Death of a baby as a result of a traumatic head injury, which the postmortem concluded could not have occurred without some force. The immigration status of mother was that she had limited leave to remain in the UK following her marriage to father. Father had some learning difficulties, which was not known to mother before the marriage. Prior to Child 1s birth mother, father and Child 2 lived with father's extended family. After moving to their own accommodation mother and father reported that paternal grandfather was physically abusive and controlling and managed their finances, including father's disability allowance. Mother had previously disclosed domestic abuse and unhappiness with father to her GP. Identifies lessons learned, including: significance of mother's vulnerabilities in relation to her arranged marriage, father's learning difficulties, her social isolation and her immigration status; and recognition of the importance of domestic abuse disclosures however low-key they may appear. Makes recommendations covering children's services, GPs, housing, hospital and ambulance services.
      
 Title:  Serious case review overview report in respect of Child 1. LSCB: Bolton Safeguarding Children Board Author: Hester Ormiston Date of publication: 2013  This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC.  This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above.                        SERIOUS CASE REVIEW  OVERVIEW REPORT   In Respect Of  Child 1    Overview report prepared by:-  Hester Ormiston, Independent Author  Signature:-_________________________   Overview Report Endorsed by:-  Mike Tarver, Independent Chair, BSCB   Signature:-_________________________    EMBARGOED UNTIL 10.00 AM ON 27 SEPTEMBER 2013 3  EMBARGOED UNTIL 10.00 AM ON 27 SEPTEMBER 2013 1. Introduction: 1.1 Circumstances that led to the Review Page 3 1.2 Terms of Reference Page 4 1.3 Timescale for the Review Page 5 1.4 Panel Membership Page 5 1.5 Individual Management Reviews & Page 6  Additional Information 1.6 Involvement of other LSCBs Page 7 1.7 Family Composition Page 8 1.8 Genogram Page 9 1.9 Family Involvement Page 10 1.10 Issues of Race, Language, Culture, Religion  Page 11  and Disability 1.11 Media Interest Page 11  2. Overview of what was known Page 11  3. The Individual Management Reviews (IMRs) Page 12  4. Conclusions and Analysis Page 33  5. Summary Page 44  6. Lessons Learned from this SCR Page 46  7. Recommendations:  7.1 Summary of SCR Recommendations Page 47 7.2 Summary of IMR Recommendations Page 47 7.3 Summary of PCT Commissioning  Page 49 Health Overview Report   2  EMBARGOED UNTIL 10.00 AM ON 27 SEPTEMBER 2013 1. INTRODUCTION  1.1 Circumstances that led to the Review   1.1.1 Child 1 was taken to the GP’s surgery by the father, Adult 2 as the child appeared unwell.  The advanced nurse practitioner at the practice examined the child, gave advice and the family returned home.  Once at home, while the mother (Adult 1) was upstairs with Child 2, Adult 2 made himself a drink in the kitchen.  He heard Child 1 crying.  When Adult 1 came downstairs she found Child 1 appeared to have stopped breathing and was floppy.  She ran with the child into the road and a neighbour, who was in the road at the time, rang for an ambulance.  Child 1 was taken by the neighbour back into the family home, Address 4 where he started CPR.  Child 1 was taken with Adult 1 to Hospital 1.  The child was, later that evening, transferred to Hospital 3 and supported by a life support machine but reported to be unresponsive.    1.1.2 The following evening Child 1 was reviewed by an eye specialist who identified evidence of retinal bleeding.  At that stage it could not be confirmed whether it was a consequence of medical intervention or non-accidental injury.  Child 1 died shortly after 9 pm.  1.1.3 A post mortem was conducted and revealed a 4 x 5 cm bruise under the skin on the right hand side of Child 1’s skull.  Under this was a 4 cm linear fracture of the skull.  The brain had haemorrhaged to both sides and blood was evident in both optic nerves.  There were also calcified nodes on the third and fourth ribs at Child 1’s spine on the left hand side.  These appeared to be old injuries but it was not known whether or not they were due to non-accidental injury.    1.1.4 The provisional post-mortem findings suggested that Child 1 suffered a fatal traumatic head injury which could not have occurred without some force being applied to an immobile baby.  Neither parent had an adequate explanation for the injuries.   1.1.5 The information in paragraphs 1.1.1 to 1.1.4 was notified to the independent chair of Bolton Safeguarding Children Board who considered that the circumstances of Child 1’s death were likely to meet the criteria set out in the first part of Working Together to Safeguard Children 2010, namely:-  When a child dies (including death by suspected suicide) and abuse or neglect is known or suspected to be a factor in the death, the LSCB should always conduct a SCR into the involvement of organisations and professionals in the lives of the child and family.  This is irrespective of whether local authority children’s social care is, or has been, involved with the child or family.   3  EMBARGOED UNTIL 10.00 AM ON 27 SEPTEMBER 2013 1.1.6 Ofsted was notified of the details of Child 1 and that a Serious Case Review (SCR) may be held.  An Initial SCR Panel was convened and the information shared at that meeting did suggest that Child 1 died as a consequence of suspected non-accidental injury.  This recommendation was endorsed by the Independent Chair of BSCB and this was shared with Ofsted in writing.    1.2 Terms of Reference (ToR)  1.2.1 Initial agency reports had been prepared by:- • Greater Manchester Police  • Bolton NHS Foundation Trust • General Practitioner, NHS Bolton • Bolton Children’s Services Staying Safe • Bolton Children’s Services, Children and Families Support Service (Children’s Centres) • Bolton Council, Community Housing Services • Bolton at Home   1.2.2 Using the information available from these reports, the Panel agreed the following questions were appropriate as key lines of enquiry in agency individual management reviews (IMRs).  1. To what extent did agencies/services/individuals recognise and take account of Adult 1’s potential vulnerabilities, in particular:- • Age • Language and literacy needs • Immigration status • Marital status • Level of isolation or integration within the local community • Relationship and support offered from wider family members  And what impact did this have on assessments, planning, intervention and outcomes  2.  To what extent did agencies/services/individuals recognise and take account of Adult 2’s potential vulnerabilities, in particular:- • Age • Learning disability/difficulty • Marital status • Parenting capacity • Level of isolation or integration within the local community 4  EMBARGOED UNTIL 10.00 AM ON 27 SEPTEMBER 2013 • Relationship and support offered from wider family members  And what impact did this have on assessments, planning, intervention and outcomes  3.  What opportunities did the agency have to observe parenting capacity and interaction between Adult 1 and Adult 2 with Child 1 and Child 2?  What impact did this have on assessments, actions and services offered at the time?  Is there anything that could have been done differently?  4.  To what extent have assessments and interventions considered diversity issues, including ethnicity, religion, language, disability and cultural issues?  5.  What opportunities did the agency/service provide to Adult 1 and Adult 2 to speak independently of one and other about any concerns or worries they had prior to the birth of Child 1?  On reflection can you identify any learning points?  6.  To what extent did the agency have awareness of domestic abuse issues within the nuclear and extended family?  What was the response of the agency and how did this feature in assessments, planning and interventions?  7.  On reflection were there any opportunities or indicators that suggest CAF processes could have supported multi-agency work?  8.  On reflection were there any signs or indicators that Child 1 was at risk of suffering significant harm or other missed opportunities to safeguard this child?  Where signs and indicators are identified, please clarify any action that was or was not taken and the reason for this.  1.3 Timescale for the Review  1.3.1 The timescale for the review was agreed from the point the family moved to Bolton until the outcome of the post-mortem.    1.4 Panel Membership  1.4.1 The SCR Panel comprised:- • Vlasta Novak, Independent Chair • Hester Ormiston, Independent Report Author • Assistant Director, Bolton Children’s Services  • Detective Inspector, Serious Case Review Team, Greater Manchester Police  • Bolton Council of Mosques 5  EMBARGOED UNTIL 10.00 AM ON 27 SEPTEMBER 2013 • District Manager, Bolton Children’s Services  • Associate Director Safeguarding (Designated Nurse), Bolton PCT  • Consultant Paediatrician, Designated Doctor for Safeguarding, Bolton PCT  • Head of Personalisation & Inclusion, Adult Community Services  • Housing Options and Advice Services Group Manager, Bolton Council Community Housing Services  The Panel was supported by:- • Safeguarding Board Officer (Advisor) • Senior Administrator, Safeguarding Children Board (Minute Taker) • Solicitors from Legal Services, Bolton Council   The Panel met on five occasions on.  The Overview Report was presented and endorsed by BSCB within the required six month timescale.  1.4.2 IMR authors were invited to attend in turn on two occasions for discussion and feedback on each agency report.  The NHS Overview report was discussed at a subsequent meeting.  1.5 Individual Management Reviews (IMRs) & Additional Information  1.5.1 The following agencies were asked to provide IMRs:- • Bolton NHS Foundation Trust (to include midwifery, health visiting and Hospital 1) • General Practitioner services • Bolton Council Community Housing Services • Bolton at Home • Children’s Services Staying Safe and Children’s Centres (combined report)  • North West Ambulance Service,  • North West Transport Service, and • NHS Commissioning Health report  1.5.2 All the IMRs have been prepared by staff or managers who have not had direct or line management contact with the family prior to the death of Child 1.  Each one has been countersigned by heads of service or equivalent.  The panel has considered each IMR, in conversation with the author, offered comments and following some revisions found that they meet the expectations of Working Together 2010.  One IMR is in a different format but provides all the necessary information and analysis to contribute to the overview report.   6  EMBARGOED UNTIL 10.00 AM ON 27 SEPTEMBER 2013 1.5.3 BSCB procedures include an expectation that all IMRs will be closely scrutinised, and if not of sufficient quality will be returned for ‘revision’ to the agency.  This process has been followed by each agency and the reports have been completed to a high standard in written styles which are clear and informative.  1.5.4 In addition to IMRs the SCR Panel requested information from:- • Greater Manchester Police • Bolton Council Adult Services • Bolton Legal Services • Hospital 3 NHS Foundation Trust   These services were asked to provide a letter or report to outline any involvement with the child or their family.  1.5.5 As there was a possibility that the immigration status of Child 1’s mother, Adult 1, could have had some impact on family relationships the United Kingdom Border Agency (UKBA) was asked for any relevant information on her stay in the UK.   1.6 Involvement of other LSCBs  1.6.1 Panel discussed that although the SCR should focus on Child 1’s life it would be useful to have background information from Area 4 where the family had lived prior to Child 1’s birth.  In particular Area 4 services were asked to provide a summary of their knowledge in relation to:- • Adult 1’s immigration and marital status • Adult 2’s learning disability/difficulties assessments, service provided and outcome • Wider family relationships, tensions within these relationships and any domestic abuse issues • Opportunities for agency’s to observe parenting capacity and outcomes from these • Services offered and accessed by the family • Profile of BME communities in Area 4 and how this family functioned within the community or accessed support to meet any diversity needs • Any additional vulnerability issues identified by services in Area 4   This information was requested and submitted by Area 4 LSCB to the SCR Panel.   7  EMBARGOED UNTIL 10.00 AM ON 27 SEPTEMBER 2013 1.7 Family Composition  Anonymised Name Relationship to subject (if applicable) Address Ethnicity or diversity issues Child 1 Subject Address 1 Pakistani/British Muslim Child 2 Sibling Address 1 Pakistani/British Muslim Adult 1 Mother Address 1 Pakistani Muslim Adult 2 Father Address 1 Pakistani/British Muslim Adult 3 Paternal Grandmother Address 2 Pakistani Muslim Adult 4 Paternal Grandfather Address 2 Pakistani Muslim Adult 5 Paternal Aunt Address 3 Pakistani/British Muslim Adult 6 Maternal Uncle Address 3 Pakistani/British Muslim    8  EMBARGOED UNTIL 10.00 AM ON 27 SEPTEMBER 2013 1.8 Genogram                           Child 1   Child 2              Deceased     Adult 1 Mother  Adult 2 Father   Adult 6 Maternal Uncle  Adult 5 Paternal Aunt  Adult 3 Paternal Grand-mother Adult 4 Paternal Grandfather Not Known 9  EMBARGOED UNTIL 10.00 AM ON 27 SEPTEMBER 2013 1.9 Family Involvement  1.9.1 The panel considered that it would be appropriate to ask Child 1’s parents, Adults 1 and 2, and the close family members living in Bolton if they wished to make any comment on the services provided across Bolton.  1.9.2 As it was important that any legal process should not be compromised, it was agreed that the independent SCR chair would write initially to Adults 1 and 2 via their solicitors to inform them of the SCR process.  On police advice a list of questions was submitted to the Senior Investigating Officer who confirmed that they were unlikely to elicit responses which might compromise any criminal proceedings.  These were sent with a further letter to the solicitors of Adults 1 and 2.  1.9.3 A letter was also sent to Adult 5 to invite her comments.  Adult 5 contacted the Safeguarding Unit, asking to meet with a Panel representative and BSCB officer.  The Panel Chair and BSCB Safeguarding Officer met with Adult 5.   1.9.4 Adult 5 considered that the services provided to the family had been good.  She commented that perhaps more practical information could have been given to Adult 1, who may have found it more difficult living as a ‘single’ family; that is, not living with the extended family who would ordinarily provide care to any child in the household.  Additionally Adult 5 noted that the service provided at Children’s Centres is good, but could provide more focussed support for parents while the children play together. It would also be useful if the service was specifically extended to fathers as well.  It was agreed that further contact would be made with the family prior to publication.  1.9.5 Following endorsement by Bolton Safeguarding Children Board and in preparation for publication further engagement was undertaken with the family.  Adult 1, Adult 2 and Adult 5 all had the opportunity to read the report in full before publication.  In response to their feedback it was agreed with Bolton Safeguarding Children Board Independent Chair that all dates, as well as gender references relating to the children would be removed from the report.  It was agreed this did not detract from the learning.  1.9.6 Adult 1 also wished to state she disputes the record that she was not happy with the second pregnancy.  She has reported that this was a planned pregnancy, she was happy about this but she was unhappy with the circumstances between her and Adult 2. In response to this feedback it was agreed with Bolton Safeguarding Children Board Independent Chair that this would be noted in the report but this is what she is believed to have said at the time.  10  EMBARGOED UNTIL 10.00 AM ON 27 SEPTEMBER 2013 1.10 Issues of Race, Language, Culture, Religion and Disability  1.10.1 Adult 1’s immigration status was that she had leave to remain in the UK for a period.  The family are Muslim with Adult 1 speaking both Urdu and Hindi.  The marriage between Adults 1 and 2 took place in Area 3, possibly by Sharia law, with no UK civil marriage; Adult 2’s family live in Area 4.  Adult 2 has been in receipt of some disability benefits because he has a learning difficulty.   1.11  Media interest  1.11.1 There was local and national media interest on the day Child 1’s parents were interviewed by the Police, following a Police press statement about a murder investigation.  The Panel considered there was likely to be further significant media interest in the SCR and any enquiries would be dealt with jointly via the Council and Greater Manchester Police’s press offices.     2. OVERVIEW OF WHAT WAS KNOWN  2.1 Background information provided by Area 4 Safeguarding Children Board indicates that Adult 2 lived with his extended family from birth in Area 4.  As a child he had few health needs but details of his education are held in some health, education and Connexions records as from the age of twelve he attended a school for pupils with moderate learning difficulty.  In particular Adult 2 was unable to read, write and communicate in line with his chronological age, and had poor concentration.   2.2 Both Adult 2 and his father, Adult 4, have a police record, each having one offence relating to motor vehicles; Adult 4 also has a conviction for Possession of a Controlled Drug and Adult 2 was interviewed for supplying a controlled drug.  2.3 Adult 2’s sister, Adult 5 also lived with the family, and her husband, Adult 6, joined them when they married.  The records suggest that Adult 2 had another sister, as there is a note of her alleging rape when she was seventeen years old.  Adult 6 was arrested and charged but the statement was withdrawn.    2.4 Adults 5 and 6 left the family home in Area 4 at some point that predates the Terms of Reference and moved to Bolton.  They reported that they found Adult 4 intimidating and controlling.   2.5  Adult 1 had joined the extended family from Area 3 and Child 2 was born.  Adults 1 and 2 moved to Bolton, asking for assistance from the police to collect their belongings and Child 2 from the family home.  At the time Adult 1 reported that she was not allowed to contact her family in Area 3; later the couple told agencies in Bolton that Adult 2’s father used to hit him, as well as dictating what they could and could not do and managing their benefits, including Adult 2’s disability allowance.  11  EMBARGOED UNTIL 10.00 AM ON 27 SEPTEMBER 2013 2.6 When Adults 1 and 2 moved to Bolton they lived with Adults 5 and 6.  Adult 5 provided them with support to apply for their own tenancy.  They presented as homeless, accepting that immediate homelessness was not likely.  However the couple presented a second time, as the lodging arrangements were no longer sustainable.  A house was allocated, which the family moved into after refurbishment.  As part of the housing application Bolton Community Housing Services checked the immigration status of Adult 1 and were told of her ‘limited’ leave to remain; they also confirmed via routine checks that Adult 2 was entitled to additional benefits because of his disability.   2.7 Child 1 was born eight months after Adults 1 and 2 moved with Child 2 into their furnished home rented from Bolton at Home.  The tenancy was in Adult 2’s name only possibly as a consequence of Adult 1’s immigration status.  As Adult 2 was aged under 25 years, the family had a Tenancy Action Plan as part of the Tenancy Sustainment Service.  This meant the family had regular visits from a Support Officer.   3. INDIVIDUAL MANAGEMENT REVIEWS  3.1 Bolton Community Housing Services   3.1.1 Community Housing Services provides a range of housing and access related services including management of the housing register and choice based lettings, homelessness and housing advice.  It is the first agency any person seeking housing in Bolton would attend.  3.1.2 The IMR has been prepared by the Head of Community Housing and countersigned by the Chief Planning and Housing Officer.  The author has an overview of all housing services that would have been relevant to the family.   3.1.3 The report uses information from case notes and staff interviews:- • Homelessness presentation case file  • Homelessness presentation case • Homelessness prevention case file  • In electronic records (OHMS, the Integrated Housing Management system).  This system holds details of housing applications, allocations and rent accounts  • Interviews with two staff members who provided the service to the family; one staff member has retired but had maintained detailed case notes  3.1.4 The front page of the report gives a brief profile of the agency responsibilities giving context to the rest of the report.  The report includes responses to a number of standard questions for an IMR which are helpful, but leads to some repetition of information which specifically addresses the key lines of enquiry.   12  EMBARGOED UNTIL 10.00 AM ON 27 SEPTEMBER 2013 3.1.5 Community Housing Services had four direct contacts with Adults 1 and 2.  Three were at the Housing Options Centre, where Adult 2 was helped to make an application for housing and when homelessness was imminent, documents were checked and a tenancy offered.  The family was visited at Adult 5’s home to confirm the circumstances of the potential homelessness, and to clarify immigration status and any specific needs.  Adult 2 was advised to attend the appointment to check he had the capacity to sign a tenancy agreement.  3.1.6 The involvement of Community Housing Services ended prior to the family’s move to their own tenancy and Child 1’s birth.  3.1.7 The service had limited opportunity to observe the family.  However the records on the family’s presentation show how the agency systems, training and supervision support staff to record contacts in a manner that takes account of abuse both to children and adults, as well as consider any disability or cultural needs.  3.1.8 The IMR concludes that the service provided to Child 1’s family followed all procedures, in a ‘professional but attentive and caring manner’.  There is one recommendation that in all contacts a record of all people present should be maintained.   3.2 Bolton at Home  3.2.1 The agency is a registered social housing provider, having taken over ownership and management of Bolton local authority housing.  It provides a range of housing services to 18,000 tenants.  3.2.2 The IMR has been prepared by the Customer Support Manager who has responsibility for services to older and vulnerable customers and countersigned by the Director of Housing Services.   3.2.3 The report has been prepared from paper records:- • The Tenancy Sustainment Service agreement  • Home visit records • Customer overview records detailing all contacts • Introductory Tenancy Progress checklist • Initial STeP assessment completed by Adults 1 and 2  • Tenancy records held in the local housing office  • Notes from an interview with a staff member after the notification of Child 1’s death  Computer records consulted were:- • OHMS allocation of tenancy records • Repairs lists 13  EMBARGOED UNTIL 10.00 AM ON 27 SEPTEMBER 2013 • Tenancy records on ethnicity, and • CORE lettings log  3.2.4 The author was unable to interview the two staff members who provided services as one had retired and the other (Support Officer 2) had left for another post.  However the staff member who has retired (Support Officer 1) had all but one of the contacts with the family and was interviewed as noted above, prior to the SCR but after the serious incident notification to local services from BSCB; the notes provide some detail for the IMR.  3.2.5 Additionally because Adult 2 was aged under 25 years, the family was referred to the Tenancy Sustainment Service and, following completion of an assessment, a ‘Successful Tenancy Plan’ (STeP) was completed.  However the paper record of the assessment and plan completed when the tenancy was taken up cannot be found after a search in the agency.  These documents would have provided more detailed information given directly by Adult 1 and Adult 2 and their acceptance of a level of support.  3.2.6 Initial contact with Adult 2 was in writing when he accepted the offer of the tenancy.  When the tenancy was ready for use Support Officer 1, assisted Adult 2 to apply for a furniture package and completed the STeP.  3.2.7 Support Officer 1 visited three times soon after the family moved in but had no contact, leaving a card asking them to make contact.  3.2.8 Support Officer 2 visited for a two month review and noted that although the family had not responded to the request for contact, the tenancy was well maintained and the family reported they had support.  Over the next nine months Support Officer 1 made eight visits, of which the family were at home for five.  In addition to this Adult 1 proactively sought advice from Bolton at Home to:- • Obtain a back door key • Resolve an issue with housing benefit • Additionally over the months, some nearby trees had to be cut down, and then damp appeared in the kitchen and later in one of the bedrooms.  Adult 1 telephoned to say that no progress had been made on treating the damp.  This was the day after Child 1’s birth.  3.2.9 The records note that during the visit Adult 2’s sister and husband with their baby were present and had been for all visits to date; it is noted that Adult 1 is looking forward to the birth of Child 1; and when the damp was noticed in the kitchen, that the baby was due.  14  EMBARGOED UNTIL 10.00 AM ON 27 SEPTEMBER 2013 3.2.10 The records do not always note who was present when contact was made, but they suggest that the family have good support from Adult 2’s sister and from neighbours.  However the notes also indicate that Support Officer 1 may have thought that Adult 2 was in breach of his tenancy agreement by allowing his sister and family to live with them.  Adult 2 denied this and Adult 5 was not seen following the comment.  3.2.11 The report concludes that the service monitored and offered support appropriately to Adult 1 and Adult 2, but that there are three areas for improvement, forming recommendations.  These are that:- • Key documents like the assessment and STeP plan should be computerised • Where there is a ‘no contact’ visit, procedures should be reviewed to ensure there is regular contact with tenants • Records of home visits should record who is present with more description of the conversation and observations  3.3 Children’s Services – Staying Safe  3.3.1 The Staying Safe Division of Children’s Services has responsibility for Children’s Centres, Family Support Teams and all Social Work teams (including Referral and Assessment (R&A), Safeguarding, Looked After Children, Emergency Duty team (EDT), Leaving Care, Youth Offending Team (YOT), Independent Reviewing Officers (IROs) and other Child Protection workers (including Local Authority Designated Officer for safeguarding, Local Safeguarding Children Board Officer, Safeguarding in Schools Officer, CAF Co-ordinator).  The work spans levels 2-4 of Bolton’s Framework for Action; however, the Family Support, Social Work and IRO teams only work at levels 3 and 4.  3.3.2 The IMR has been prepared by the Head of Service, Child Protection and Leaving Care, who has responsibility for Safeguarding, Common Assessment Framework (CAF), IROs and the Leaving Care Service.  It is countersigned by the Director of Children’s Services.  The report reviews services provided by Children’s Centres, the R&A Team and the EDT.  3.3.3 The report has used electronic social work records of case notes, emails, contact records, initial assessment and strategy discussions, as well as paper and electronic records from two Children’s Centres:- • IT records of registration and attendance • The registration form • Records from the crèche • Multi Agency Resource Panel (MARP) referral and panel minutes   Additionally two Children’s Centre managers and a family worker, three social workers and two emergency duty social workers were interviewed.  15  EMBARGOED UNTIL 10.00 AM ON 27 SEPTEMBER 2013 3.3.4 The first contact with Children’s Services was when Adult 1 and Child 2 registered at Children’s Centre 1, the nearest centre to their address while living with Adult 5.  They attended nine drop in activities.  After a four month gap, they attended one more drop in activity and Child 2 went into the crèche while Adult 1 attended one ESOL (English for Speakers of Other Languages) class.  There was no concern reported from any of these sessions and this pattern of attendance is normal.  The service is available for parents (usually mothers) to use when they wish with no action if they do not attend.  It was also noticed when preparing the IMR that Adult 1 had attended once at Children’s Centre 3.  3.3.5 Adult 1 began attending for ante-natal care at Children Centre 2 coming five times until a week before the birth of Child 1.  At Children’s Centre 1, Adult 1 used the name she had used for her Children Centre registration but at Children’s Centre 2 she sometimes used a different name, but the same as the one she used for NHS records.  3.3.6 About two weeks after Child 1 was born, a referral was made to the MARP for family support from Children’s Centre 2.  When the family worker contacted the home to arrange a visit, Adult 2 answered the telephone and only said ‘No, No, No’.  The family worker then agreed to make a joint visit with the referrer, Midwife 8, but for personal reasons was not able to contact Adult 1 before Child 1’s death.   3.3.7 The referral had not indicated a level of priority at a time when the Children’s Centre resources were stretched.  A follow up to the brief details originally recorded on the referral noted that:- • Adult 2 had learning difficulties not known to Adult 1 at the time of their marriage • Child 2 also had some developmental delay • Child 2 was in receipt of Speech Therapy services • Child 2, Adults 1 and 2 all slept in one bed in the lounge because of damp in the bedroom • The family was struggling financially as they were repeatedly repaying money claimed from Department for Work and Pensions by relatives in their name • Adult 1 was isolated and struggling without support  3.3.8 On the day of Child 1’s admittance to hospital, the R&A social work team was contacted by Hospital 3 notifying of the imminent death of Child 1, with brief details of the circumstances of admission to the local hospital, medical condition and that at present the cause of death did not appear suspicious.   16  EMBARGOED UNTIL 10.00 AM ON 27 SEPTEMBER 2013 3.3.9 Hospital 3 notified the emergency duty team that because of the retinal bleeding found by an eye specialist, non-accidental injury could not be ruled out.  Later EDT was notified that Child 1’s death had occurred.  Senior managers were informed of the death.  Following senior manager’s discussions and decisions the GMP Public Protection Investigation Unit was informed.  Both GMP and Children’s Services knew that a post mortem would be conducted and no action would be taken until information was available from it to confirm the cause of Child 1’s death.  3.3.10 As soon as the EDT knew that Child 1 had died, agency checks were made with Area 4 Children’s Services as Hospital 3 indicated that the family had returned there with Child 2.  Following some negotiation and when the death of Child 1 was identified as potentially non-accidental, Area 4 Children’s Services’ EDT visited the family with the local police. They observed that Child 2 was safe and well.  The negotiation for a home visit by Area 4 Children’s Services was supported by GMP PPIU.  Adult 1 and Adult 2 were advised to return to Bolton (and that they cannot have direct care of Child 2).  3.3.11 The R&A team and EDT only had contact with the family from the time of Child 1’s admission to hospital and the procedures were followed properly with senior managers informed and updated appropriately.  3.3.12 The review of the Children’s Centre services has raised some suggestions for change.  The agency is conscious that the service is a universal service provided with the intention of welcoming parents from the community who may be less willing to attend if they thought their parenting was being monitored.  However the IMR makes four recommendations that:- • Staff should be trained to ensure that registration details are completed more fully or with explanations for any gaps • The signing in sheet should note if the person attending is registered or not (registration is not required to attend) • The service should consider the development of a brief record for each session, noting the title, learning for the parents, and which adults and children were present • The referral process for MARP should be reviewed to ensure a CAF is completed if more than one agency is in contact with the family  3.4 Reports included in the NHS Bolton Commissioning Report  General Practitioner  3.4.1 Child 1’s family were registered with two different general practitioner practices (GPs), the first was close to the address of Adult 5.  They registered with the second practice which is close to Address 1 after they moved into their own tenancy.   17  EMBARGOED UNTIL 10.00 AM ON 27 SEPTEMBER 2013 3.4.2 The IMR was prepared by the GP clinical advisor for NHS Bolton and countersigned by the Associate Medical Director, NHS Greater Manchester.  The author interviewed two GPs and the Advanced Nurse Practitioner (ANP) from the current practice, and read the records for Child 1 and Child 2, and Adults 1 and 2 from both practices.  The chronology only contains contacts directly involving Child 1, but the narrative includes some historical information from the first GP practice where it is relevant to the key lines of enquiry.  3.4.3 Child 2 had been diagnosed with an iron deficiency as part of routine health visiting screening and had been referred to dietetics.  Child 2 was also receiving speech and language therapy input.  The GP notes do not indicate any concern for wellbeing.   3.4.4 Historically Adult 2 had input from his GP in Area 4 for his learning difficulty but there were no recordings linked with this in the Bolton records.  3.4.5 The only significant record for Adult 1 was a record made (in the first Bolton practice) where she had told the GP that Adult 2 had hit her and she did not want another pregnancy.  She was given advice and a telephone number to ring if she wanted support.  3.4.6 Child 1 was seen three times at the surgery.  The first occasion is recorded as a query about jaundice and the midwife visiting the surgery agreed to follow up as a routine part of their service.  The second visit resulted in an admission to Hospital 1 as the child was vomiting and had ‘motley’ skin which can be an indication of a serious illness.  Child 1 was discharged the same day with a prescription for anti-reflux treatment which the parents collected from the GP practice two days later.  3.4.7 The day of Child 1’s final admission to hospital parents had earlier requested a GP appointment.   Following the request for a same day appointment, the Advanced Nurse Practitioner (ANP) saw Child 1 with Adult 2.  She saw from the notes that there had been a previous concern with vomiting and she concluded that the problem was a continuation of reflux.  She examined Child 1’s chest and abdomen but did not remove all clothing.  She advised a review if the condition deteriorated.  3.4.8 None of the practitioners considered that there were any cultural or language issues, with both parents communicating clearly and understanding responses.  There was also no evidence of Adult 2’s learning difficulty noted in the records.   3.4.9 The narrative picks up two issues that should have been responded to differently.  The first is that with such a young baby, the ANP should have removed the clothing to examine fully and have made an accurate record of alertness.  The post mortem of Child 1 suggests that the death would not have been prevented by such action, but it is good practice.  18  EMBARGOED UNTIL 10.00 AM ON 27 SEPTEMBER 2013 3.4.10 The second issue is that GP Practice 1 gave advice to Adult 1 about seeking help when she revealed some domestic abuse, but did not note it in the records in such a manner that it would alert other practitioners in the practice, and did not notify the health visitor.  This should be a routine response especially as there was a pre-school child in the family.  If the health visiting service had knowledge of the issue more enquiries probably would have been made when Child 1’s pregnancy was known.    3.4.11The IMR suggests that cultural issues could potentially have prevented Adult 1 from seeking further help or advice.  It is known that the GP gave Adult 1 a Children’s Services telephone number to ring for advice.  It would have been more appropriate if details had been given of culturally appropriate services which are available in the local community.  The records do not note if the GP explored further the content of the information, for example the frequency or severity of the abuse.  3.4.12 The IMR notes that both GP practices provided a good quality primary care service to the family; in particular good practice in guaranteeing that young children are seen on the same day and that practitioners are all well qualified and experienced in paediatric health.  However the IMR identifies the issues in paragraphs 3.4.9, 3.4.10 and 3.4.11 as recommendations to share with all Bolton GP practices.   3.5 Bolton NHS Foundation Trust  3.5.1 Bolton NHS Foundation Trust was created from local community and hospital based services.  This SCR is the first completed since the services came together under one management structure.  The IMR has used the SCR opportunity to check consistency of understanding and use of procedures within different sectors of the organisation.  This means that some learning is not directly linked to the SCR but will contribute to improved safeguarding responses across the new Trust Arrangements.  3.5.2 The IMR has been prepared by the Trust’s Named Nurse Safeguarding Children and countersigned by the Associate Director of Patient Safety/Deputy Chief Nurse, Bolton NHS Foundation Trust.  To complete the report, the author has read:- • The health visiting records (including those from Area 4) for Child 1 and Child 2 • The midwifery records for Child 1 and Adult 1 • Hospital 1 records of Child 1’s admission  • Accident and Emergency records for Child 1 from Hospital 1   The author interviewed the health visitor, the health visiting staff nurse, the midwife and paediatrician.  The author did not review the records of the therapy services provided to Child 2, and the panel confirmed that sufficient detail of service delivery and parenting of both children had been gained from the primary health service records and interviews. 19  EMBARGOED UNTIL 10.00 AM ON 27 SEPTEMBER 2013 3.5.3 The records from the health visiting and midwifery service are completed to a good standard, and include good detail of who was present, the focus of the contact and a summary of discussion.   3.5.4 The health visiting service contacts mainly concerned Child 2 starting with a detailed assessment being completed.  Both adults reported they were in good health and Adult 1 said she had no concerns in relation to personal safety or domestic abuse. It is not known if Adult 2 was present while domestic abuse and personal safety issues were discussed.  The family was not unusual in that Adult 2 was present less often, but when there he demonstrated appropriate care and concern for Child 2.  3.5.5 The focus of most visits was attention to some developmental needs of Child 2, linking with speech, diet, play and sleep pattern.  Appropriate referrals were made to specialist services and when the health visitor was giving detailed advice on diet, she arranged to visit with an Urdu speaking interpreter.  However the record confirmed that Adult 1 spoke English sufficiently well to understand the content of health visiting and midwifery contacts.  3.5.6 Discussions covered matters concerning benefits, progress on audiology and speech therapy appointments and encouragement to attend activities at the local children’s centre to give Child 2 more opportunities to play.   3.5.7 Adult 1 attended all her ante-natal appointments and was well during the pregnancy.  It was recorded that both adults were happy to be having a second child.  The records note however that there were continuing difficulties with Child 2’s development and behaviour.  Child 2’s blood count had improved with a varied diet and medication.  3.5.8 Adult 1 indicated that she and Adult 2 planned to separate as he was reported to have started a new relationship.  In the same conversation Adult 1 said she was concerned that if Adult 2 took Child 2 to the family in Area 4 when she went into hospital for the birth of Child 1, she may not be able to get Child 2 back.  Adult 1 reported that Adult 2 planned to return to live with his family, but that he would look after Child 2 in Bolton during her hospital admission.    3.5.9 Towards the end of the pregnancy Adult 1 discussed finding a nursery placement for Child 2.  Just before Child 1’s birth, Child 2 missed some routine health appointments but this was not considered an indicator of compromised parenting, but rather due to the imminent birth.  3.5.10 Child 1 was born by normal delivery at Hospital 1 and was discharged home.  When the midwife visited the family was sleeping downstairs as they said the bedroom was damp.  Child 1 was over wrapped and advice on safe sleeping was given as expected in BSCB’s recent initiative called ‘Sleep Safe’.    20  EMBARGOED UNTIL 10.00 AM ON 27 SEPTEMBER 2013 3.5.11 Adult 1 took Child 1 to the surgery. She saw the GP about a concern that Child 1 had jaundice, and separately she saw Midwife 1 about the umbilicus.  The records note that Adult 1 was tearful.  Adult 1 described the earlier abuse from Adult 2’s family and said she wanted her family to come to stay from Area 3.  The midwife reported this information to her colleague who visited the family, but had no further discussions about family circumstances.  3.5.12 Child 1 developed well, putting on weight appropriately.  Just prior to discharge from the midwifery service to the health visitor and GP, Midwife 8 discussed the issues Adult 1 had raised with her colleague.  Following this discussion Midwife 8 made a referral for family support.  3.5.13 Health Visitor 2 completed her primary visit and recorded discussion of key issues on safe sleeping, feeding, immunisation and skin care, as well as the family situation.  The adults reported they were applying for rehousing as a family.  3.5.14 The records indicate no concern of the care of either Child 1 or 2.  Child 2 was referred by an ophthalmologist to a paediatrician because of some unusual behaviour, for example hand flapping, limited language, tantrums and repetitive behaviour.  Child 2 had not been seen by the paediatrician at the time of Child 1’s death. In line with the universal service as part of the Healthy Child Programme, Health Visitor 2 had no further direct contact with the family, but kept in touch by telephone and from records received from the GP practice.  3.5.15 Other than the birth of Child 1, Hospital 1 had contact with the family when Child 1 was admitted following presentation at the GP surgery with vomiting.  Child 1 was discharged the same day with a prescription for anti-reflux therapy.  The final contact was the admission of Child 1 for cardiac arrest.  3.5.16 The IMR acknowledges the wide range of issues discussed by health visitors and midwives with Adult 1.  While there were some clues that Adult 1 felt isolated there were also a number of protective factors, including attending the Children’s Centres for activities, attendance at ante-natal care, family members visiting and using community resources.  3.5.17 Staff Nurse 1 took care to ensure that an interpreter was present to speak in Urdu when she was giving detailed information but Adult 1 had a good understanding and kept dietary records in good English.  Other than the abuse in Area 4 the staff had no concerns about the adults as parents.  When matters of diet or over wrapping were pointed out, the family responded appropriately and immediately.  Adult 1 found it more difficult to consistently implement the advice given in respect of Child 2’s routines but she co-operated with staff at all times.  21  EMBARGOED UNTIL 10.00 AM ON 27 SEPTEMBER 2013 3.5.18 While Adult 2 was seen less often (four times), there were no concerns about his parenting; he demonstrated a good relationship with Child 2.  Importantly none of the staff identified any issues as a result of him having a learning difficulty.  Learning difficulty was not evident in his ability to manage and respond to the needs of Child 2.  This was a professional judgement made from a number of observations and not formal assessment or further enquiry being undertaken to consider if his learning difficulty had any impact on his parenting.  3.5.19 The only indicator of risk noted was that both parents were young, but both approached parenting with maturity.  Adult 1 had three opportunities to talk about domestic abuse from Adult 2, but on each occasion said she had no concerns for her personal safety.  At the last direct contact, both adults seemed relaxed and comfortable with each other.  Staff are experienced in signs of abuse or difficult relationships, but did not find this to be the case for Adult 1 and 2.   3.5.20 The IMR identifies three areas where the service could have made further assessments or enquiries. These are:- • The impact of Adult 2’s learning difficulty on his parenting • The family isolation, especially Adult 1 • In the context of the social isolation, how extensive was the support provided by the wider family when Child 2 was born  Overall however there was no evidence of significant harm.  3.5.21 The report notes that the family were provided with good health services, with a child centred focus, good relationships with community NHS staff, referrals as needed for other services, and attention given to culture and language.  However as noted in paragraph 3.5.1 the SCR has given an opportunity to consider the provision of a child focussed service in the context of the whole Bolton NHS Foundation Trust.   3.5.22 The recommendations relate to:- • Awareness of the vulnerability of infants to include all services in community and acute setting • All services have up to date knowledge and skills about domestic abuse • Raise awareness with relevant staff about the CAF process specifically when to start a CAF and CAF skills • Exploring children’s identity issues when health services are provided • Assessment and recording in relation to attachment • Review of oversight of the work of support staff in health visiting teams- specific to health visiting Teams • Consider implications of research and practice developments in other areas for keeping infants safe 22  EMBARGOED UNTIL 10.00 AM ON 27 SEPTEMBER 2013 • Remind relevant Foundation Trust staff of the SUDC process in relation to ensuring that contact has been made with the police  3.6 North West Ambulance Service (NWAS)  3.6.1 NWAS provides emergency and non-emergency pre-hospital medical care to all patients throughout the North West Region.  It also provides patient transport services for those patients unable to travel independently to and from hospital.  3.6.2 The IMR has been prepared by the Safeguarding Practice Manager and countersigned by the Head of Clinical Safety.  The report is written using the electronic records from the Sequence of Events (SOE) of the Emergency Service Control and Command System and the clinical record completed by the attending crew with details of the incident, patient observations, clinical interventions and treatment.  The three staff who attended the emergency call were interviewed by the police and the records of these have contributed to the IMR.   3.6.3 NWAS has maintained two separate databases of vulnerable children and adults since 2006.  There had been no referrals for any adult or child from Address 1.  3.6.4 An emergency call made by a passer-by was received (this was about seventy minutes after the appointment, in paragraph 3.4.7 above at the GP practice).  The address was logged and the patient identified as a child of a few months who was in the mother’s arms but not breathing or conscious.  The call was coded as ‘urgent’ using standard government codings and initially a single crew Rapid Response vehicle was allocated.  The coding was then upgraded to ‘priority’ and a two person ambulance allocated.  A different Rapid Response vehicle with a paramedic who had paediatric training and a different ambulance with two staff became available closer to Address 1.   3.6.5 The vehicles arrived at the address.  The Rapid Response paramedic found Child 1 inside Address 4 receiving cardio-pulmonary resuscitation from the male caller.  He picked up the baby and proceeded to the ambulance and, with the ambulance senior paramedic, continued to provide treatment using a bag valve mask and then a defibrillator.  3.6.6 Initially Adult 1 was in the ambulance with Child 2, but she took Child 2 back into the house, and was taken back to the ambulance by the Emergency Medical Technician to travel to the hospital.  3.6.7 The ambulance crew alerted the hospital of the nature of the emergency, arriving at Hospital 1 shortly after.  23  EMBARGOED UNTIL 10.00 AM ON 27 SEPTEMBER 2013 3.6.8 During the journey the Emergency Medical Technician asked Adult 1 what had happened.  The conversation was difficult because of Adult 1’s limited English at that time, but by asking ‘yes/no’ questions and with gestures, a picture of events was described, of the visit to the GP, and Adult 1 coming downstairs and seeing that Child 1 ‘wasn’t right’.  3.6.9 At the hospital the technician stayed with Adult 1 until a nurse came to take over her care.  3.6.10 The IMR notes that the service met all expected practice standards, notifying NWAS Support Centre of a possible Sudden Untoward Death of a Child.  The exception was that the records show that the Emergency Control Centre did not notify the police.  3.6.11 The IMR makes two recommendations.  The first is to remind all staff that Language Line is available as an emergency service to ensure crucial information can be noted prior to arrival at hospital; the second is to ensure the review of Sudden Untoward Death of Children procedures are urgently updated to stress the need to notify the police when the service takes a child to hospital when there is an Acute Life Threatening Event or a Sudden Untoward Death.  The failure to report to the police has been noted in a previous SCR by NWAS.  The importance has to be stressed as it prevents contamination of a possible crime scene.    3.7 North West and North Wales Paediatric Transport Service (NWTS)  3.7.1 NWTS was set up to transport by ambulance any critically sick or injured child from general hospitals to the nearest paediatric intensive care unit (PICU).  The service provides paediatric specialist NHS staff (doctors and nurses) to manage the care during transport, as well as advice support on patient management before transfer or when transfer is not possible.  3.7.2 The IMR was written jointly by the lead consultant and lead nurse and countersigned by the Clinical Nurse Manager.  The report is based on written reports, telephone records and interviews with staff.  3.7.3 The service contact with Child 1 was brief from the first contact to when the handover to Hospital 3 PICU took place.  The timing of the call meant that two teams of staff were involved, the daytime team handing over to the night team.  The first team spoke to the family on arrival at Hospital 1, and the night team spoke to them on arrival at Hospital 3.  3.7.4 The narrative in the IMR notes that the consultant at Hospital 1 was asked to check if Child 1 was known to the local safeguarding team, because of the uncertainty of the cause of the cardiac arrest although the notes of examination are clear that there was no external sign of NAI.  It is noted in the chronology as well as the narrative that the possibility of NAI was discussed at handover to Hospital 3.  24  EMBARGOED UNTIL 10.00 AM ON 27 SEPTEMBER 2013 3.7.5 The service always follows up to find out the progress of patients within 24 hours of the transfer.  NWTS was told Child 1 was very poorly and later notified of the death, and the referral to the Coroner.  3.7.6 The IMR notes that recording for Child 1 did not meet the expected standard, as two sets of documents had been completed.  The second set made an assumption that history taking and examination had been completed prior to arrival at Hospital 3.  Also the paperwork, although safeguarding concerns had been highlighted as a possibility, did not record what action had been taken to refer to the relevant agency.  Additionally the review identified that the driving staff at present do not have any safeguarding training.  3.7.7 All three of these points have been included as recommendations for the service.  3.7.8 The IMR is not presented in the same format as other IMRs, but because of the limited contact with the family, all the necessary information is evident in the report.  3.8 Hospital 3 NHS Foundation Trust  3.8.1 Hospital 3 NHS Foundation Trust is one of two specialist Paediatric Tertiary Centres in the North West of England providing medical care for very sick children.  The paediatric intensive care unit regularly manages the care of children who then become the subject of SCRs and so has in place procedures that recognise the uncertainty that can surround the cause of admission.   3.8.2 The addendum IMR was prepared by a Nurse Consultant, the named nurse for Safeguarding Children and countersigned by the acting Director of Nursing and Executive Lead for Safeguarding.  It was agreed that Terms of Reference used by other IMR authors were not fully relevant; instead the IMR (referred to as an addendum IMR for this reason) used the following questions for analysis:- • What opportunities did the agency have to observe parenting ability and interaction between Adult 1 and Adult 2? • What impact did this have on assessments, actions and services at the time and were these all appropriate? • On reflection were there any signs or indicators that Child 1 was at risk of suffering significant harm?  • Did all agencies and professionals give due and proper consideration to all diversity issues, including ethnicity, religion, language, disability, culture, social background and integration?  • Did all agencies keep the child and their experiences at the centre of their assessments of and interventions with the family?  • Were information sharing and communication systems within and between agencies and across boundaries effective?  25  EMBARGOED UNTIL 10.00 AM ON 27 SEPTEMBER 2013 • Was record keeping and documentation of an adequate standard?  To prepare the report the author used the paper and electronic records created at the hospital and the NWTS transfer information.  3.8.3 The report gives in detail not only all the medical interventions and notes of Child 1’s deteriorating condition, but also every communication between staff and between staff and the family.  Child 1 was admitted and died shortly after with parents present.  3.8.4 The report demonstrates the care taken to ensure all possible causes of Child 1’s collapse could be investigated, including non-accidental injury, at the same time allowing the family members to be with Child 1 and to grieve.  3.8.5 On admission it was known that because it was 50 minutes before Child 1 could be resuscitated following the cardio respiratory arrest, it was unlikely that the child would live.  The family had been prepared for this by staff at Hospital 1 and this continued at Hospital 3.  Adult 1 stayed with Child 1 during the night, while the rest of the family (Adult 2, Adult 3, Adult 4 and Child 2) returned home.  3.8.6 As part of normal procedure for an unexplained collapse, Child 1 was referred to the ophthalmologist.  This showed evidence of retinal bleeding that was not caused by the prolonged resuscitation.  Hospital 3 had already notified Bolton Children’s Services of the life threatening condition, that Child 1 was likely to die and that the SUDI protocol would be followed.  During the afternoon, a further call was made to Bolton Children’s Services.  The checks showed that neither Child 1 nor Child 2 was known to Social Care.  3.8.7 The specialist resource at Hospital 3 means that very poorly children are regularly admitted in unexplained circumstances.  Experience has shown that preparing staff and the family for any type of investigation into the causes prevents both distress to family members, and possible interference of evidence at an early stage.  This has led to the inclusion of action to be taken in the SUDI protocol called the Acute Life Threatening Episode (ALTE).  This addition, with an ALTE pro-forma to complete is accepted across the Area 5 authorities.  3.8.8 Hospital 3 began the implementation of this procedure with notification to Safeguarding Consultant 1.  The purpose of the procedure was explained to the family and information collected (by Safeguarding Consultant 1) from them to contribute to the records.  Later in the day, Safeguarding Consultant 3 explained that the matter would be referred to Children’s Services and the police.  Safeguarding Consultant 3 telephoned Bolton Children’s Services on the morning to confirm the information about Child 1’s death, referral for a post mortem and notification to the Coroner, following the SUDI protocol.  26  EMBARGOED UNTIL 10.00 AM ON 27 SEPTEMBER 2013 3.8.9 Child 1’s family were only in contact with Hospital 3 for 24 hours.  During that time, Adult 1 and Adult 2 spoke freely of their life when living with Adult 4 and their concern that he would take over the arrangements for their baby.  Adult 2 was described by Adult 4 as having the mental age of 12, but Adult 1 described him as ‘lagging behind by two years’.  During all the conversations, Adults 1 and 2 seemed to understand the staff concerns, and presented as caring parents.   3.8.10 The report demonstrates that staff were aware of Adult 2’s learning difficulty, and that English is not Adult 1’s first language.  All communication was given in a simple form, in Hindi when requested and was only shared with the wider family with the consent of Adult 1 and 2.   3.8.11 Hospital 3 has a Child Protection policy ensuring the needs of any child are paramount; as Child 1 was very poorly from admission, nursing was provided  on a one to one ratio, so care was safeguarded at all times.  However this is balanced by the Trusts challenge to meet the twelve principles of a good death as defined in their hospital procedures.  As Child 1 could not communicate in any way, the staff ensured that parents were in close contact at all times.  Also the bereavement policy ensured the parents were able to cuddle, wash, take photographs, and take away imprints of Child 1’s hands and feet.   3.8.12 Overall the IMR demonstrates full adherence to the procedures, inclusion of the family and sensitivity to the issues presented by the extended family, while remaining focussed on nursing and treating a very sick baby who was likely to die.  3.8.13 The review of records identified two inappropriate records.  One staff member, Safeguarding Consultant 2, had recorded them as ‘lovely and devastated’.  The IMR notes that this is a subjective statement, which should not be part of the factual record.  A second concern was an electronic entry by a nurse that there were no safeguarding concerns when an earlier paper record notes the query of the retinal haemorrhages in the right eye.  3.8.14 Hospital 3 had notified Bolton Children’s Services early that the SUDI protocol would be implemented following the death of Child 1.  However when the call was made to notify of some safeguarding concerns following the Area 5 ALTE procedure there was an expectation that Children’s Services would notify the local police to ensure consideration of protection of a possible crime scene.  There is no similar protocol in the remainder of the North West and the response in Greater Manchester is to wait until the notification of death or confirmation of NAI before involving the police.  3.8.15 The IMR has two recommendations linked with the points made in paragraphs 3.8.13 and 3.8.14, to improve standards of record keeping by including such examples within the safeguarding training, and to work with agencies in the North West, including NWTS to adopt the principles and actions from the Area 5 ALTE procedure.  27  EMBARGOED UNTIL 10.00 AM ON 27 SEPTEMBER 2013 3.9 The NHS Bolton Commissioning Report  3.9.1 The NHS Bolton Commissioning report has been jointly prepared by the Associate Director of Safeguarding (Designated Nurse) and a Consultant Paediatrician (Designated Doctor) from NHS Bolton and countersigned by the Interim Accountable Officer from the Commissioning Group for Bolton.  3.9.2 The authors have used the five NHS IMRs as the basis of the NHS Commissioning Health Report as well as:- • Feedback and comment from panel discussions on each IMR • A training meeting for NHS IMR authors • Discussion with the Lead Commissioner for the regional PICU service to gain agreement to include the Hospital 3 IMR in the report • An analysis of the integrated health chronology • Consideration of practice standards • Additional review of health visiting records, particularly those transferred from Area 4 to clarify how care was provided to Child 2, prior to the move to Bolton  3.9.3 The authors note at the beginning of the report that it had been difficult to prepare the NHS chronology as the region uses a different template from Bolton.  Following discussion at panel, it was agreed that the differences should be discussed at the LSCB and any relevant action taken.   3.9.4 The NHS Commissioning Health report is written in a clear, simple style. It outlines the contact the family had with NHS services and where appropriate considers whether the service has fully met practice standards.  Any evidence of not meeting standards is limited but is important to consider.  The report considers as more than meeting practice standards:- • Quality of the health visitor ‘movement in’ visit  • Service provided by both GP practices, especially the prompt appointment service for babies and young children • Wider assessment provided by the ophthalmologist leading to a referral to a paediatrician • Role of the health visitor in making referrals for therapy services and follow up on progress • Transfer and communication between health visiting and midwifery services • Quality of the midwifery service • Quality of the primary health visiting visit following Child 1’s birth • Emergency services provided by NWAS and NWTS, including excellent response times • Services provided by Hospital 3 28  EMBARGOED UNTIL 10.00 AM ON 27 SEPTEMBER 2013 3.9.5 Overall the authors are able to report that the family was provided with a good quality service, and a particularly sensitive service during the time of delivering acute emergency services.  3.9.6 The NHS Bolton Commissioning Report, following the commentary on the description of events, identifies five themes for consideration that link with the terms of reference.  These are:- • Communication  • Plurality of vulnerability factors in the family and assessment • Cultural issues • Learning difficulties • Domestic abuse  3.9.7 In the introduction to the Themes, the authors note that while within the review, participants can use hindsight, it is important to only make judgements on practice based on the information available at the time.  Within the comments against each theme the authors cross reference them against each of the eight terms of reference.  However the terms of reference are not specifically addressed limiting cross reference in section 4 of this report.  3.9.8 In the commentary the report notes that the majority of contacts and service provision met all expected standards, for example the detail recorded in health visiting assessment visits, referrals for speech and language therapy, specialist dietary advice, and checking how well the family were able to follow advice.  The Commissioning Report commented on this good practice, but notes three areas where judgements could have been different as described in paragraphs 3.9.10 to 3.9.15 below.    3.9.9 The information recorded by the GP about domestic abuse was not given to the Health Visitor, nor coded as an alert, or referred to Social Care.  During health visiting visits the matter of personal safety was properly raised but without Adult 1’s disclosure, or some indication of her situation, the health visitor was not in a position to pursue Adult 1’s responses.   3.9.10 One of the authors of the Commissioning report has checked carefully the notes transferred from Area 4.  There is no indication of any domestic abuse between the adults in the extended family.  With hindsight, the information suggests a level of acceptance within the family of some violence.  The Commissioning Report notes that the GP IMR identifies that some action should have been taken, and recommends closer liaison between Health Visitors and GPs as there should have been some consideration of the impact of the domestic abuse on Child 2.  29  EMBARGOED UNTIL 10.00 AM ON 27 SEPTEMBER 2013 3.9.11 The omission of giving information to the health visitor was further exacerbated when during the pregnancy of Child 1, both parents were reported to be pleased.  Not knowing that Adult 1 had told the GP that she did not want another pregnancy, while Adult 2 did, prevented the midwife from checking more carefully with Adult 1.  In hindsight, staff can see that potentially Adult 2 had a controlling role.  3.9.12 The point in paragraph 3.9.9 is also pertinent for NHS staff responses when Adult 1 discussed that Adult 2 was seeing someone else and that they were planning to separate.  Community NHS staff had established a good rapport with both adults, and Adult 1 and 2 began to talk about their experiences with the extended family in Area 4.  The staff would have had a more complete picture if they had known about Adult 1’s separate concerns and they would have been able to consider the impact on Child 2 and the expected baby.  The NHS Bolton Commissioning Report notes that no other agency had either alerted the staff to any concerns or asked for information as they were concerned.  3.9.13 However, while the omission was regrettable, it is not the view of the NHS Commissioning authors, or the panel, that even with greater efforts to check that Adult 1 was able to talk about any difficulties in her marriage, there would have been a different outcome.  3.9.14 In relation to NHS community staff the last area considered is the lack of information on Adult 2’s learning difficulty.  Again the authors checked the information transferred at the time from Area 4 Community NHS records.  There was one reference, within the notes to his learning difficulty, but the information was not included in the summary as a factor relating to his parenting capacity.  This summary is used to highlight any particular needs, issues or concerns.  None of the NHS staff who met Adult 2 were aware that he had a learning difficulty, and there is no suggestion that the difficulty had an impact on his parenting.  In fact there are positive comments on the relationship between Adult 2 and Child 2.  3.9.15 The NHS Bolton Commissioning Report comments on the prompt and responsive service provided in the emergency by both NWAS and NWTS.  However there was a delay in notifying the police of the unexplained injury as it was not done by NWAS as expected.  Hospital 1 did not check the notification had been made by NWAS, nor did NWTS.  The police only became aware of the possibility of an unexplained serious injury or death when Children’s Services notified them.  While in this instance the timing was not crucial, in some circumstances the police can only complete investigations properly and promptly if a notification is made at the earliest opportunity.  This is recognised in the individual IMRs and the Commissioning report.  30  EMBARGOED UNTIL 10.00 AM ON 27 SEPTEMBER 2013 3.9.16 When Child 1 was transferred to Hospital 3, because of the unexplained nature of the cardiac arrest, the hospital followed their procedure for ALTE.  As noted in paragraph 3.8.14, this procedure is not in place across the whole of the North West.  This led to a misunderstanding between Hospital 3 and Bolton Children’s Services.  In discussion in panel, there seemed to be a further lack of clarity in the procedure.  The notification from Hospital 3 to Bolton Children’s services, after the ophthalmologist had identified retinal haemorrhaging, was intended to trigger notification to the police. In fact the notification to the police was only made after Child 1’s death.  The detail of the expectations of the pro-forma will need to be clarified, if as recommended it is accepted as a regional procedure.  THEMES EMERGING FROM THE NHS BOLTON COMMISSIONING REPORT  3.9.17 Theme 1 – Communication    The conclusions identify some lack of communication which can be improved.  These are:-  • Information sharing between GP, the health visiting service and Children’s Social Care should include key factors that could impact on parenting; the GP IMR has a recommendation to remedy this point and since the death of Child 1, this is included in the NHS Bolton Safeguarding Policy • Notification to the police when a baby has an unexplained condition that could have been caused non-accidentally.  As non-accidental injury must always be a possibility, individual IMRs have made recommendations, and the NHS Bolton Commissioning report makes two recommendations linked with this issue.  One is that BSCB and NHS Bolton should ask Greater Manchester to adopt a similar ALTE pro-forma, and the second that NHS Bolton should use the pro-forma within local services.  3.9.18 Theme 2 - Plurality of vulnerability factors in the family and assessment  The report considers the strengths of both parents observed by NHS staff.  Until Adult 1 talked to the health visitor about her marriage, and her loneliness, there was little indication of vulnerability.  The report refers to research that indicates the vulnerabilities known to the service, even with the additional information from the visit to the GP, it would not reach a threshold for a family action or child protection meeting, but did meet the threshold for additional support.  3.9.19 The report also comments that most of the health visiting visits were undertaken by a staff nurse.  Supervision from the health visitor should have reviewed the support needed by the family and the health visitor should have considered completing a CAF.  This is included as a recommendation in the Bolton NHS FT IMR.  31  EMBARGOED UNTIL 10.00 AM ON 27 SEPTEMBER 2013 3.9.20 Theme 3 - Cultural issues  The report notes that information on the extended family in Area 4 which would have provided a fuller context for the situation of Adult 1 in particular but also Adult 2 was not included in the transfer notes.  However even though the extent of Adult 2’s learning difficulty was not known or the degree of isolation Adult 1 was experiencing, NHS staff could have provided some information and guidance on community support.  In Bolton with a large and mixed cultural population there are many opportunities for women to gain support from the community in culturally sensitive groups.   3.9.21 All the NHS staff recorded good language skills, and the health visitor checked that Adult 1 could understand the more complex information in the dietary advice with the use of an interpreter.  In Area 4, the records indicate Adult 4 translated for Adult 1, but with hindsight this is noted as a possible controlling action.  3.9.22 There are no recommendations linked with cultural issues, as the staff recognised the needs of Adult 1 and had taken action to support her.  3.9.23 Theme 4 - Learning Difficulties  The report notes that no health professional observed any concern about Adult 2’s ability to parent.  He had sole care of Child 2 on a number of occasions. Learning difficulty is not a key indicator of safeguarding concerns, (noted the overview of Serious Case Reviews, found it a factor in 15% of cases), and the conclusion is that it did not have an impact with Adult 2.  However his learning difficulty may have had an impact on Adult 1’s feelings of isolation.  A wider conclusion is that fathers should be routinely included more in discussion of child health.  3.9.24 Theme 5 - Domestic Abuse  The response to the one record of domestic abuse does not meet the expected standards within the LSCB procedures.  The omission of not passing on the information has been noted in detail in the report, but the NHS Bolton Commissioning Report concludes that it also points to the wider concern of the lack of engagement by GP practices in child in need and child protection procedures.  In this case the lack of information about the behaviour of Adult 2, and the experience of abuse in Area 4 meant that assessments of Child 2 did not take any account of domestic abuse but that the service offered to Adult 1 and the children would not have differed.  Adult 1 was asked at least twice if there was any domestic abuse, and had the opportunity to speak more easily when the interpreter was present.  3.9.25 The NHS Bolton Commissioning Report draws some general conclusions that are reflected in the individual IMRs and makes four recommendations, linked with the commentary in paragraphs 3.9.10 to 3.9.13.  These are:-  32  EMBARGOED UNTIL 10.00 AM ON 27 SEPTEMBER 2013 1. Greater Manchester LSCBs and NHS Greater Manchester amend the current  Protocol “Sudden Unexpected Deaths in Childhood to include guidance on the management of a child suffering from an ‘Acute Life Threatening Event’ (ALTE).  This will ensure a consistent response by agencies to notifications of children experiencing a life threatening event where non accidental injury is always a differential diagnosis.  2. Bolton Foundation Trust to consider adopting the ALTE pro forma for use in children who remain in Bolton for their investigation and treatment.  This should specify explicitly who will be contacting each agency involve and when this has been done so that there is no delay in involvement of any individual agency.  3. Hospital 3 to review the ALTE pro forma to include an explanation about what ALTE protocol requires for areas that do not have an operational ALTE protocol and agree and document which agency will take responsibility for notifying the Police as the existing protocol only states that the Police must be informed.  4. Raise awareness of the impact of additional stressor including poor housing, social isolation, poverty and domestic abuse on parents with particular regard to parents with learning difficulties.  This recommendation relates to frontline health workers responsible for assessing children and family’s needs and also managers responsible for clinical supervision.   4. CONCLUSIONS AND ANALYSIS  4.1 To what extent did agencies/services/individuals recognise and take account of Adult 1’s potential vulnerabilities?  In particular:- • Age • Language and literacy needs • Immigration status • Marital status • Level of isolation or integration within the local community • Relationship and support offered from wider family members  And what impact did this have on assessments, planning, intervention and outcomes?  4.1.1 Generally agencies consider that staff in contact with Adult 1 had an understanding of her vulnerabilities.  However when each of the bullet points is taken in turn, much less was known than emerged in the SCR process.  33  EMBARGOED UNTIL 10.00 AM ON 27 SEPTEMBER 2013 4.1.2 The only agency to comment on the young age of Adult 1 was Bolton at Home.  Because of the ages of both Adult 1 and Adult 2, they were offered additional support as part of the STeP programme to help maintain the tenancy, as young people rather than as young parents.  The visiting officer had recorded brief details of visits and contacts, which suggested the couple, were managing the tenancy well and asking for help when it was needed.  4.1.3 All the agencies who met Adult 1 knew that English was not her first language, but their records show that her spoken, and when seen, her written English is of a good standard.  The Children’s Centre registration details record her first language as Urdu and her English as ‘basic’ but it is not known if this was her judgement or a staff member’s.  She did attend an ESOL on one occasion.  It is not known if her failure to attend more classes was due to her assessment of them not being necessary, or for other reasons.  As the service is available for those who wish to use it, rather than as part of a plan, it was not appropriate to follow up any non-attendance.   4.1.4 As part of the service for Child 2, the health visitor wished to ensure Adult 1 understood detailed dietary information and advice.  For this visit an interpreter who spoke Urdu accompanied the health visitor, but at the visit it was agreed that Adult 1 had no need of the service and clearly understood the information and advice being shared.  4.1.5 However when Child 1 was taken to hospital and Adult 1 was distressed, she did wish to revert to her first language.  The staff member in the ambulance was able to talk by use of closed questions and gestures, but could have used Language Line.  At Hospital 3 one of the consultants spoke Hindi and by choice she used this language to speak to the family on admission.  At other times all staff members used English and considered Adult 1 understood.  4.1.6 Once again, the only agencies that were aware of Adult 1’s immigration status (discretionary leave to remain) were the housing agencies.  Her status had been confirmed as part of the housing application.  NHS agencies only record immigration status if the person is recorded as either an asylum seeker or refugee as there are specific health arrangements for people with such status.    4.1.7 The UKBA notes that at the time of Child 1’s death her immigration could not be described as ‘precarious’, but a mother of two small children, only having eighteen months security remaining, may have a different view.  However agencies providing universal services had not asked her about this.   4.1.8 The only agency in Bolton who had any details of Adult 1’s marriage was Bolton NHS Foundation Trust. Adult 1 told her midwife after the birth of Child 1 that it had been an arranged marriage that took place in Area 3.  However staff also viewed Adult 1 as mature and engaging well with services.    4.1.9 The background details from Area 4 give this information as it had been recorded by Area 4 Police when Adult 2 had been interviewed in relation to supplying a controlled drug but was not known generally to agencies in Bolton. 34  EMBARGOED UNTIL 10.00 AM ON 27 SEPTEMBER 2013 4.1.10 In relation to the last two bullet points, I have taken them together.  The housing agencies knew of the support offered by Adult 5, both in providing accommodation when the family moved to Bolton because of the abuse from Adult 4, supporting the housing application and providing support after the family moved into Address 1.  At one point a Bolton at Home staff member asked if Adult 5 and her family were living at this address as they had been present each time she called.  Adult 1 had also told the agency she had good contact with neighbours.  The STeP service was intended to ensure the family had sufficient support to maintain the tenancy, but that is the whole extent of their interest.  4.1.11 Children’s Centres are part of Bolton’s universal provision to support families. While their remit is to help parents to parent well and provide opportunities to mix and socialise, it is specifically not a service which asks for any personal details unless the adult offers the information or there are child protection concerns.  When the midwife made the single agency referral, there was no indication that Adult 1 was socially isolated, but just that she would benefit from some support.  4.1.12 Within the NHS, the first GP in Bolton probably had the best indication of Adult 1’s isolation, when she told him that her husband had hit her, she was lonely and she did not want another baby.  The GP notes also included some information about the abuse in Area 4.  However this was not coded for future practitioners to see; this meant that when Adult 1 began to talk to other health services her conversation was not seen in the context of her earlier conversation.  Direct information about Adult 1’s experience in Area 4 was only given by her to Midwife 1 (at GP). It was when Midwife 8 followed up this discussion on her visit that the single agency referral was made as Adult 1 had said she felt isolated.  4.1.13 Staff Nurse 1 had noted when she was working with the family to improve Child 2’s diet, that Adult 6 was visiting to help reinforce the programme of change.  This was recorded as positive family support.  4.1.14 When the family was at Hospital 3, the vulnerability of Adult 1 was recognised, first by the staff member from NWTS who stayed with her, and then by Hospital 3 staff.  They fully understood her need to be fully included, respected her request for all information to be given to her and Adult 2 before discussion with the wider family, and consulted when decisions about withdrawal from life support had to be made.  4.1.15 On reflection, agencies have identified that their services could further improve by:-  • NHS community staff have a wider understanding of the range of stressors that can cause vulnerability within a family • Children’s Centres ensure full and accurate factual details are taken when families register for attendance 35  EMBARGOED UNTIL 10.00 AM ON 27 SEPTEMBER 2013 • NHS agencies use Language Line for emergencies as well as for more routine • Ethnicity is recorded, including first language  4.1.16 However, as will be noted later in the report, there is a balance to be made of intrusion into the lives of those who do not ask or appear to need support, and the need to know so that support can be offered and made available.  4.2 To what extent did agencies/services/individuals recognise and take account of Adult 2’s potential vulnerabilities, in particular:- • Age • Learning disability/difficulty • Marital status • Parenting capacity • Level of isolation or integration within the local community • Relationship and support offered from wider family members  And what impact did this have on assessments, planning, intervention and outcomes  4.2.1 For Adult 2 comments made in paragraphs 4.1.8 and 4.1.10 above also apply.  He still met the criteria for inclusion on the STeP programme.  Other than the note about his age from Bolton at Home, no agency had recorded any comment about his age.  4.2.2 English is Adult 2’s first language but he also speaks Urdu and Punjabi.  The cognitive assessment completed as part of the court process notes that Adult 2 ‘can express himself quite adequately and although he sometimes uses words idiosyncratically his meaning is generally quite clear’.  This is relevant for the agencies responding to any recognition of Adult 2 having a learning disability/difficulty.   4.2.3 As part of the housing application Community Housing Services checked the status of Adult 2’s learning difficulty with him, his sister, and the GP.  The notes state he has a ‘relatively low level raising no significant concerns for independent living nor in terms of parenting capacity’.  Any further comment is not available as it would be on the assessment that cannot be found in Bolton at Home records.  4.2.4 Children’s Services only knew that Adult 2 had a learning difficulty from a note on Midwife 8’s single agency referral.  When the Family Worker telephoned to arrange to visit in response to the referral, her assumption at his response was that he did not speak good English.  On reflection it may have been because he knew nothing of the referral, or didn’t want any agency involved in the family.   36  EMBARGOED UNTIL 10.00 AM ON 27 SEPTEMBER 2013 4.2.5 While Bolton NHS FT knew from Adult 1 and Adult 2 that Adult 2 had a learning difficulty, both had described as ‘difficulty in reading and writing’.  Adult 5 had told Bolton Childrens Services that Adult 2 had a learning difficulty, and described it as ‘being about seven years younger than his chronological age’.  It was only when the family was at Hospital 3, when Adult 4 described him as having a mental age of 12, while Adult 1 described him as two years behind that there was any suggestion that his capacity as a parent might be limited.  The staff at the hospital recorded that when the family was arranging to leave, he seemed confused about where he should go, but this is the only recording that suggests he was unable to understand fully expectations and his responsibilities. The panel considered Adult 2’s response could equally be a response to an emotional and draining situation.   4.2.6 In relation to Adult 2’s parenting capacity, observations from the health visiting service, who saw him four times, the midwife and Bolton at Home staff were all positive.  He was seen to care for and play with Child 2, and when Child 1 was ill the second time, it was Adult 2 who took the child to the surgery.  All the staff who observed Adult 2 were trained in Child Protection and were aware of which signs to look for to identify any safeguarding concerns.  The NHS Bolton Commissioning Report concludes that more information would have been helpful in the context of including fathers more in child health assessments.  This has been identified in a number of Serious Case Reviews, and noted in the fourth Biennial study of SCRs published by Ofsted in June 2009.  It had studied 189 SCRs completed between 2005 and 2007.  Two of the key findings were that there was a dearth of information about men in most serious case reviews, and a failure to take men into account in an assessment.  4.2.7 Adult 2 was not considered to be socially isolated.  The housing agencies noted that he had and appreciated support from his sister.  Support Officer 1 also found the whole family was out on six of 12 visits, suggesting they had people to visit or places to go.  NHS community staff found he was often out when they visited and assumed he was not isolated.  4.2.8 In summary, Adult 2 presented as an adult who was able to communicate with staff from the different agencies, was an active parent to Child 2, and after the birth, to Child 1, and appeared to have support both from family and the community.  4.3 What opportunities did the agency have to observe parenting capacity and interaction between Adult 1 and Adult 2 with Child 1 and Child 2?  What impact did this have on assessments, actions and services offered at the time? Is there anything that could have been done differently?  4.3.1 Records and staff interviews confirm that observation of Adult 1 and Adult 2 as parents were positive.  Some agencies (Community Housing Services, Bolton at Home, Children’s Services) only saw the adults with Child 2, but it was noted in particular that Adult 2 had a good relationship with this child, with a note from Staff Nurse 1 that Child 2 was missing Adult 2 when he was absent from the home. 37  EMBARGOED UNTIL 10.00 AM ON 27 SEPTEMBER 2013 4.3.2 The GP record indicates that they were seen as a normal, caring family; the limited observation at Hospital 3 gave no indication of anything different.  4.3.3 The more detailed records are from the two Health Visitors and the two midwives.  Adult 1 is recorded as mature and in control of family matters, but showing warmth and with a positive relationship with Child 2.  This assessment was confirmed by observations from ward staff when Adult 1 stayed with Child 1 in Hospital 1 during admission.  When Adult 1’s demeanour was different, it was recorded, as ‘tearful’ and ‘sad’.  The conclusion that both parents were competent is based on the full health visiting assessment, and then working with the adults using the Solihull Resources (a Parenting Support Programme) to help make changes with Child 2.  4.3.4 Adult 2 was seen by Community Health staff four times, and was not seen alone; however his parenting was observed to be appropriate with good interactions with Child 2.  4.3.5 When Adult 1 and Adult 2 first moved to Bolton their relationship was assumed to be a strong one.  Together they had defied Adult 2’s family and left the extended family home to live as a family unit.  The first indication that their relationship had some difficulties was, when Adult 1 told GP1 that she did not want another baby, that Adult 2 had hit her a few times, she felt lonely, that her parents were abroad and that Adults 3 and 4 had thrown them out.  This was not explored further by the GP and not coded in the notes to draw the attention of later practitioners.  4.3.6 Further information was given when Adult 1 told Staff Nurse 1 that Adult 2 was ‘seeing someone else’ and they had discussed separating after Ramadan.  She was also concerned that Adult 2 would take Child 2 back to Area 4 when she was in hospital for the birth of Child 1, and that he would not bring Child 2 back to her.   4.3.7 Adult 1 told Staff Nurse 1 that they were planning a separation by mutual agreement.  Just after Child 1’s birth, Adult 1 revealed some of her isolation when she told Midwife 1 of the reason for the move from Area 4.  She also wanted her mother to come from Area 3 to help her.  When Midwife 1 asked her about the conversation she said she felt isolated.   4.3.8 This conversation prompted the single agency referral to MARP.  However when Health Visitor 2 made the primary visit following the birth of Child 1, the plans had changed to seeking rehousing as a family.  At no time was there any negative interaction between the adults, and it is possible that the disclosures could be seen as more associated with Adult 1’s greater vulnerability immediately before and after the birth of Child 1.   4.4 To what extent have assessments and interventions considered diversity issues, including ethnicity, religion, language, disability and cultural issues?  38  EMBARGOED UNTIL 10.00 AM ON 27 SEPTEMBER 2013 4.4.1 On the whole agencies had recorded diversity issues.  Community Housing Services had confirmed the immigration status of Adult 1, checked with family and GP for information on Adult 2’s possible disability, noted both adults had a good standard of spoken English and recorded all the basic monitoring information.  It is expected that similar records would have been made by staff at Bolton at Home but the STeP documents are missing.   4.4.2 It has already been noted in paragraph 4.1.11 that Children’s Centres provided by Children’s Services are a universal service which is non-intrusive.  However the records were not sufficient to give basic factual information which would demonstrate how well it was reaching out to isolated communities.   4.4.3 Attention was given by most agencies to language, with either records that both adults communicated well in English, or in a couple of cases more specific support before making the judgement.  Staff Nurse 1 used an interpreter in Urdu when she wanted to ensure more complex information was understood, but following that visit it was noted the service was not needed again.  4.4.4 The Children’s Centre provided ESOL classes, but because of the emphasis on people attending when they wished Adult’s 1 attendance at only one class was not questioned.  It may have been that she appreciated her English was of a good standard.  4.4.5 There is evidence that agencies considered culture more widely than just language.  However one element of this may have been the health visiting and midwifery services interpreting Adult 2 being absent on many visits as him taking a ‘traditional role’ in parenting, rather than checking more about the impact of his learning difficulty on his role in the family.  4.4.6 Hospital 3 however had clear records of understanding the wider cultural needs with discussions about funeral arrangements, accepting the role of the wider family and also some use of Hindi, when a consultant was able to do so.  4.4.7 It has been noted in paragraph 4.1.5 that NWAS did not use Language Line, but it could have been inappropriate given the critical circumstances and with Adult 1 able to understand sufficiently.  Hospital 3 had been told by Adult 1 and separately by Adult 4 that Adult 2 had a learning difficulty, and so ensured that all communication was in simple terms and that he understood.  4.4.8 Although the Area 4 records indicate some learning difficulty, the GP found no difficulty in communication with Adult 2 either because of learning difficulty or language.  Bolton NHS FT has included a recommendation that includes ensuring staff have wider understanding of identity within the cultural and ethnicity context.  This recommendation is endorsed by the NHS Bolton Commissioning Report.  39  EMBARGOED UNTIL 10.00 AM ON 27 SEPTEMBER 2013 4.5 What opportunities did the agency/service provide to Adult 1 and Adult 2 to speak independently of one and other about any concerns or worries they had prior to the birth of Child 1?  On reflection can you identify any learning points?  4.5.1 Few agencies had opportunities to see either Adult 1 or Adult 2 alone and Bolton at Home notes in the IMR that as a housing agency, staff do not try to do so.  4.5.2 Children’s Services only saw Adult 1, but always in activity groups when the opportunity for staff to speak alone to any adult would have been limited.  The Children’s Centre had recorded Adult 1 as an Urdu speaker, and possibly did not appreciate the standard of her English.  Only the administrative staff member spoke Urdu, and the IMR suggests that Adult 1 spoke in Urdu to other parents.   4.5.3 The NHS records show that when Adult 1 was in a situation when she could speak freely (GP1, Midwife 1, Health Visitor 2 and at Hospital 3), she did reveal her concerns about Adult 2, Adults 3 and 4, and her feeling of loneliness.  However when asked as part of the health visiting initial assessment, Adult 1 had said she had no concerns about personal safety or domestic abuse.  If the GP record had been appropriately coded other practice based staff would have known of the history of domestic abuse.  Also if the GP had notified the health visitor of the information it is possible Health Visitors 1 and 2 would have asked further questions when Adult 1 knew them better.  Adult 1 had spoken to Staff Nurse 1 about financial concerns as well as the plan to separate, but had not spoken of any concern about having a second child.  4.6 To what extent did the agency have awareness of domestic abuse issues within the nuclear and extended family?  What was the response of the agency and how did this feature in assessments, planning and interventions?  4.6.1 Community Housing Services were the first agency to have contact with Adult 1 and Adult 2.  They were accompanied to their appointments by Adult 5, who confirmed the account of abuse they had experienced from Adult 4.  It is expected that Bolton at Home also had this information.  Both agencies did not consider the family to be at risk as they had taken steps to come to live in Bolton.  This information was also held in a brief note in the GP records.  4.6.2 In addition, Adult 1 had told Staff Nurse 1 that Adult 4 was claiming Adult 2’s benefits.  Staff Nurse 1 recognized this as a concern and although not constituting physical violence was evidence of controlling and intimidating behavior of wider family members.  Adult 1 told Midwife 1 that the family had moved to get away from Adult 4 and the staff member understood the family was not in contact with the extended family in Area 4, but had support from an uncle (Adult 6) in Bolton.   40  EMBARGOED UNTIL 10.00 AM ON 27 SEPTEMBER 2013 4.6.3 Adult 2 gave Health Visitor 2 the same information some days later, but the record says the abuse was when he was a child.  When the family was at Hospital 3, staff there recorded the historical abuse and respected the wish of Adults 1 and 2 that they only speak to Adults 3 and 4 with their permission.  4.6.4 In relation to abuse within the nuclear family, Adult 1 was asked about this directly on 2 occasions but she denied that there was any.  As indicated previously, if the GP record had been known, Health Visitor 2 may have asked this question in a different manner, and received a different reply.   4.6.5 The midwifery notes also indicate that questions were asked about emotional well-being which include prompts about personal safety and relationships during the ante-natal period.  No concerns were reported by Adult 1 at that time.  4.6.6 When Adult 1 spoke to Staff Nurse 1 about the plan for separation, Adult 1 was clear that the plan to separate was mutual and amicable.  4.6.7 The last time Health Visitor 2 saw Adult 1 and 2 together they were described as ‘being relaxed with each other and there was not an awkward or uncomfortable atmosphere.  Adult 1 was not seen to be intimidated by Adult 2 and appeared to make decisions about the family.’  4.6.8 Health staff interviewed stated they are aware of domestic abuse issues and how they impact on children and high risk factors, but they did not detect any high risk factors for Adult 1.   4.7 On reflection were there any opportunities or indicators that suggest CAF processes could have supported multi-agency work?  4.7.1 Housing agencies in Bolton are fully included in the arrangements for CAF, but in all their contacts found the family did not appear to need more support than that offered by Adults 5 and 6.  Adult 2 has additionally reported good relationships with neighbours.  4.7.2 Community NHS staff completed detailed assessments when the family moved into Bolton, and after the birth of Child 1.  However these staff did not have the benefit of the information given by Adult 1 to the GP.  It is possible/probable that when Adult 1 and 2 began to disclose some details to Staff Nurse 1 and then to Midwife 1 an earlier referral would have been made for support from MARP.  With information on the abuse in Area 4, Adult 1’s loneliness, and her not wanting a second pregnancy, the health visitor would have understood that Adult 1 has some long standing concerns, and was missing her family and the support they would offer.   41  EMBARGOED UNTIL 10.00 AM ON 27 SEPTEMBER 2013 4.7.3 Communication between health visiting and midwifery services was good, and the services although child focussed, included discussions on other family matters.  Health Visitor 2 on reflection, without the information from the GP, considered she could have completed a CAF just before Child 1’s birth.  Midwife 8 did make a referral, but using the single agency form, when with the additional information a CAF may have been more appropriate to access family support.  This view is supported in the NHS Bolton Commissioning Report.   4.7.4 The Children’s Services IMR notes that the services should have insisted on a CAF because when the midwife sent in the referral, the family was known to health visitors, Children’s Centre, speech therapy, and the STeP housing programme.  In this instance the referral could have led to a more robust response.  Completion of the CAF process would have included the historical information from Area 4 giving a full picture of the family situation.  4.7.5 This point was discussed in panel, but panel members who are familiar with CAF thresholds considered that with all the information, and with hindsight, meeting the criteria for CAF was borderline.  4.8. On reflection were there any signs or indicators that Child 1 was at risk of suffering significant harm or other missed opportunities to safeguard this child?  Where signs and indicators are identified, please clarify any action that was or was not taken and the reason for this.  4.8.1 The housing agencies only had contact with the family prior to Child 1’s birth, but both confirm they had no concerns from their observations of the care given to Child 2.  Additionally the family had recognised the negative impact of abuse and fled to protect themselves and their child.  4.8.2 Children’s Services Children’s Centres also only saw Adult 1 prior to Child 1’s birth.  The staff had no concerns about the safety of a child cared for by Adult 1 from her presentation at the Children’s Centres.  4.8.3 In the GP IMR, the author interviewed the doctors and ANP who saw Child 1.  They conclude that there was nothing to indicate that Child 1 was at risk of significant harm.  These staff also would not know of the information recorded by the previous GP about Adult 2 hitting Adult 1, or the abuse from Adult 4, as the records had not been coded to draw attention to it.  Even with this information the panel agreed that there was no evidence of significant harm to either Child 1 or 2.  4.8.4 The community health records are detailed and were used to apply the Significant Harm checklist.  The chronology indicates a family who asked for appropriate services and who responded to the planned care for Child 2.  The records also show that the staff informed each other as new information was given particularly by Adult 1, and that a wider picture was building up.  42  EMBARGOED UNTIL 10.00 AM ON 27 SEPTEMBER 2013 4.8.5 However the Bolton NHS FT IMR also highlights two points.  The first is that even though full assessments were completed these were focussed and did not explore how Adult 2’s learning difficulty could impact both on his parenting and Adult 1’s feeling of isolation.  In the absence of usual risk factors of substance misuse, mental health issues and domestic abuse only known of in the wider family, the learning difficulty of Adult 2 did not appear to be a significant risk factor.  These comments lead to a recommendation in the NHS Bolton Commissioning Report that frontline NHS community staff and their managers who provide supervision should have improved awareness of how additional stressors can have an impact on young parents, especially when one parent has a learning difficulty.  4.8.6 The second point is that assumptions may have been made about Child 1 as this was not a first baby.  However no one has recorded any assessment of how much care was provided by the extended family in Area 4, and then Adults 5 and 6 in Bolton.  This information may have been significant in understanding any pressures for Adults 1 and 2 caring for two children independently.  4.8.7 However on the positive side, there was no evidence of previous injuries to either child, and the parents were seen to interact appropriately and with emotional warmth to the children.  While the parents were receiving support from an increasing number of agencies, there was no evidence to suggest risk of significant harm.  4.8.8 This TOR is targeted to Child 1, but the IMR from Hospital 3 has raised an important issue for children’s services and the police where there is a life threatening illness and one or more other children in the family.  All LSCBs have Sudden Unexplained Death of a Child/Infant (SUDC or SUDI).  However there are no shared protocols for similar action when a child might have a serious or acute life threatening event but not die.   4.8.9 Hospital 3 has developed a protocol that has been accepted by all the Area 5 local authority LSCBs.  This is known as Acute Life Threatening Event (ALTE), and is set out within the SUDI protocol, the difference being that in the instance of an infant death, the matters are within the remit of the Coroner.   4.8.10 The definition used to initiate ALTE is:-  ‘Any sudden/unexpected collapse of an infant requiring some form of active intervention/resuscitation and subsequent intensive care/ high dependency unit admission and [the collapse] remains unexplained.’  The protocol expects hospital staff to notify the local Children’s Services for any child where the injury is either suspicious or unexplained.  The early notification is to allow local procedures to follow through with checks of other children in the family and notification to the police should there be a need to secure the scene of a potential crime.  43  EMBARGOED UNTIL 10.00 AM ON 27 SEPTEMBER 2013 4.8.11 When Hospital 3 notified Bolton Children’s Services it was with the expectations in that the actions in paragraph 4.8.8 would be carried out.  However in the absence of such a procedure in Greater Manchester, the accepted practice in Bolton is only to take any action when it has been confirmed that there is evidence of NAI.  In fact the pro-forma does not assign specific tasks to be completed, but lists collection of contact telephone numbers and if the agency is included in the discussion.  This SCR has identified that the pro-forma if adopted should be amended to provide clarity.   4.8.12 Discussion in the SCR panel confirmed that there had been a genuine misunderstanding, with Bolton Children’s Services accepting the information as an early alert to a child death with no apparent suspicious circumstances.  However this delayed and confused the welfare check on Child 2, and delayed notification to the police.  This second delay was further exacerbated by NWAS not notifying the police of the emergency call as is expected.  The Bolton NHS FT IMR recommends Hospital 1 A&E department should check that a police notification has been made.   4.8.13 When Bolton Children’s Services were notified later in the day of the retinal haemorrhage, the senior manager made the decision to wait until the morning to notify the police of developments.  However this decision was made with the expectation that NWAS would already have notified the police of the circumstances of the admission to Hospital 1.  4.8.14 The panel agreed that wider acceptance of the ALTE protocol would be beneficial for all LSCBs where infants could be admitted to Hospital 3 and also to Hospital 2.  It is included as a recommendation of the NHS Bolton Commissioning Report as well as within the Hospital 3 report.  Additionally the NHS Bolton Commissioning Report recommends introducing a similar protocol for children who remain in Bolton for investigation and treatment.   5. SUMMARY  5.1 The narrative on each IMR and the responses to the Terms of Reference indicate that agencies worked competently, mainly meeting expected standards of practice and with an understanding and respect for the cultural identity of the family.  The records also describe a young couple who showed maturity, ability to manage the household, and a warm and caring approach to parenting.   5.2 The main service providers were staff from NHS services provided universally, but with increased support and specialist services when assessments demonstrated the need.  The Ofsted Biennial review referred to in paragraph 4.2.6 also notes: Almost half of 189 children were under one year of age and a third were very young babies under 3 months.  This repeats the findings of the last biennial analysis and reinforces the importance of the safeguarding role for health staff (especially midwives and health visitors) working with young babies and their families, as noted by Lord Laming (2009).   44  EMBARGOED UNTIL 10.00 AM ON 27 SEPTEMBER 2013 ‘Progressive universalism,’ offers a more targeted health visiting service to families assessed as having a higher level of need. But if this need is not identified in the antenatal period, or soon after, the children will not get access to this additional support and monitoring by health professionals.  It is the view of the panel that NHS community staff provided this service.  5.3 When Adult 1 used services at the Children’s Centres she was able to meet with other parents who spoke Urdu.  Her attendance with Child 2 was not consistent, but the reason for this is not known.  5.4 Housing services provided a prompt assessment of need, recognised when the family’s needs became more urgent and as part of the STeP programme provided more support to maintain the tenancy because of their young age.  5.5 When Child 1 was in cardiac arrest, emergency services and both hospitals provided prompt, specialist, and sensitive care.  5.6 The IMRs identify some occasions of poor or missed communication, (specifically the GP not passing on information from Adult 1, the health visitor not considering a CAF, transfer between the teams in NWTS, NWAS not notifying the police of the unexplained cardiac arrest and the misunderstanding between Hospital 3 and Bolton Children’s Services), but on the whole communication within and between services was good, and recorded in detail.  5.7 The key area where, with hindsight, agencies acknowledge a better service could have been provided is understanding the context of the capacity to parent. Assessments did not complete the picture of Adult 1 needing more personal support and her possible acceptance of domestic abuse and Adult 2 possibly needing more direct input to help him to parent because of his learning difficulty.  Equally, except for housing agencies, it was not known for some time that the family had fled from abuse within the extended family.  5.8 Panel had discussion about the level of need demonstrated when information from all agencies was combined into the chronology and IMRs.  As the NHS Commissioning Health report notes the service did not offer Adult 1 information and guidance on the opportunities to get more support from within the community.    5.9 However panel agreed that even with the information combined the family needs did not meet the threshold for formal co-ordination of multi-agency working using the CAF and Child Action Meeting process as detailed in Bolton’s Framework for Action.   5.10 It is within this context that the panel concluded that the death of Child 1 was neither predictable nor preventable.  In fact, the Panel acknowledged the challenges all workers face when assessing risk, managing resources and getting the right balance between support and the need to respect private family life.  This case has highlighted this, particularly as this family generally offered a good standard of care and were responsive to their children’s needs.  45  EMBARGOED UNTIL 10.00 AM ON 27 SEPTEMBER 2013 6. LESSONS LEARNED FROM THIS SCR  6.1 Each agency has identified individual recommendations, mainly linked with improving records or direct communication.  The panel considered that apart from these the recommendations led to three main areas of learning from the SCR.  They are:-  6.2 Recognition of the importance of domestic abuse, however low key the disclosure appears to be, when there are children in the household.  The GP did not liaise with the health visitor about Adult 1’s disclosure of domestic abuse, nor did he code that disclosure on her records so that it would be seen immediately if there were further disclosures.  With this information, when Adult 1 was asked about her safety, the question could have been phrased acknowledging a history of abuse, making it easier for her to disclose any further concerns. It is possible that Adult 1 would have disclosed information about the family in Area 4 much sooner, giving a clearer picture of her life.   6.3 Recognition of the stressors contributing to the vulnerabilities of Adult 1 and Adult 2.  There was only partial recognition of Adult 1’s vulnerabilities in relation to a number of circumstances: her arranged marriage; her suggestion that the pregnancy was not wanted by her; her husband’s learning difficulties; her abusive and controlling father-in-law; her isolation after leaving Area 4; financial issues; her immigration status and her need for support from her own family in Area 3.  6.4 Also Adult 2’s learning difficulties were not understood or fully explored.  Agencies provided services based on their expectation that Adult 2 was the head of the household, in a traditional cultural model when in fact Adult 1 was in control.  If staff had employed a more challenging assessment of family functioning, these elements may have been known earlier.  Some understanding of Adult 2’s limitations caused by his learning difficulties would have completed the picture of Adult 1’s situation.   6.5 With all the information now gathered about the two adults, it is accepted that it would have been appropriate for a CAF to be made, so that all options to support the family could have been considered between all the agencies.   6.6 Use of ALTE protocols.  On the day the child presented at hospital, there was a sequence of not notifying the police of the unexplained cardiac arrest of Child 1.  It is expected that the person taking the call at NWAS headquarters will notify.  This was not done, and on arrival at Hospital 1 there was no check that it had been done.  The ALTE protocol in use at Hospital 3 intends that when a child has a life threatening illness or injury the local children’s services are notified, who should in turn notify the police. This pro-forma should be explicit about who has specific responsibilities for each action.  46  EMBARGOED UNTIL 10.00 AM ON 27 SEPTEMBER 2013 6.7 Bolton Children’s Services were notified of Child 1’s admission to Hospital 3 and that Child 1 was unlikely to live.  Initially it was notification only.  After there was a possibility that this cardiac arrest was unexplained a further notification was made.  The expectation at Hospital 3 was that Children’s Services would notify the police.  The ALTE protocol is in place to ensure that all agencies are alert to the possibility of beginning procedures linked with safeguarding.  6.8 These three areas of learning are reflected in the recommendations in the NHS Bolton Commissioning Report and the GP IMR.  The recommendation on adopting the ALTE pro-forma at Hospital 1 would ensure clarity on who should make the appropriate notifications.  The SCR panel has fully discussed the individual agency and NHS Bolton Commissioning report recommendations and fully endorses them all.  The panel has no further recommendations.   7. RECOMMENDATIONS  7.1 Summary of IMR Recommendations  • This review has found a good standard of practice in all agencies.  The family were provided with a range of universal services that met their needs, taking account of their culture and language.  Within the NHS in particular the agencies can be proud of the quality of service provided as a routine and at the time of the emergency.  However, as always when services are examined in detail, there is learning leading to some recommendations to improve practice or develop services further.  • Bolton Safeguarding Children Board will request and require all agencies who contributed to this SCR to provide six monthly progress on the implementation of their action plans until all elements have been completed.  7.2 Summary of IMR Recommendations  Hospital 3 recommended that:- • Record keeping issues highlighted within the addendum report shall be used as a basis for learning with both the health professionals directly involved in the care of the child and as part of the mandatory safeguarding training provided to all health professionals across the organisation • Health Overview Author makes a recommendation to the Northern Strategic Health Authority to request all LSCB’s across the region review and amend their current SUDI/SUDC protocol to include guidance on the management of a child suffering an ALTE, which would include triggering a referral to Children’s Services and the Police  47  EMBARGOED UNTIL 10.00 AM ON 27 SEPTEMBER 2013 Bolton at Home recommended that:-  • Introduces electronic storage of STeP assessments  • Reviews its contact processes for customers • Reviews the collation and recording of customer information as part of home visit process  Bolton NHS Foundation Trust recommended that:-  • All services have up to date knowledge and skills about domestic abuse   • Awareness is raised with relevant staff about the CAF process specifically when to initiate CAF and develop CAF skills  • Children’s identity issues are explored when health services are provided  • Assessment and recording in relation to attachment is further developed  • Review oversight of the work of support staff in Health Visiting teams- specific to HV Teams  • Consider implications of research and practice developments in other areas for keeping infants safe  • Remind relevant Foundation Trust staff of the Sudden Unexpected Death of Children process in relation to ensuring that contact has been made with the police  • Increase awareness of the vulnerability of infants to include all services in community and acute setting  Children’s Services recommended that:-  • To ensure the registration forms in the Children Centres are fully completed at the time of registration. To check details are up to date on the registration form if families present at a different centre  • Review the signing in process, to ensure all names are captured and match with the registration forms  • Consider a general overview recording of each session and to think about how learning can be transferred into the home  • Review the referral process to the MARP  48  EMBARGOED UNTIL 10.00 AM ON 27 SEPTEMBER 2013 Community Housing Services recommended that:-  • Case record/Visit forms should be amended to indicate all individuals present during contacts  • Briefing note to staff regarding change to record keeping  GP recommended that:-  • Promote as good practice referring cases of domestic abuse to Health Visitors where preschool children are in the family and code the domestic abuse in the records  • Promote as good practice stripping off babies fully for examination by GPs  North West & North Wales Paediatric Transport Service (NWTS) recommended that:-  • Ambulance staff to undertake safeguarding training   North West Ambulance Service (NWAS) recommended that:-  • NWAS Safeguarding Children Policies and Procedures are strengthened in relation to taking into account issues of ethnicity, diversity, culture and language which may pose barriers. Current policy and procedures due to be updated  • Specific reference to ‘language- line’ will be added into the policy and procedures to ensure staff can communicate effectively with patients and relevant others  • Update the Sudden Untoward Death of Children Procedures to ensure that during any Acute Life Threatening Event (ALTE) or sudden untoward death of a child, the police must be notified by the relevant Emergency Control Centre Call Taker  7.3 Summary of PCT Commissioning Health Overview Report     The PCT Commissioning Health Overview Report recommended that:-  • Greater Manchester LSCBs and NHS Greater Manchester to amend the current Protocol “Sudden Unexpected Deaths in Childhood” to include guidance on the management of a child suffering from an ‘Acute Life Threatening Event’ (ALTE).  This will ensure a consistent response by agencies to notifications of children experiencing a life threatening event where non accidental injury is always a differential diagnosis  49  EMBARGOED UNTIL 10.00 AM ON 27 SEPTEMBER 2013 • Bolton Foundation Trust to consider adopting the ALTE pro-forma for use in children who remain in Bolton for their investigation and treatment.  This should specify explicitly who will be contacting each agency involved and when this has been done so that there is no delay in involvement of any individual agency  • Hospital 3 to review the ALTE pro-forma to include an explanation about what ALTE protocol requires for areas that do not have an operational ALTE protocol and agree and document which agency will take responsibility for notifying the Police as the existing protocol only states that the Police must be informed  • Raise awareness of the impact of additional stressors including poor housing, social isolation, poverty and domestic abuse on parents with particular regard to parents with learning difficulties.  This recommendation relates to frontline health workers responsible for assessing children and families’ needs and also managers responsible for clinical supervision  50  