Non-accidental head injury to a baby boy, Freddie, in September 2017 causing life changing brain damage. Freddie's twin brother Finlay was previously admitted to hospital with a non-accidental injury. Both were subject to children in need plans. Learning: highlights a number of missed opportunities to safeguard including systemic failures to record, share, access, understand or use historical information; poor communication between hospital and community staff and inadequate discharge planning; poor recording of individuals who had access to the children, in hospital and in the community; and the voice of the mother is largely unheard. Recommendations include: improving safeguarding knowledge and skills, including information sharing, of health professionals within neonatal units; safeguarding systems in midwifery services should be reviewed to ensure that parental records are flagged to highlight a safeguarding history or other risk information and shared with children's services; all safeguarding assessments by children's social care practitioners, and decisions by managers, should record an evaluation of historical factors pertaining to a parent or member of a household; and the development of a culture of discussion and challenge between health and care professionals where power and hierarchy can influence decisions.
      
 Title:  Serious case review: Baby Freddie: overview report. LSCB: Durham Local Safeguarding Children Board Author: Kate Mitchell Date of publication: 2020  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.                            Version: Endorsed Report Date: 14th March 2019       Serious Case Review  BABY FREDDIE  Overview Report             Author: Kate Mitchell, MA, CQSW         1Contents   1. Introduction          2        2. Process and Methodology        2        3. Independence of the Author        3        4. Overview Panel         3           5. Confidentiality          5          6. Family Involvement         5          7. Staff Involvement         5           8. Race, Religion, Language and Culture      6        9. Family History           6  10. Summary and Analysis of significant events during Freddie’s life   9    11. Lessons Learned: SCR Terms of Reference     25     12. Recommendations        34        Appendix 1: A short summary of lessons learned in other SCRs   37            21 Introduction  On a date in September 2017, Freddie’s mother called the ambulance as Freddie was not responding normally. The Ambulance Service transported him to the Accident and Emergency Department where he was admitted with a suspected bleed to the brain. Freddie was diagnosed with subdural haemorrhage acute and chronic. Later that day Freddie was transferred to a tertiary hospital outside of County Durham, as he was acutely unwell with cerebral and retinal bleeding.,. Freddie’s mother gave an account of Sibling 3 having tripped over the dog and fallen onto Freddie. Initially, the injuries were deemed to be consistent with this account; however, following escalation by nursing staff, it was deemed to be a Non-Accidental Injury (NAI) and safeguarding procedures were commenced. A Strategy meeting held that same day initiated a section 47 investigation. The siblings were removed under a section 20 agreement to foster care.    The Local Safeguarding Children’s Board (LSCB) determined this case to meet the Serious Case Review criteria and established an Overview Panel in accordance with procedures. The Overview Panel considered all the information available at the time and having been advised that Freddie had sustained serious and permanent impairment of health or development, and that he had been subject to a Children in Need Plan within the preceding six months, recommended to the Chair of the Board to undertake an Extended Review within the meaning of the ‘Welsh Model’.1    2 Process and Methodology  2.1 The process for this Extended Practice Review:  Terms of Reference were developed, identifying questions arising from the scoping and first Panel meeting.   The focus of the Welsh Model is on current practice and a timeline of 12 months prior to the event that led to the Review; however, significant context is considered where it is believed to have impacted on the events during the timeline. This was the case in this Review.   Chronologies were requested from all partner agencies and merged into one timeline.   1 Part 7, Volume 2 – Child Practice Reviews – of the Social Services and Well-being (Wales) Act, 2014.     3 The merged chronology, genogram, information from agencies and discussions in Panel were used by the Lead Reviewer to develop an initial analysis with ideas and questions about what happened in the case.   This initial understanding was further discussed in Panel and informed the preparation of a Learning Event for practitioners and line managers to test out and further explore operational practice issues.   During the process, issues and questions were clarified by services as required.    The Learning Event was a critical part of the review. It was a full day workshop in which line managers and practitioners reflected and discussed the questions and identified learning for future practice. The Learning Event was attended by thirty practitioners and managers representing all the agencies involved in this case. Five discussions, reflecting the five episodes described above, were held simultaneously and repeated throughout the day, so that every participant attended four discussions. Participants had been provided with a template prior to the event to enable them to reflect and prepare. Questions were devised to reflect the analysis by the Review Team, and facilitators, made up of members of the Panel, were briefed to focus on these questions to direct discussions. Participants were briefed to focus on systems – constraints, resources, knowledge and skills, organisational goals and values, etc. to support learning. The output has been integrated into the analysis and overall lessons learned in this Report.    The output from this process has been collated and synthesised into this Report.   The Report aims to be succinct and focused on improving practice through the Recommendations.  2.2 Parallel processes: There was a Police investigation running parallel to the Serious Case Review process and this was taken into consideration in terms of the timeline for completing this review. The Review was delayed by several months in order to include staff members involved in that process; however, it was then decided to continue with the Review in order that the findings could be implemented in a timely fashion.  The Police investigation was concluded after the completion of the Serious Case Review and mother pleaded guilty to the charges and received a custodial sentence.      43 Independence of the Author The Panel commissioned Kate Mitchell as Lead Reviewer for the review process and Independent Author of this Overview Report. Kate Mitchell is independent of all agencies engaged in this case, has been commissioned previously to undertake SCRs for Durham LSCB, but has not been employed by any agency in this County. Kate Mitchell chairs and authors Domestic Homicide Reviews and Safeguarding Adult Reviews in other counties, and has, since 2008, been commissioned to undertake independent practice reviews in a number of criminal justice and social care services. Prior to 2008, Kate Mitchell was employed in the Probation Service, as a practitioner and manager including working with Community Safety Partnerships, chairing MAPPA and representing the Service in the LSCB.    4 Overview Panel Membership  Role Organisation Lead Reviewer and Author Independent Business Manager Durham LSCB Admin Co-ordinator Durham LSCB Strategic Manager – Safeguarding and Professional Practice Durham Children and Young People’s Service, Durham County Council (DCYPS) Named Nurse, Safeguarding Children North Tees and Hartlepool NHS Foundation Trust (NTHFT) Named Nurse, Safeguarding Children Harrogate and District NHS Foundation Trust (HDFT) Detective Inspector, Safeguarding Durham Constabulary Named Nurse, Safeguarding Children County Durham & Darlington NHS Foundation Trust (CDDFT) Named Nurse Safeguarding and Looked After Children   North Durham CCG, Durham Dales & Easington CCG and Darlington CCG Lead Health & Wellbeing Operational Lead Education Durham, Durham County Council Named Nurse Safeguarding Children Community Health Services South Tyneside NHS Foundation Trust Legal Services Manager Durham County Council      55 Confidentiality 5.1 Working Together to Safeguard Children, 2015, sets out the requirement for publication in full of the overview report from SCRs. Whilst the circumstances described in this Report will inevitably be recognised and members of the family identified, by members of the family, the public and agencies who knew Freddie’s family or who are familiar with the case, the Panel has taken steps to safeguard the confidentiality of Freddie and his family. Freddie and Finlay are pseudonyms for the children at the centre of this Report and are used throughout, and in communications outside the agencies involved in the Review. Identifiable data including dates and personal details such as dates of birth, names and addresses, gathered and used during the Review, have been removed or generalised with the aim of retaining its meaning whilst being confidential. 5.2 Freddie and Finlay are names allocated by the LSCB to protect the confidentiality of the baby at the centre of this Review, and his twin brother. Older siblings are referenced as Siblings 1, 2 and 3. The children’s mother is referenced as such and mother’s partners as Partner 1, 2, etc. Maternal grandmother is referenced as MGM. 6 Family Involvement 6.1 The Review Team contacted members of the family to offer the opportunity to contribute to the Review. The father of Sibling 3 took up this offer and met with the Team. His perspective and experiences are included in this Report. 6.2 The family will be contacted when the Report is completed, to discuss the outcome of the Review and discuss the LSCB’s plans for publication.  7 Staff Involvement The Overview Panel consisted of managers in partnership agencies who were independent of the case. Managers and practitioners involved in the case were invited to the Learning Event, with the exception of practitioners engaged in ongoing criminal proceedings. These practitioners were represented by colleagues. The output of the Learning Event, representing staff involvement, has been incorporated into this Report, as has further information contributed by individual members of staff, after that event.      68 Race, Religion, Language and Culture 8.1 Family members involved in this case are white, European, with the exception of Sibling 3 who is of mixed African/European heritage. All are English speaking. No religion has been recorded.  8.2 The family lives in a small town in County Durham. It is an area of higher than average deprivation than similar communities in the north east, reflected in complex social and health needs. Low-cost housing owned by absentee landlords without active tenancy management, causes anti-social behaviour issues for local people and agencies. Conversely, low social mobility and a strong community aspect reflects the traditional mining community of the area, and many families continue to be closely located with strong kinship networks.   9 Family History    9.1 The ‘Welsh Model’ focuses on the 12 months prior to the event, a timescale which includes the pre-birth and lifetime of Freddie and Finlay. It was clear there was information prior to this timescale, which was relevant in considering subsequent events. This section is a synthesis and analysis of that information.   9.2 Information about Freddie and Finlay’s mother in her own upbringing is limited and fragmented, however, it is clear that her early life was characterised by domestic abuse, frequent separations and reconciliations between parents and numerous moves of house. The family was known to Children’s Social Care (CSC). Her mother having left the family home, she spent a period in Care and was mostly brought up by her father. There were concerns about the capacity of both parents to meet the needs of their children and there were no lengthy periods of agency involvement that could have potentially addressed these concerns. The impact on her, of living in a household with domestic abuse, was not explored or understood.   9.3 As a young person, the children’s mother was victim of a serious sexual assault which affected her both mentally and physically. It is likely that the accumulation of these childhood experiences will have had a lasting impact on her emotional well-being and on her parenting capacity.  9.4 At 17 years old, the children’s mother was first pregnant. She did not engage with health services, and routine domestic abuse inquiry was not made as her partner was present at that appointment. She disclosed her experience as a victim of serous sexual assault; there   7is no record to indicate that this disclosure was followed up by an inquiry/ referral, even though she was, at this time, still a child. Those childhood experiences may have influenced her view of services, or fear of medical procedures, and impacted on her future engagement.   9.5 Sibling 1 was born in March 2008 and Sibling 2 in March 2009. Both babies were born prematurely and without ante natal care. There is no evidence in the records, that health agencies explored the needs of the young mother, given her history, or her capacity to meet the babies’ needs.  9.6 Between 2009 and 2011, there were 13 referrals to CSC. Four related to incidents of domestic abuse. The referrals highlight concerns about neglect, parental separation, alcohol use and developmental concerns. Three initial assessments were carried out, but a Core Assessment was not undertaken until March 2011, following a decision to place the children’s names on the Child Protection List. Police were so concerned about the neglectful state of the home that she was arrested and cautioned for neglect; Sibling 1 and 2 were placed with her mother (maternal grandmother/MGM). In May 2011, following private law proceedings with a comprehensive report to the Court prepared by CSC, which reflected significant improvements in the children’s development whilst with MGM, a Residence Order was granted to MGM. The names of the children were removed from the List in November 2011 and Siblings 1 and 2 have remained in the care of MGM to date.    9.7 CSC reported to the Review that the early years of Siblings 1 and 2 mirrored the children’s mother’s own childhood experiences. There were clearly opportunities to intervene more rigorously and repeat short term assessments did not lead to lasting change. There is very little reference in the reports to the children’s mother’s own experience of being parented by her mother and/or father, and there was no evidence of a parenting assessment of MGM. However, it was reported by CSC and other agencies that MGM had provided a good quality of care to Siblings 1 and 2 and there were no concerns about her capacity to parent the siblings long term. This discussion has relevance in considering events of May 2017.  9.8 The children’s mother has a history of post-natal depression, low mood, overdose and self-harm. In 2011, 2012 and 2014, she was referred by her GP to a mental health service and attended on two occasions. In an assessment she made lengthy disclosures concerning her early experiences and was referred for talking therapy but did not attend. She was discharged and referred back to the GP.   8 9.9 In 2014-15, the children’s mother was in a relationship with Partner 1 (i.e. the first partner who is recorded by any agency). This relationship was recorded by police when called to a series of domestic incidents: three in 2014 concerning Partner 1; and three in 2015 concerning Partner 2. All were graded as Standard or Medium. Partner 1 is diagnosed with grand mal epilepsy and has a history of crises relating to this condition, calling ambulances, and attending at Accident & Emergency.   9.10 Sibling 3 was born in July, at 28 weeks gestation. He remained in the Special Care Baby Unit for 12 weeks. There had been a referral for a pre-birth assessment for Sibling 3 and this was still in progress when Sibling 3 was born prematurely. A discharge meeting noted the domestic abuse incidents; and that the children’s mother’s new partner, Partner 2, was only allowed supervised contact with his own child, while Partner 1, the father of Sibling 3, was under investigation for sexual relations with an under-age girl. A home assessment established that conditions were not suitable, and the children’s mother went to stay with Partner 2 with Sibling 3, until repairs were completed, but within two days is recorded living back at her home when police attended a domestic incident, in which the children were present. A Strategy discussion led to Sibling 3’s name being added to the Child Protection List in the category of Neglect. Three weeks later, there was a further domestic abuse incident with Partner 2, as a result of which the children’s mother was taken to MGM’s home with Sibling 3 and ended the relationship. In December, they moved to her own property.  9.11 CSC identifies that the opportunity for a more in-depth assessment was presented when Sibling 3 was born prematurely. The decision not to consider a s47 inquiry at that time may have been reasonable. However, the disclosure of Partner 2’s offending behaviour was not available at the time of that assessment.   9.12 In January, 2016, it was recorded that mother was back in the relationship with Partner 2 but living apart. At a Review Child Protection Conference in February, it was agreed that Sibling 3 should stay on Plan as work remained outstanding. In June, the Core Group noted concerns about mother’s vulnerability, mood and social isolation, and she was again referred to the mental health service but did not attend until August when a detailed assessment took place and she was referred back to GP as ‘no secondary mental health services’ were indicated. This was the second time the children’s mother had given detailed historical information about her traumatic experiences, her vulnerabilities and lifestyle to this service, and been discharged, which may not have encouraged her to   9engage with services. CSC was not informed of the discharge, so was unable to consider other resources.  9.13 In July 2016, the Core Group recorded that the children’s mother engaged well and positive work had been undertaken. At this time, it was recorded that Sibling 3 had been recently diagnosed with cerebral palsy and the children’s mother was managing this well. Sibling 3 was de-escalated to Children in Need (CIN) status to be managed through Team Around the Family (TAF) procedures. At a TAF meeting in August, Sibling 3 was said to be progressing well. Support was offered by Community Support Team and the social worker until mid-August when the risk was assessed as low and the case was closed. 9.14 In October, their mother was pregnant with Freddie and Finlay.   10 Summary and Analysis of significant events during Freddie’s life     This section summarises and analyses the integrated chronology and further information received from Children’s Social Care and Education; a meeting with Sibling 3’s birth father; and discussions in Panel meetings. The synthesis and analysis of this information identified five practice episodes which formed the basis for the Learning Event when the episodes were discussed in detail with practitioners and managers, and their feedback has been included here.  10.1 Practice Episode 1: October 2016 to mid-March 2017. Mother’s pregnancy with Freddie and Finlay.  10.1.1 This was the children’s mother’s fifth pregnancy: her personal history indicated that she was vulnerable and suffered low mood; she was known to form relationships with perpetrators of domestic violence and alleged sex offending; she had a history of premature births; two children whose early life mirrored her own, now cared for by her mother; a toddler with cerebral palsy. She had a history of non-engagement with health services during pregnancy. This history appears not to have been considered in assessments and decisions relative to this pregnancy. The Panel member has accessed limited electronic records that she was seen by community midwives, but despite this known history and that the babies were likely to be born pre-term, these records provide no evidence of professional curiosity or exploration, or discussion with the children’s mother about her social circumstances. During her pregnancy, she was   10also not attending health appointments with Sibling 3, who had now been diagnosed with cerebral palsy.  10.1.2 The children’s mother’s voice appears to be absent in records up to this time, apart from Mental Health Services. The Review has not seen evidence that professionals asked her about her needs, or what resources would help, given her history. She had a history of non-engagement; records suggest there is equally a history of the system not engaging with her.   10.1.3 As with previous pregnancies, the children’s mother did not engage and then presented when the babies were about to be born, prematurely.  Discussions at the Learning Event in relation to this practice episode:  10.1.4 Sibling 3 was de-listed around the time the mother became pregnant with Freddie and Finlay. Had Sibling 3 still been on the Child Protection List, the unborn twins would have been considered in the safeguarding arena from that point. This case would therefore have taken a different direction, but this pregnancy could not have been known to CSC at the time of de-listing. However, information that siblings had previously been removed, and one sibling subject to a Child Protection Plan, could have been used effectively, to assess risks to the unborn twins. In this regard, the Learning Event discussed gaps in information sharing at the ante-natal stage:   10.1.5 Information gathered by the midwife to complete the antenatal risk assessment was self-reported by mother. This did not highlight the historical issues. The Panel member for CDDFT investigated this concern following the Learning Event and found that historical information which was available to the midwife through the electronic GP system was not utilised to support the antenatal risk assessment. This was a missed opportunity to submit a safeguarding referral. Access to the same electronic GP system is not consistently available to all community midwives. The expectation is that the community midwife would utilise the revised antenatal risk assessment tool to support gathering information regarding vulnerabilities and enhance the professional curiosity. CDDFT has now updated The Antenatal Risk Assessment Tool to provide more detailed questioning around vulnerabilities and facilitate the midwife’s analysis and subsequent actions.  - There was a lack of follow up when the children’s mother failed to attend antenatal appointments. This was a missed opportunity for professional curiosity and further enquiry which could have potentially led to a safeguarding referral being made. The   11Panel member subsequently explored this issue and found no evidence that this midwife received safeguarding supervision. CDDFT has guidance for missed appointments and there is a need to ensure midwives are aware of this and are implementing it in practice. - It was noted that a mother’s record is flagged if an unborn is subject to a Child Protection Plan. In CDDFT, the flag is then transferred to the child’s records when born. Parental records are not flagged if they have had children removed or subject to CP Plans. In NTHFT records are flagged for both mother and child, regardless of whether they are unborn or born. If records were flagged in all cases, it could prompt the Midwife at booking to make further enquiries and an immediate referral to Children’s Services.  There is therefore a need to flag parental records in CDDFT. Work is ongoing within CDDFT Midwifery to develop a policy about this issue.   10.2 Practice Episode 2: Mid-March to end of April 2017. Freddie and Finlay were born and placed in the Neonatal Unit   10.2.1 After the children’s mother went home on Day 3, with the twins in NNU, first in an Out of Area Hospital then in a Hospital in County Durham, her engagement with the hospitals and with the twins was dismal. Over 40 days, she visited nine times and there were significant gaps between visits. Rarely were both babies awake on her visit. There were six phone calls from her on the 28 days she did not visit, and four ineffective telephone contacts from NNU staff to her. As she could not be contacted, the twins’ mother was not aware of their transfer to a hospital in County Durham on Day 9; this transfer had been arranged by health professionals in discussion with their mother, to bring the twins closer to home and assist her to visit. On Day 40, she stayed overnight to prepare for the babies’ discharge.   10.2.2 The children’s mother’s problems with phone credit and transport, and caring for Sibling 3, which she stated stopped her being able to attend, were well documented by NNU practitioners; there were conversations with her about these issues, but no action to support or advise her and conversations were not followed up. Staff were aware of the previous medical history, but not the social care history or previous safeguarding concerns. Across all NNUs, telephone contacts were unsuccessful. Information was shared between the two hospitals during the transfer of the twins.   10.2.3 On Day 10, NNU staff contacted the Specialist Midwife and there was an agreement to monitor the mother’s level of visiting. There was a Paediatric Review on Day 12, when the decision was to continue to monitor. There was a safeguarding discussion   12on Day 13 with the specialist safeguarding midwife, when the decision was to ‘continue to monitor’ and to submit a safeguarding referral as mother was not prioritising the needs of the children. It was recorded that a safeguarding referral should be made; but two days later the referral had not been sent and it was recorded it would be sent the same day; it was not. On Day 17, the NNU nurse said the threshold for safeguarding had not been met. The Health Visitor clinical lead in discussion with the specialist safeguarding midwife did not consider the risks met the threshold for statutory safeguarding.    10.2.4 Names of the children’s mother’s birth partner, and of family and friends later visiting in her company were not recorded, relationships are unclear, and the impact of this on child wellbeing – especially given the lack of bonding noted above – was not referenced. For example, on Day 23, the children’s mother visited with ‘partner’ whose name is not recorded, whereas earlier records state she was alone, i.e. had no partner. On Day 25, she visited with ‘a friend’. On Day 41 (day of discharge) it was noted that Freddie and Finlay’s father was Partner 3 (though it was also said that he had no PR and was not named on the birth certificate) and that her new partner was Partner 4.   10.2.5 Poor attendance by the twin’s mother continued, and it was known that she was struggling. On Day 35, the Specialist Midwife agreed there should be an Early Help Referral. It is not clear whether a referral was made; One Point has no record of an Early Help Referral; the Health Visitor (HV) was co-located with One Point and a referral if submitted would have been immediate.   10.2.6 The children’s mother attended hospital on Day 36 and there was a discussion with her about discharge arrangements, but there is no record of talking about her need for support given that she would be returning home with vulnerable twins and a toddler with cerebral palsy.  10.2.7 On Day 41, there was a discharge planning meeting with the children’s mother and the NNU nurse and the HV was also present.  There is no evidence of discharge planning minutes but documentation highlights a family worker, and help being given with housing and ‘extra additional support’. The specialist safeguarding midwife was not invited to this discharge planning meeting. The NNU discharge summary refers to the mother’s new partner and stated that support was to be provided to the family through early help co-ordinated by the HV. During Freddie and Finlay stay on the second NNU, both the community midwife and the HV expressed concerns with regard to the home   13conditions and the unsuitability of this for discharge. There is no evidence this was revisited prior to discharge. There was a discussion during discharge about help with housing, and the HV concluded that a referral to early help was required.  10.2.8 Four days after Freddie and Finlay went home with their mother, the Health Visitor discussed Early Help with her. This was two weeks after the Specialist Midwife planned a referral to Early Help, indicating a lack of referral and a lack of communication between hospital and community. Three weeks later, a health professional was told there was referral in process, which suggests none had been made, at that time. Although the midwife had stated the house was not suitable for the babies to be discharged, and there was a discussion during discharge about help with housing, this appears not to have been communicated to the HV, who in turn concluded that a referral to Early Help was required.  10.2.9 A number of concerns arise from this episode: communication between hospital and community staff; understanding of safeguarding and the 0-19 Pathway; lack of continuity in planning referrals and in discharge planning meetings. Above all, attachment, which should have been a major concern and itself raised the need for a TAF, for an early help referral, and subsequently for a safeguarding referral, was not referenced. It is clear in hindsight that a referral to CSC should have been made and that NNU practitioners and managers should have been discussing not whether this was a safeguarding matter – in the Reviewers’ view, it evidently was – but whether they should initiate a TAF. This raises the question of whether the 0-19 pathway is understood, and the need to identify what the barriers for NNU staff are, in implementing it.   Discussions at the Learning Event in relation to this practice episode:  10.2.10 The Learning Event discussions supported these initial findings, in relation to the skills and knowledge of Neonatal practitioners. There is a need to ‘go back to basics’ with Neonatal staff in terms of Working Together, roles and responsibilities, disguised compliance and understanding the safeguarding process. Practitioners agreed there was a flawed understanding of the safeguarding process, of the language of child protection and the resources available; and the multi-agency responsibility for safeguarding. An understanding of the threshold for a referral to Children’s Services is not clear to health practitioners in this setting.   1410.2.11 The Learning Event identified deficits in information sharing processes. There was limited handover of information between the two Neonatal Units, relating to the number of times the children’s mother had visited, and of her lack of engagement in the care of the twins. This review process has identified the Neonatal Units across the region have access to a regional electronic case management system (‘BADGER’)  to record information or upload documentation. This information is not accessible to all health staff including safeguarding teams. CDDFT should review access and ensure   information sharing processes are robust. There is a regional proforma for handover between Neonatal Units and the Learning Event recommends this should include a chronology of visits made by parents. 10.2.12 There is a need for consistency in Discharge Planning Meeting arrangements. There are no minutes to establish fully who was present or clarify the actions required for the family. CDDFT has developed a proforma which is utilised at all discharge planning meetings held in the NNU, the meetings are also chaired by the NNU staff. In the case of Freddie and Finlay’s discharge from Neonatal, the people who needed to be there, were not: the GP, the Specialist Safeguarding Midwife. Therefore, this was a missed opportunity to share historical information.   10.3 Practice Episode 3: First NAI incident: Finlay  10.3.1 The babies had been at home for a week when their mother took Finlay to Accident and Emergency Department with an injury to his mouth, stating that she had noticed blood when bottle-feeding. On examination, this was assessed as a torn fraenulum caused by excessive force in bottle feeding. Finlay was admitted to hospital. On admission, it was recorded that Finlay was unkempt and dirty.  10.3.2 Timing of events, in a potential NAI, is important for the record, and we are told this is current policy in agencies. A number of these events are not timed, and it is difficult – and important – to be able to identify the sequence of decision-making. This policy therefore needs to be implemented.  10.3.3 The following day, ‘the grandfather of mam’s partner’ and Partner 4 were recorded as being present with Finlay, with no further detail or inquiry regarding names and relationships. Later that day, it was recorded that ‘partner’ was looking after the other children, and no name is recorded. It has emerged since the incident, and was not previously known to any service, that Partner 2 and his mother had been involved in   15the care of the twins on a frequent basis throughout their lives, and it could therefore be assumed that they were involved at this point.  10.3.4 A Strategy meeting was held later that day, attended by hospital and community health staff and the paediatrician. It is clear from the Paediatric report and agency records that the injury was judged to be NAI and there was to be a s47 inquiry. In the meantime contact by the children’s mother and her partner was to be supervised.  10.3.5 Later that evening, MGM arrived at the hospital and it was decided by the CSC team manager in consultation with the Police that Finlay could go home with her. MGM agreed that all the children could be placed with her, and it was recorded that this had been assessed as suitable. MGM was now caring for five siblings: Siblings 1 and 2 had lived with her for some years on a Residence Order; and Sibling 3, who had cerebral palsy, and the twins, aged six weeks, arrived on this day. MGM also agreed to supervise contact between their mother and the children. A CSC assessment was recorded, but the Panel was concerned that this did not appear to consider MGM’s support needs and the children’s mother’s own experience of being parented by MGM.   10.3.6 This led the Review to query whether the assessment of MGM’s parenting capacity on that date was a reiteration of the assessment that had taken place some years before when Siblings 1 and 2 were placed with her. The Panel was assured that MGM’s care of Siblings 1 and 2 had been good but was concerned about MGM’s own support needs to enable her to care for three additional children with complex health needs.  10.3.7 Five days after the NAI, CSC recorded that the section 47 inquiry had completed and a decision was taken to return the children to their mother’s care and manage the case through the Children in Need (CIN) process. A complete assessment is on record which records the medical opinion that the mechanism behind the torn fraenulum was most likely caused by the use of excessive direct force, raising a strong suspicion of physical abuse.  It was therefore recognised that the mother had been too forceful in feeding baby Finlay, however, she had sought medical attention appropriately and worked with professionals during the investigation. She was seen as a caring mother with positive support from her own mother. Historical information was acknowledged in relation to her own developmental delay and that she formed abusive relationships, however, the assessment observes ‘enhanced demonstrable pro-child developmental skills’ and sees her as truthful in her version of events leading to the injury. It was noted that her partner, whilst having a conviction for violence, was not assessed by the   16Probation Service as a risk to children and he was seen as supportive. Therefore, the assessment in relation to the children’s mother’s ability to care for pre-term babies was positive; she was seen as caring and, with support and information, able to care for the twins.  10.3.8 The Review has highlighted a contradiction in the recording of these events by Children’s Social Care and Legal Services. It is clearly recorded in the CSC record that legal advice was sought and this advice was that the case could be managed through the CIN process, with mother being provided with intensive support. However, Legal Services has reported to the Review that the recollection of the advisor (there is no written record of this consultation) is that ‘the threshold for immediate removal was passed’ and the children should be accommodated while intensive support was provided to the mother.  There was no ICPC at the conclusion of the section 47 inquiry, and no indication of consulting other agencies.   10.3.9 Two weeks later, a health professional was told by CSC that there was a ‘tight CIN plan in place’ but had not seen this. Also, that a ‘family worker is in the process of being assigned’ which suggests the referral for Early Help from April, had not been actioned. The Plan was first shared in the middle of July 2017.   10.3.10 This episode raised three concerns for the Review. First, the support offered to extended family caring for children in an emergency. The decision to place the children with MGM was consistent with practice under the Children Act 1989 where the local authority is required to consider connected persons in preference to placements with strangers. However, the Review Team would have wished to see reference to support offered for MGM in this difficult situation.   10.3.11 Secondly, the Review finds the decision to step the case down to CIN four days after the NAI questionable. Process was not followed in that there was no ICPC or other consultation or communication with other agencies; information from the NNU, or the Health Visitor, for example, could have highlighted their mother’s lack of engagement and attachment during the twins’ first 40 days, which was significant information, given that they had been home for one week when the NAI occurred. The CSC assessment, given the information available to the Review, appears overly optimistic. However, it is reasonable that CSC holds that their decision was in accordance with legal advice. There is no written record in Legal Services of that consultation and the Review must therefore tend towards the written record in CSC as evidence. It is however clear to   17the Reviewers, from a position of hindsight, that the children should have been removed at this point. The Review will recommend that there is a follow-up process in Legal Services, to ensure that, where legal advice is to issue care proceedings, this should be followed up in writing where it is provided by phone, and also followed up with CYPS to find out what action they have decided to take.  Discussions at the Learning Event in relation to this practice episode: 10.3.12 In relation to both Episode 2 and Episode 3, the Health Visitor was covering sickness and vacant caseloads, and therefore did not have the information required to support the family. It was unclear whether the family had additional needs or required support given that mother was on her own and had one child with additional needs and the twins were premature. From a Health Visiting point of view, this was a missed opportunity for key background information to be considered, and to consider whether the family required additional support. In terms of learning, consideration is being given to the Health Visiting Service attending the weekly meetings with Neonatal Unit in order to improve the communication flow between the acute and community health services. The participants at the Learning Event queried whether this could be extended to Paediatrics to ensure robust information sharing. Health Visitors are now required to review records of siblings and older children to be fully aware of the family history. 10.3.13 Learning was identified for the Emergency Department and Paediatrics practitioners. Clinicians observed that the children’s mother did not have eye contact and appeared stressed, and they recognised the torn frenulum as NAI. However, whilst they correctly submitted a referral to Children’s Services, they did not consider how they should respond to mother, a potential perpetrator, who was in contact with Freddie whilst in the department. Fortunately, the mother did not stay in the hospital overnight. This issue waited until the following day when the Consultant confirmed it was NAI. 10.3.14 A number of queries were raised, relating to assessment and decision making following the section 47 process:  Whilst the medical report was definitive in that the injury was NAI as a result of excessive force, there was thought to be an element of professional over-optimism in the assessment that led to the de-escalation of the NAI to a Children in Need case. Mother agreed to work with professionals, however, she had no history of engagement. Information about the children’s mother’s lack of attachment to the babies, and the implications of this for safeguarding, was not available to this assessment. Professional optimism is problematic when insufficient weight is given to static risk factors, i.e. historical risk factors that cannot change without a fundamental alteration.   18 There was a gap in communicating the outcome of the section 47 to other professionals; therefore, information and decision making was not known by other agencies who did not have the opportunity to challenge or escalate this decision.   The decision to discharge Finlay to MGM was made outside the Strategy Meeting and was a single-agency decision which appears not to have considered that MGM would be caring for five children, one of whom had additional needs and the twins were vulnerable due to their prematurity.  10.3.15 Service improvements in CSC since this incident include improving the Strategy meeting process, in response to a JTAI; and the implementation of a new case management system and reinforcing with staff the need to record in real time.  10.3.16 Organisational issues were identified as factors affecting this process, and leading to decisions which were not child-centred:  At the time, there was a significant organisational change within CDDFT in that the acute and community safeguarding teams were split across two Trusts.  Whilst the procedures were clear regarding challenge and escalation, practitioners report a lack of confidence in practice and believed there was a need for development of professionals at the front line, to change the culture and support staff to follow this process.  It was discussed whether there was learning for Legal Services, particularly that there is no follow-up process by Legal Services and therefore advisors would not be aware whether their advice had not been implemented.   10.4 Practice Episode 4: May to September 2017. Freddie and Finlay were subject to CIN procedures   10.4.1 Finlay was admitted to hospital with facial swelling five days after the NAI incident and discharged six days later. This was a general health condition and not one raising concerns. However, during the period he was in hospital, including having surgery, his mother’s non-engagement with the hospital and failure to visit Finlay was recorded. He was discharged to his mother and Partner 1, who was now back in the household.  10.4.2 The first TAF at the end of May 2017 was held at the family’s home. The HV had submitted an Early Help Referral the day before, though to which agency and what was the outcome, is not clear. However, the meeting clarified that a Family Worker   19from Families First had already been appointed to assist the children’s mother with parenting strategies. She discussed her difficulties in managing Sibling 3’s behaviour. From this point, the emphasis appears to have shifted away from Finlay and the NAI event. The background to the CIN was not referenced; there was reference to ‘a tight CIN plan’ but no clarity about what this meant. The Review is therefore not assured that the issues that led to the s47 and then the CIN plan, were being addressed.   10.4.3 In early June there was a domestic incident when Partner 1 was abusive to the children’s mother and was spoken to by police. CSC was not aware of the incident and believed that the home situation was stable. Police information received by the Review indicates that this incident met the threshold for communicating with CSC (“All domestic incidents where children are currently open to child services are shared direct with the relevant teams by police.”) however there is no record of the information having been shared with CSC. The relationship may have ended again, as the children’s mother told the Health Visitor in early August 2017, that her ‘ex’ was watching her, and no name was recorded.  10.4.4 In mid-July, the HV received a copy of the Family Plan from the social worker, dated early May. There is no record of the Plan having been shared in early May when the decision to manage through CIN was made, or at the first TAF at the end of May.  10.4.5 The Families First record shows that of nine planned visits to the home, five were ineffective, i.e. the family was not at home. At the end of July, there was a ‘de-escalation meeting’ between Families First Team and One Point Team, when it was agreed that the case would be downgraded to One Point. At the Learning Event, the practitioners involved expressed that this had been a management decision, taken without consultation with the professionals working with the children’s mother, who took the view that the work had not been progressed due to her lack of engagement. Her engagement with medical appointments for the children continued to be sporadic during this period. Nonetheless, it was then reported to the next TAF, at the end of July 2017, that the plan was for the case to de-escalate, continue with family support and parenting advice; and that One Point would continue with the provision of family support, with no further TAF. This meeting also referenced the children’s mother’s need for support with Sibling 3’s behaviour and did not refer to the reasons the CIN process was initiated. The Review Panel is therefore not assured that this had been addressed.     2010.4.6 In early August 2017, the Health Visitor observed that the children’s mother was vulnerable (Maternal Mood Assessment) and continued to have issues with Sibling 3’s behaviour; the HV decided to arrange a joint home visit with the Family Support Worker but this was not arranged until later in September. At that visit, the children’s mother reiterated her concerns with Sibling 3’s aggressive behaviour. Therefore, the issues which were the rationale for the HV’s referral for family support at the end of May, and the focus of the Family Support Worker’s intervention, were continuing. The HV recorded that in their discussion, the mother demonstrated she was aware of strategies to manage Sibling 3, and that her mother, MGM, who was present at the meeting, demonstrated good management of Sibling 3. This discussion appears to have reassured the Health Visitor and the Family Support Worker, and it was agreed that the case would be closed to the family support worker. It was not recorded whether the children’s mother declined further intervention, or whether no further intervention was required.   10.4.7 The following day, Freddie was taken to Accident and Emergency with a head injury.   10.4.8 From merged chronological information, it is now known that Partner 1 and his mother were involved in the care of the twins, Freddie and Finlay, throughout this period, providing emotional and financial support and care on a day to day basis, which was not known to services at the time. Additionally, Partner 2, Sibling 3’s father, told the Review that he had been engaged in Sibling 3’s care and providing financial support, throughout his life, despite often being refused contact by the children’s mother. Neither of these supportive paternal arrangements were spoken of, by the children’s mother, in her discussions with professionals.   10.4.9 A number of queries were raised in the analysis of this episode, which immediately preceded the injury to Freddie. The rapid de-prioritisation of the case from an initial NAI to CIN then case closure, appears to be contrary to the evidence available, and not supported by evidence of the mother’s engagement with the process. Assessments are on record and underpinned these decisions, with the exception of the de-escalation of family support provision from Families First to One Point, which is a lower level of support. Subsequently, professional optimism may have taken over, for the Health Visitor and the One Point Family Support Worker were reassured that MGM demonstrated good parenting strategies, even though MGM did not live in this household; and were further reassured by the children’s mother that she understood how to manage Sibling 3’s behaviour. The case may evidence disguised compliance,   21where parents are able to decoy professional staff, in this case by using terminology they have learned, and which, though not demonstrated, is reassuring to workers.   10.4.10 The parenting needs evidenced by the NAI in early May, which had led to the CIN, appear not to have been referenced at any subsequent point. Interventions were effectively re-focussed on to Sibling 3’s behaviour.   Discussions at the Learning Event in relation to this practice episode:  10.4.11 As referenced above, the Learning Event questioned how, given a significant injury (torn frenulum), the case was de-escalated to CIN. There was no documentation to identify the mitigating risk factors and protective factors; it was not known who was present when the decisions were made, or the information used to inform the decision. There was a TAF, which practitioners reported was focussed on domestic abuse and mother’s self-esteem issue and the original reason for intervention appeared to have been lost. Practitioners noted that the case was then closed before the work was completed and there was no discussion with other TAF members about the decision to close the case. The closure of the case was a managerial decision, which clearly, on the basis of discussions with practitioners, was not understood by those working with the family.  10.4.12 Disguised compliance was thought not to be clear in this case. There was an over reliance by professionals on what mother was saying and telling professionals, and professional optimism.   10.4.13 Information sharing processes raised a number of issues:   Full information was not gathered or collated in a way that the risk indicators were fully understood.   As agencies used different case recording systems, there was no one person co-ordinating and collating information held by all agencies which may have identified concerns.    There were access issues internally in that some professionals did not have full access to their own electronic case management system.    22 Police participants in the Learning Event advised that even the Investigating Officer was not aware of some information that has been gathered as part of the Review process.  There was a lack of understanding of the wider family network. Some of the individuals who had access to the children were not recorded. Professionals were not aware of how much contact Sibling 3 had with his father, which included overnight stays.  From a Police point of view, there was a missed opportunity to identify those that had contact with the children when formulating the pool of perpetrators in relation to the final event.  Information about domestic abuse incidents was not shared with Children’s Services as they had been graded as ‘standard’ and these are currently not shared with Children’s Services or Health.  Only those incidences graded medium and high are shared.  This was a learning point for the Police.  Professionals report that they are fearful of sharing information in case it breached confidentiality.  It was stated at the Learning Event that Working Together to Safeguard Children 2018 has clear guidance around information sharing in terms of what can and cannot not be shared, yet this is still not widely practiced by multi-agency practitioners.  Professionals said they were careful when recording information such as their feelings as this may later be disclosable.    10.4.14 The Learning Event questioned whether workload issues were a factor in de-escalating the case so quickly, and this was discussed and explored by Panel members who could find no evidence to support this. However, it is believed that organisational changes such as restructuring can impact on the skillset and knowledge of practitioners.  10.5 Practice Episode 5: Freddie was admitted to hospital  10.5.1 The children’s mother called the Ambulance Service in the morning, reporting that Freddie was not responding and was bruised. On their arrival, she told paramedics that Sibling 3 had been running around and had fallen on top of Freddie.  Freddie was taken to Accident and Emergency.   10.5.2 A Strategy Meeting was held that day, in which there were conflicting opinions regarding Freddie’s injury, between the A&E consultant who considered the injuries to be indicate a non-accidental injury, and the paediatric consultant, who found Freddie’s injuries consistent with his mother’s account of Sibling 3 falling onto him, and planned   23to discharge Freddie home without conducting medical examinations on the siblings. Nursing staff who agreed with the opinion of NAI escalated the disagreement to the Designated Doctor who determined that medicals on the siblings must be undertaken. The Consultant reconsidered and came to the opinion that on the balance of probability, this could be NAI. Freddie had a subdural haemorrhage acute and chronic, and two injuries, a new, and an old injury, possibly occurring over the previous thirty days. The Consultant continued to decline to medical the siblings, recommending that there should be a health visitor review of Sibling 3. Nursing staff and the Senior Nurse Safeguarding Children expressed concern given that Sibling 3 had, by the mother’s account, fallen over the dog and landed on Freddie, and may therefore be injured; as such, a health visitor review was not sufficient. This disagreement was escalated to the Named Nurse Safeguarding Children and the Designated Doctor who determined that medicals on the siblings must be undertaken.  10.5.3 There was a s20 agreement with the children’s mother and the three siblings were placed in foster care. Freddie remained in hospital.  10.5.4 It was recorded that the maternal uncle and Partner 5 (previously unrecorded) were present in A&E.  10.5.5 The agreed outcome was that Freddie had suffered a serious non-accidental brain injury with life changing brain damage, caused by shaking and possibly impact of his head. Given that the injuries could have occurred within the past three months, the pool of potential perpetrators was large. A section 47 inquiry was initiated.  10.5.6 The Review was concerned about the divergence in professional opinion in this case, which, whilst it was properly and successfully escalated, appeared to the Review Panel to have been unnecessarily disruptive during an emergency situation and to have potentially been a high-risk decision. The Panel discussed the power relationship between consultant and nursing staff and concluded that the escalation had been good practice. The Review Panel has received assurance that this professional issue has been managed and learning has taken place within the organisation regarding this incident.      24Discussions at the Learning Event in relation to this practice episode:  10.5.7 The quality of care from the pre-alert by the Ambulance Service to arrival at the Emergency Department and the medical interventions was seen as good practice.   10.5.8 The divergence of professional opinion was discussed by participants who described the escalation process. It was felt that a Paediatrician’s initial views had an influence on actions and decision making and professionals found it difficult to challenge this.  However, the Safeguarding Team was contacted, actions and decisions were challenged, and the disagreement was effectively escalated.   10.5.9 There were concerns about the children’s mother being present in the Emergency Department unsupervised. This seems to have reflected the nature of Freddie’s arrival: clinical staff alerted to an emergency had found Freddie breathing and conscious and some had left, possibly creating a sense of reassurance. It was however noted by participants, that where there is a suspicion of NAI, there needs to be clear and transparent documentation about the nature of the presentation and subsequent investigations. This would help to clarify the concerns raised in this Review, about the way potential NAIs are managed.   10.5.10 It was noted that whilst the actions and decisions had no impact on Freddie’s health, from a police point of view this created evidential difficulties as, had an MRI been carried out, this may have supported the criminal prosecution.  10.5.11 In terms of organisational factors affecting actions and decisions, it was noted that at the time Freddie was in hospital, there were a number of NAI cases on the ward. Also, the turnover of Consultant Paediatricians at this Hospital was acknowledged.  However, in this case there were experienced paediatric nurses and safeguarding nurses present and this is reflected in the outcome.  10.5.12 From a paediatric and health professional point of view, participants felt that health professionals worked well together from a clinical perspective, however, as soon as it is identified as a safeguarding issue they perhaps did not work as closely.  Improvements have been made to address this and there are now Safety Huddles where Paediatric and Emergency Department staff come together to discuss a case openly and transparently and allow challenge. The Safeguarding Children Team now has a daily visible presence in the Emergency Department, and paediatrics across both acute hospitals, which supports staff in safeguarding children.   25  11 Lessons Learned: SCR Terms of Reference  This section concludes the Review by drawing on the information above to highlight lessons to be learned to improve practice, and identifies good practice, in relation to the specific questions set out in the Terms of Reference.   11.1 How was previous relevant information or history about the child and/or family members known and considered in professionals' assessment, planning and decision-making? How did that knowledge contribute to the outcome for these children?  11.1.1 This Review has highlighted a number of missed opportunities to safeguard Freddie, and indeed Finlay, arising from systemic failures to record, share, access, understand or use historical information. These are described in detail in the section above and summarised in response to the specific questions below.   11.2 In making the decision to close the Plan for Sibling 3, what consideration was given to the potential risks to unborn children?  11.2.1 The Plan for Sibling 3 was closed three months before his mother was known to be pregnant with Freddie and Finlay. There are no references in the record of any proposed action or consideration of potential risks to unborn children, although this would appear to be reasonable given that she had a history of child protection and was in a new relationship. It was noted that should she enter into any future relationships where there was domestic abuse then Sibling 3’s welfare would need to be reconsidered.  11.2.2 A concern for this Review is that, once the children’s mother was known to be pregnant, the history was not considered, and there was no assessment at that point, regarding the potential risks to unborn children. There are static risk factors including her personal history; having had children removed previously; a history of domestic abuse incidents; relationships with birth fathers who themselves have histories of offending including violence, substance misuse and other vulnerabilities that affect their social functioning. There was no evidence provided to this Review that these static risk factors were considered during antenatal care in 2016/17, when the twins   26were in Neonatal care in 2017, when the first NAI incident occurred in May 2017, or during the family support intervention in the summer of 2017.  11.2.3 Additionally, there were dynamic risk factors including ongoing domestic abuse and vulnerabilities of members of the household including complex needs of mother’s partners; Sibling 3’s complex health needs; and her own continuing failure to engage. These were also not considered in assessing the risks to the unborn Freddie and Finlay. The antenatal assessment was based on self-report by the children’s mother and did not include liaison with Children’s Services, so the historical information was not shared. There was no follow-up to her failures to engage in antenatal care, which arguably could have resulted in a referral to Children’s Services and initiated a pre-birth assessment for the twins. Parents’ records are flagged only when children have been removed or are subject to Child Protection Plans. Residence Orders had been granted to MGM in respect of Siblings 1 and 2 and as such, they were not considered to have been removed. There was therefore no safeguarding intervention prior to the twins’ birth, which was a missed opportunity.   11.2.4 The Learning Event made two recommendations which could improve the assessment process at the ante-natal stage: - The Antenatal Risk Assessment Tool: this has since been updated to improve the quality of information gathered by the midwife and the analysis and subsequent actions taken by the midwife.  - Parental records could be flagged to highlight a safeguarding history, which would trigger liaison by the midwife, with Children’s Services.   11.3 Were the respective statutory duties of agencies fulfilled?  11.3.1 The Review identified a number of concerns. First, information sharing: there was poor communication between hospital and community staff; a lack of continuity in planning referrals both while the twins were in Neonatal care, and subsequently; and inadequate discharge planning.  11.3.2 Secondly, skills and knowledge of staff in the health system in relation to safeguarding. The lack of engagement by the children’s mother with the babies during their Neonatal stage, should have raised concerns about attachment, but this is not referenced. A referral to CSC was not made and NNU practitioners and managers did not initiate the TAF process. This raises the question of whether the 0-19 pathway is understood by staff in the NNU, and the Learning Event participants indicated it was not and told us there is a need to ‘go back to basics’ and train staff in Working Together roles and responsibilities. This has now commenced within the NNU across CDDFT.   2711.3.3 CDDFT has guidance for missed appointments and there is a need to ensure midwives are aware of this and are implementing it in practice, as this could have made a difference during the mother’s ante-natal care.  11.4 Were there obstacles or difficulties preventing agencies from fulfilling their duties?  11.4.1 Organisational issues were identified that may have affected safeguarding practice at the relevant times and may have resulted in decisions that were not child-centred:   Significant organisational change within CDDFT during 2016, following the tendering process of the 0-19, health visitor and school nursing services, meant the acute and community safeguarding teams were split across two Trusts, and staff moved employment, at the time the twins were in Neonatal care. Transition arrangements were in place during this time period and safeguarding support continued to be offered to health staff.  After Freddie and Finlay were discharged from Neonatal care, the Health Visitor was covering sickness and vacant caseloads, and did not have the information required to support the family.  In CSC, after the s.47 investigation in May 2017, there were staffing issues in that the Team Manager was new to the team as well as the Social Worker who had not been involved in the Strategy Meeting or decision making.   Whilst the procedures were clear regarding challenge and escalation, the Learning Event identified a lack of confidence in practice and suggested there needs to be some development of professionals at the front line, to change the culture and support staff to follow this process.  At the time Freddie was in hospital, there were a number of NAI cases on the ward. Also, the turnover of Consultant Paediatricians at this Hospital was acknowledged. However, in this case there were experienced safeguarding nurses present and this is reflected in good practice, appropriate challenge and escalation, and a good outcome, ultimately, for the twins.  Participants at the Learning Event said there were information sharing constraints in that they believed HDFT staff cannot view safeguarding information recorded by CDDFT. The Panel member did not agree this point. It may be that there were transitional issues during the organisational changes in 2016 and if this is not the case, staff need to be reassured.       2811.5 Was there evidence that the mother’s experience of services, or her views of parenting, were sought, assessed, and considered in making decisions about the children?  11.5.1 Considering the children’s mother’s history and vulnerabilities (described above) and that she had previously demonstrated she was unable to care for the older children, her voice is absent from the records prior to 2017. There are notable exceptions. In 2009, she sought support from her GP for low mood and was referred to TEWV for mental health support but did not attend. In 2012 she was referred to TEWV following an overdose and attended an assessment which records her experiences and vulnerabilities in detail. She was given leaflets and support numbers. In 2016 she was referred again to TEWV, by her health visitor who was concerned about her low mood and reports of self-harm, and the assessment again records her experiences and vulnerabilities in detail. TEWV decided there was no role for secondary care and referred her back to her GP. The information about this assessment was not fed back to the health visitor, and social care was not aware, although information about Sibling 3’s Child Protection Plan had been provided to TEWV; therefore, it was not possible for services to take account of that assessment information in their future work with her. The Review notes that these were very detailed assessments in which the children’s mother disclosed difficult and distressing information, with no outcome. It would be reasonable to assume that this experience affected her motivation to engage with services, given that historically, services failed to engage with her needs.  11.5.2 In 2017, when the twins were in Neonatal care, there is evidence that their mother’s voice was heard by staff. She said she had difficulty attending because she had no money for fares and could not afford credit for her phone to keep in contact. This account was recorded without apparent challenge and without referring to Children’s Services or other support services; the babies were transferred to a Unit closer to their home to assist her to attend, and this did not lead to greater engagement. As described elsewhere, safeguarding advice was not followed. The effect was that the mother’s needs, as voiced by her, were prioritised over the needs of the twins.  11.5.3 From May to September 2017, through the process of the NAI, the de-escalation of the case to the CIN process, then from Families First to One Point, and the closure of the case in September, the evidence seen by the Review indicates that the mother’s needs continued to be prioritised over safeguarding the children. There were clear static and dynamic risk indicators, yet the rationale for the intervention had been lost and refocussed on the mother’s parenting needs.    2911.5.4 The Review heard that professional optimism played a role, in that the children’s mother expressed her needs and her understanding of parenting, and of the babies’ needs, in a way that reassured practitioners. The Review considered whether disguised compliance had affected interventions and decisions, i.e. where the mother had appeared to be implementing advice. Whilst there is evidence that practitioners were reassured by her use of the correct terminology, for example, when she was able to explain that she had learned a range of parenting strategies, this was not thought to be disguised compliance. It is likely that she was simply repeating information she had been given. Professional optimism is more likely; for example, it is recorded that MGM was advising the children’s mother, and it appears that practitioners believed MGM was more present in the household, as a good parenting model and influence, than was actually the case.  11.5.5 There was evidence that practitioners did not have all the information about the family to inform assessments and interventions. For example, we now know that Partner 1 and his mother were involved in the care of Freddie and Finlay, throughout this period, providing emotional and financial support and care on a day to day basis, which was not known to services at the time. Additionally, Partner 2, Sibling 3’s father, was engaged in Sibling 3’s care and providing financial support, throughout his life, despite often being refused contact by the children’s mother. Neither of these supportive paternal arrangements were spoken of, by the children’s mother, in her discussions with professionals.  11.6 What evaluation and assessment was used to make decisions about the de-escalation of the case, from s47 to CIN?  11.6.1 This episode, from May to September 2017, immediately preceding the injury to Freddie, raises three concerns for the Review.  11.6.2 First, the Review considered the support offered to extended family caring for children in an emergency. The Review Team would have wished to see MGM’s support needs assessed, and support offered for MGM in this difficult situation. She was being asked to care for five children, of whom one had cerebral palsy and two were premature births. 11.6.3 Secondly, the rationale for the decision to step the case down to CIN four days after a NAI was questioned by the Review Panel. The CSC assessment appears over optimistic and did not include information about mother’s lack of attendance and attachment – itself a risk factor – during the baby’s Neonatal care which had ended   30only one week previously. There is a difference of opinion recorded by CSC of the legal consultation, and the recollection of the legal advisor of the same consultation.   11.6.4 Intervention was then focussed away from the incident which had led to the CIN, and on to Sibling 3’s behaviour, de-prioritised, and closed when assurance was received from mother that she had learned parenting strategies, whilst the evidence was that she had continued a pattern of failing to engage, and the injury was not further referenced. 11.6.5 With the benefit of all the information available to the Review, the reviewers consider there to have been important missed opportunities to safeguard both babies during this period.   11.7 How did the multi-agency team assess and meet the whole family’s needs? 11.7.1 Ante natal stage: Information gathered by the midwife to complete the antenatal risk assessment was self-reported by mother, not gathered on the father and not revisited throughout the pregnancy. Historical information which was available to the midwife through the electronic GP system was not utilised to support this assessment.  11.7.2 Information about the ante natal care was recorded electronically and the documentation is very limited. There is no evidence of professional curiosity or exploration by the midwife. 11.7.3 Neonatal stage: the gaps identified in safeguarding knowledge, and the delayed referrals for safeguarding, meant that opportunities for a multi-agency assessment were missed during this stage. There is a need to develop knowledge, in the words of the Learning Event, to ‘go back to basics’ and revisit Working Together, and to improve information sharing processes.  11.7.4 On Day 41, there was a discharge planning meeting held with the children’s mother, her HV, and the NNU nurse.  There is no evidence of discharge planning minutes, but documentation highlights a family worker, and help being given with housing and ‘extra additional support’. The specialist safeguarding midwife was not invited to this discharge planning meeting. The referral to CSC and therefore their involvement in discharge planning was missed.  11.7.5 Practitioners reported experiencing access issues internally, during the timescale, so that some professionals did not have full access to their own electronic case management system.  11.7.6 In the Learning Event it emerged that some professionals are fearful of sharing information. There were concerns about breaching confidentiality, and about recording information which may be based on feelings and may be disclosable. Whilst Working   31Together to Safeguard Children 2018 has clear guidance around information sharing in terms of what can and cannot not be shared, this is still not widely practiced at a multi-agency level and there is a clear staff development need.  11.7.7 There was a lack of evidence throughout, that information was systematically gathered, collated, analysed and applied in a way that led to the wider family network, and that the risk indicators present in the household, were assessed and supported.  There was no one process for co-ordinating and collating information held by all agencies which may have identified concerns.  11.7.8 There was poor recording of individuals who had access to the children, in hospital and in the community. Whilst the mother’s serial relationships create a recording challenge, this meant that risk indicators arising from her partners were not fully appreciated. Conversely, professionals were not aware of supportive relationships which could have contributed to assessment and planning, for example, how much contact Sibling 3 had with his father, which included overnight stays.   11.7.9 Police participants in the Learning Event advised that even the Investigating Officer was not aware of some information that has been gathered as part of the Review process. From a Police point of view, there was a missed opportunity to identify those that had contact with the children when formulating the pool of perpetrators in relation to the final event. 11.7.10 The police system of grading and reporting domestic abuse incidents meant information about domestic abuse in the household was not shared with Children’s Services or Health. This is a learning point for the Police. 11.7.11 Practitioners asked whether a central database could be implemented by the MASH, on which every professional can record safeguarding information, and this can be accessed by professionals to inform decision making 24/7. The Panel considered that this was unrealistic, and it was information sharing that needed to improve.  11.8 How robust was the decision making at the Strategy stage (May 2017) and were those decisions implemented?   11.8.1 At the point of the Strategy meeting, there was a delay in providing the Medical Report which had been submitted to the MASH, with other professionals. 11.8.2 The Section 47 investigation did not progress to Initial Child Protection Conference and the case was de-escalated four days later to CIN. The Review has seen the assessment undertaken during the section 47 investigation and believes there was an over-optimism in this, and that static risk factors, such as mother’s history, her failure to engage with professionals, and her lack of attachment to the twins, as evidenced by   32her lack of attendance during their Neonatal time, were not given sufficient weight.  As there was no ICPC, there was no opportunity for other professionals to escalate disagreements about this decision, and no opportunity to share important information.  11.8.3 Practitioners reiterated the concerns identified in the Review that the decision to discharge Finlay to MGM was made outside the Strategy Meeting and was a single-agency decision which appears not to have considered MGM’s support needs when she was caring for five children, one of whom had additional needs and the twins were vulnerable due to their prematurity. 11.8.4 The organisational issues identified include that the health visitor was covering absence and unaware of the family’s needs; there was a missed opportunity for key background information to be considered, and to consider whether the family required additional support. In terms of learning, consideration is being given to a Single Point of Contact from the Health Visiting Service attend the weekly meetings with Neonatal Unit in order to improve the communication flow between the acute and community health services. This could be extended to Paediatrics to ensure robust information sharing. Health Visitors are now required to review records of siblings and older children to be fully aware of the family history. 11.8.5 In 2016, as referenced above, there was significant organisational change within CDDFT in that the acute and community safeguarding teams were split across two Trusts following a tendering process. Transition arrangements were in place during this period and safeguarding support continued to be offered to health staff. 11.8.6 It was noted that Legal Services and Children’s Social Care have a difference of opinion about the advice provided following the NAI. CSC recorded that legal advice was to manage the case through CIN whilst providing intensive support to the mother; whilst the recollection of the legal advisor, which is not recorded, was that the children should be accommodated whilst mother was provided with intensive support.  It was clarified that there is no follow-up process by Legal Services to review whether advice – where this applies to accommodating children – had been implemented. There will be a recommendation in relation to this.  11.9 Where decisions were made outside the Strategy meeting, is there evidence that there was consultation and communication to other agencies involved?  11.9.1 The decision to discharge Finlay to MGM after the Strategy Meeting and before the Section 47 investigation had completed, was taken by CSC in consultation with the Police. A CSC assessment of MGM is recorded, but the Panel was concerned that this did not appear to consider MGM’s support needs, now caring for five children and   33supervising the mother’s contact. There is no evidence that other agencies were consulted, or the information shared with them.  11.9.2 The Review notes that further decisions, to de-escalate the case to CIN, were made without an ICPC, as a single-agency decision, as discussed above.  11.10 Were decisions properly challenged and escalated where necessary?   11.10.1 Professionals who became aware of the de-escalation of the case after Finlay’s NAI in May 2017, were unable to challenge this decision as it was taken outside the multi-agency forum and the record of that meeting was provided several weeks later.  11.10.2 Practitioners at the Learning Event told the Review they disagreed with the managerial decision to end the family support intervention in July 2017; and appear not to have been aware that there is an escalation process in Families First. This would bear examination by the commissioners of that service, to ensure an escalation process is in place and that practitioners are aware of it.  11.10.3 Practitioners in agencies where the procedures are clear regarding challenge and escalation, reported a lack of confidence in practice; a development need for professionals at the front line was identified, to change the culture and support staff to follow this process. 11.10.4 The divergence of professional opinion at the point of Freddie’s injury in September 2017, was escalated effectively and ultimately had a good outcome.     3412 Recommendations       This Review identified gaps in multi-agency working, and a single-agency focus by practitioners. There were missed opportunities to safeguard Freddie and his twin, Finlay. Organisational factors such as restructuring may have had an impact on skills, knowledge, and understanding of policies and procedures; one participant at the Learning Event observed that the concerns highlighted in the Review suggest a need to ‘go back to basics’ and to restate the principles of Working Together. As outcomes from this Review, the Panel wishes to see improvements in:  multi-agency working in safeguarding  knowledge and skills in safeguarding in medical settings  communication and information sharing between professionals  practitioner and manager risk assessment skills   Recommendation 1:  Safeguarding Knowledge and Skills in Neonatal Units To improve safeguarding knowledge and skills, including information sharing, of health professionals within Neonatal Units: 1.1 Training is to be provided in Working Together to Safeguard Children, 2018, for managers and practitioners, and reviewed through supervision.  1.2 Staff in Neonatal Units are to be briefed on the significance of attachment in safeguarding. 1.3  Safeguarding supervision will be reviewed to ensure this is now in place (implemented since the events in this Report). 1.4 The Regional Neonatal Transfer proforma (currently in use) is to be reviewed to ensure that key safeguarding and social issues are included. 1.5 A joint workshop with Children’s Social Care staff and Neonatal staff will be convened to raise awareness of the safeguarding roles and responsibilities of each service and to look at ways in which they can work better together, for example, 0-19 practitioners attending local maternity meetings.   Recommendation 2:  Safeguarding Systems in Midwifery Services To address the systems changes needed to highlight safeguarding history and follow up missed appointments: 2.1 Systems will be reviewed, and action taken as required, to ensure that parental records are flagged to highlight a safeguarding history or other risk information such as adverse   35experiences; and that this information is utilised by the midwife, to liaise with Children’s Services. Work has taken place since the events of this Report, to review systems and explore flagging of parental records, and this work will be coordinated with systems already in place via Hospital Systems and SystmOne. 2.2 The guidance that is in place, for missed appointments in antenatal care, will be revisited.   Recommendation 3:  Risk assessment skills in Midwifery and Children’s Social Care 3.1 In midwifery services, the updated Antenatal Risk Assessment Tool will be reviewed both against its effectiveness, and to ensure it has been embedded into practice by all midwives. 3.2 In antenatal services, the antenatal risk assessment will be available on both mother and child’s records, where this is not already in place. 3.3 In Children’s Social Care, all safeguarding assessments by practitioners, and decisions by managers, will record an evaluation of historical factors which are fixed risks pertaining to a parent or member of a household and which cannot be changed but may be managed; as well as current, dynamic risk factors which can be changed by an intervention.   Recommendation 4:  A culture of discussion and challenge between health and care professionals where power and hierarchy can influence decisions The resilience of the safeguarding process will be strengthened by reducing the reliance on the expertise of one professional and one discipline in potential non-accidental injury cases. This will be achieved through developing a Safeguarding Pledge that promotes a culture of discussion and challenge between professionals in health and social care disciplines, in medical and community settings, to explore views and opinions, and supports and enables professionals to do this.   This Safeguarding Pledge will re-state that the organisations are committed to safeguarding and will take action in agencies and as a partnership of agencies, to ensure safeguarding is not de-prioritised during organisational change.      36Recommendation 5:  Legal advice in CSC consultations  Where Legal Services are consulted during section 47 inquiries and assessments, and where the legal advice is to issue care proceedings, this will be confirmed in writing.  CSC managers will follow up with practitioners and record that the advice has been implemented or record the rationale for a different decision.  Since these events, a Legal Protocol has been agreed between CSC and Legal Services, and this will be reviewed to ensure it is in place and effective.  Recommendation 6:  Assessment and decision making in section 47 investigations. In this case, there was a gap in information sharing between CSC and the Health Visitor who would have been aware of the issues concerning mother’s engagement during the twins’ time in NNUs. The final decision was single agency.  CSC will ensure that the investigation and decision making during a section 47 process includes practitioners who were present at the Strategy Meeting, and any additional relevant practitioners including those with previous involvement with the family.     37 Appendix 1  The following is a short summary of SCRs in England and Wales, where the lessons learned resonate with the findings of this Report.   Baby Bailey (Durham)i concerned the death of a seven-week-old boy in 2015. The family was known to multiple agencies due to concerns about neglect of two older siblings. Mother didn’t present for antenatal care until she was over 26 weeks pregnant and did not attend several medical appointments for herself and her children. Home conditions throughout the period under review fluctuated from "just good enough" to "unsafe".  Recommendations include providing guidance for instances when children are not brought to medical appointments; and to ensure there is a standardised approach to strategy meetings.  Baby Cii, a ten week old female in a family known to agencies, with an elder sibling in care and another on the child protection register, was admitted to hospital following concerns regarding failure to thrive. On examination, Baby C was found to have a torn fraenulum (possibly indicative of force feeding). Health professionals did not communicate well with one another, or with social work services, and so opportunities were missed to safeguard Baby C. There were problems around assessment of parental capacity and motivation to change, with social workers being overly optimistic about their ability and co-operation.  Recommendations include: Children's services to undertake core assessments which ensure that the analysis of information effectively integrates the impact of the family history on current parenting, parenting capacity, and parental motivation to change and the likelihood that change will be sustained.  Child Ciii was a 3-month-old girl who, after her death, was found to have multiple fractures consistent with non-accidental injuries. Child C was born prematurely at 28 weeks and admitted to neonatal unit. Hospital staff made referral to children's services regarding mother's limited visits during her baby's stay and engagement with staff. A child protection plan was made for Child C and her sibling. Mother and children moved in with maternal grandmother, to avoid children being taken into care. Maternal history of: domestic abuse; abuse as a child; reluctance to engage with services.  Recommendations include training for staff working with avoidant and hard to engage families should include identifying disguised compliance; and the relevant LSCB's must get assurance that agencies demonstrate how fathers or absent parents are included in any assessments.  Child Miv Non-accidental injuries to a 13-month-old child. Child M was taken to A&E at age 3 weeks and again at age 5 months with what looked like non-accidental injuries and after the second incident both children were made subject to a child protection plan, Sibling 1 for emotional abuse and Child M for physical abuse. Mother had no recourse to public funds and this may have resulted in avoidant behaviours. Following unsupervised contact with father, Child M was returned home in pain and swelling. Lessons learned: examples of parental avoidant behaviour or disguised compliance which exacerbate risks to children; occasions where more robust professional curiosity or challenge would have been justified; professional responses appeared more positive than the available evidence would suggest particularly concerning the child's injuries.  Recommendations include: to enhance confidence within professional networks in the context of respectful certainty/cognitive dissonance to develop plans and interventions to respond to the possibility of deliberate harm even in the absence of conclusive evidence; support practitioners working with avoidant families, frequently fluctuating circumstance and disguised compliance.    38Child and siblingv aged 7 and 22 months found to be neglected due to parental substance misuse and domestic abuse. Home conditions were deemed unfit for human habitation. The older child was found to have a significant disability which had not been addressed. Learning includes: babies discharged home after birth with no professional oversight of home conditions is a risk for children born to vulnerable mothers; perception that health visitors should not make unplanned visits.  Recommendations include: guidance to midwifery staff requiring that all women receive a postnatal visit at their normal address; all agencies to provide assurance that their assessment processes enable the effective involvement of fathers, partners and other men within the household.  Child L and Child Mvi: Severe neglect of twins aged 22-months. Mother had three children removed from her care several years earlier due to neglect and emotional abuse. Twins were born prematurely and required treatment at several hospitals. On discharge, the twins were made subject to a child in need plan for six months, but this was closed after three months. A health visitor supported the mother and twins. They were found to be suffering from extreme neglect. Findings include: the need to remind key practitioners of national and local safeguarding policies and procedures; identification of concerns as to the function of the governance and supervision of child protection cases. Recommendations include: to remind all staff of the need to have knowledge and awareness of learning from SCRs when carrying out child protection roles; to ensure record keeping is enhanced and expeditiously recorded onto the computer management system.  Child L and Child Jvii aged 6 weeks and 5 months: the younger sustained a NAI on at least two separate occasions. The elder had sustained a mouth injury and bruising 10 months earlier and had been subject to a Child Protection enquiry but after a Child and Family assessment the case was closed. Both parents of Child J had traumatic backgrounds. They were offered extra support with enhanced health visiting, teenage pregnancy programme, housing, benefit and educational issues but the couple were unable to take advantage of this help. Seven health visitors were involved with the family as well as others offering other services. Issues identified include the need for practitioners to be aware of the significance of early life experiences; the need to understand normal child development which would have improved the quality of decision making; inter-agency cooperation; the need for effective supervision and managerial oversight.   i Hyde, Clare (2017) Serious case review overview report: Baby Bailey 2016. Durham: Durham Local Safeguarding Children Board. ii Wonnacott, Jane (2008) Serious case review: executive summary in respect of Baby C. Dorset: Dorset Safeguarding Children Board. iii Barking and Dagenham Safeguarding Children Board (2018) Serious case review: Child C: final report [full overview report]. Barking and Dagenham: Barking and Dagenham Safeguarding Children Board. iv Smith, Fergus and City and Hackney Children's Safeguarding Board (CHCSB) (2018) Serious case review: Child M [full overview report]. City of London and Hackney: City of London and Hackney Safeguarding Children Board. v Johnson, Fiona and East Sussex Local Safeguarding Children Board (2018) Report of the serious case review regarding Family 'S' [full overview report]. East Sussex: East Sussex Local Safeguarding Children Board. vi Byford, David and [Unnamed local safeguarding children board] (2018) Child L and Child M: serious case review: overview report. [S.l.]: NSPCC on behalf of an unnamed local safeguarding children board. vii Dalton, Mark (2017) Serious case review: overview report: Child L and Child J. Somerset: Somerset Safeguarding Children Board.   