in an unsafe sleeping environment. This case is a salutary reminder that abstinence from substances is not always a static factor which means that parenting capacity can change and deteriorate very quickly. The presence of a specialist midwife for substance misuse would have continually re-enforced the messages that ME required and may have eroded her conscious and subconscious attitude to the use of drugs alongside the care of children. A specialist midwife would also have undertaken an ongoing risk assessment which identified the risk and resilience factors including the lifestyle of the partner.  4.12 The chronology shows that ME was slow to respond to GP invitation for Child E to access immunisations.  Non-attendance at medical appointments had been an indicator of the deteriorating functioning of the family leading up to the CAF, and    11 was attributed as an indicator of the effects of ME using drugs. Given the short period of time concerned, it was not possible to identify a pattern, but had this continued, it was likely that a CAF would have been further invoked.  Pennine Care Foundation Trust identified that given the history of CAF, further collaboration with other professionals should have been considered by the health visitor when engagement by ME started to decline and some concern was noted at the 6-8 week development assessment.  4.13 It is evident from the chronology that on three occasions ME was given detailed advice on safe sleeping.  This provides a positive picture of how safe sleeping is being promoted in hospital, midwifery and health visiting services. ME did not heed this advice with fatal consequences for Child E.   5.  Findings and Recommendations  5.1 The early help intervention was agreed by the panel to be a proportionate response appropriately placed within the threshold of need. A short intervention resulted in some positive progress in respect of the children which gave professionals reassurance that ME was committed to changing the factors that were impacting on her parenting, primarily her drug use.  5.2 Shortly after the cessation of the CAF, there was information available within the multi-agency partnership which confirmed that ME had not worked openly and moreover that her drug use had continued. The particular areas of learning can be outlined as follows:  1.    In order to optimise single agency identification of risk following the cessation of CAF, the rationale for closure should identify trigger points to review necessity for further multi-agency sharing of information 2. Understanding multi-agency referral pathways is crucial to professionals’ sharing information with purposeful intent      12 3. Specialist midwives are best placed to support pregnancy of women with a known drug history   4. Professionals must be ever mindful of the cycle involved in achieving lasting change and that motivation, action and maintenance have equal importance when seeking reassurance that change has occurred  5. Professionals must ever mindful of repeated indicators of concern and act collaboratively with other agencies to review indictors of risk  5.3 The review has identified that safe sleeping is firmly embedded into relevant health services.  5.4 The lessons learnt by individual agencies, supported by actions plans are as follows:  5.4.1 HMR CCG   Health agencies need to work together in order to ensure that new born babies are registered with a GP Practice 5.4.2    Pennine Acute Hospital Trust   The need for a clear pathway or assessment for early help referrals by Midwives.  5.4.3    Pennine Care Foundation Trust  The need to engage in early help assessment at the first point of concern when there is a history of previous concern   The need for recordings to give a whole picture of the adults who present with children  and to record reasons for non-engagement  5.5       Multi-agency recommendations      13 1. Multi-agency partners to review guidance ascribed to cessation of CAF to include a risk indicator to support single agency identification of risk to initiate further multi-agency consultation  2. The Board to be provided with assurance about how the role of specialist midwifes is developed and promoted amongst the wider health economy 3. That this review is used as an instructive case scenario to support early help services to understand barriers to best practice      