Summary of a review into the death of an 11-month-old boy in March 2011, as the result of a serious head injury. Post mortem revealed older fractures and bruising. Mother was arrested under suspicion of causing EY's death. EY was looked after by the local authority until 7 months-old and parents had indicated that they wished him to be adopted; his older brother had not been looked after but parents had considered adoption. Mother concealed both pregnancies, initially concealed the existence of EY from members of her family and later concealed his existence to GP and children centre staff. Injuries to EY were observed by social workers, children centre staff, GP and Health Visitor in the weeks prior to his death. Issues identified include: insufficient recognition of the risks associated with concealed pregnancy; inadequate assessment; superficial engagement with family; underestimation of the risks associated with re-unification following a considerable period of separation; insufficient understanding of role of father and extended family; and non-compliance with child protection procedures in relation to reporting suspicious injuries. Identifies key lessons for practice, including: better coordination of health care for children who are discharged from being looked after; investigation in cases of concealed pregnancy, including the psychological and psychiatric status of parents; and recording in health records that takes account of the needs of other health professionals. Makes various interagency and single agency recommendations, covering: social care, health services and family support services.
      
 Title:  Serious case review: executive summary: services provided for OY and EY and members of their families during the period January 2008 - February 2011. LSCB: Windsor and Maidenhead Local Safeguarding Children Board Author: Keith Ibbetson Date of publication: 2014  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.                         1Serious Case ReviewEXECUTIVE SUMMARYServices provided for OY and EY and members oftheir families during the periodJanuary 2008 - February 2011Windsor and Maidenhead LSCBIndependent Chair and Serious CaseReview Panel Independent ChairDonald McPhailSerious Case ReviewOverview Report AuthorKeith Ibbetson21Background to the SCR and the reasons for carrying it out1.1BetweenAprilandNovember2011WindsorandMaidenheadSafeguarding Children Board (LSCB) conducted a Serious CaseReview (SCR) of the services provided to two children who arereferred to as OY and EY. When he died in March 2011 EY was aged11 months and his brother OY was nearly two. EY died as a result ofheadinjurieswhicharecurrentlythesubjectofacriminalinvestigation. OY is the subject of care proceedings.1.2The SCR was carried out in order to fulfil the requirements ofChapter 8 of the statutory guidance Working Together to SafeguardChildren1 and the Berkshire Local Safeguarding Children BoardsProcedures. 2 The LSCB is required to conduct a SCR when a childhas died and abuse or neglect are suspected to be a factor in thedeath. Initial medical opinion indicated that this was the case andthefindingsofthepost-mortemenquiryconfirmedthis.Thecircumstances required a SCR. The children normally lived withtheirmotherintheboroughofWindsorandMaidenhead.Ittherefore fell to the Windsor and Maidenhead Safeguarding ChildrenBoard to undertake the SCR.1.3The decision to hold the SCR was made by the Independent Chair ofthe LSCB on 30 March 2011. The review covers the period fromJanuary 2008 until the death of EY. This review period was chosento include all of the significant involvement of agencies with childprotection responsibilities in the lives of the children. The decisionto conduct a SCR was also taken in the light of the followingknowledge:a number of agencies and professionals with child protectionresponsibilitieshadprovidedservicesforthechildrenandfamilyEY had been looked after by the local authority until the age ofseven months although the case was closed by the localauthority three months before his deathEY’s parents had initially indicated that they wished him to beadopted1 HM Government, Working Together to Safeguard Children – 2010.2 http://berks.proceduresonline.com/chapters/p_ser_case_rev.html3a number of professionals had noticed bruising and scratchesto EY in the weeks before his death.EY’s older sibling OY had not been looked after. Neither of thechildren had been the subject of a child protection plan at anypoint.1.4The findings of the SCR and the multi-agency action plan wereaccepted by the LSCB at its meeting on 16 November 2011. This isthe Executive Summary of the findings of the SCR. The SCRoverview report has also been published. Information that is judgedto be considered potentially harmful to the surviving brother of EYhas been removed from the published version of the full report.2Arrangements for the SCR2.1The SCR reviewed the work of the following agencies who wereinvolved with the family during the period up to and including 2008.All are based in Windsor and Maidenhead or are members of theLSCB because they provide a significant range of services tochildren and young people in the borough:Berkshire East Community Health Services (which provided thehealth visiting service)Primary Care (covering the services provided by three GPpractices)Heatherwood and Wexham Park Hospitals NHS FoundationTrustRoyal Borough of Windsor and Maidenhead CounciloSafeguarding Services 3 (which provides local authoritychildren’s social care services)oServices for Families (which provides and commissionsChildren’s Centre services and other family services)2.2Under the SCR arrangements all of these agencies were asked toreview their records, produce an internal chronology of theirinvolvement, interview key staff and provide an individualmanagement review. The authors of individual managementreviews were senior staff with expertise in children’s safeguardingor independent authors.3 This service is referred to as ‘children’s social care’ in the body of the report42.3Additional information was also provided to the SCR by thefollowing agencies which had only brief or limited involvement:South Central Ambulance ServiceCombined Legal Services (which provides legal advice to socialcare staff in Windsor and Maidenhead and is hosted by ReadingBorough Council)Themother’sschoolrecordscontainedsomeverylimitedinformation which was taken into account by the SCR. No faith,voluntary or community groups were identified as having beeninvolved.2.4The review was conducted by a SCR panel which included seniorrepresentatives of participating agencies with expertise insafeguarding children and detailed working knowledge of theprofessional standards relevant to all of the services involved. TheSCR panel was chaired by the independent chair of the LSCB. TheSCR overview report was prepared on behalf of the LSCB by KeithIbbetson. Both the SCR panel chair and the report author areindependent of the agencies involved and have expertise inchildren’s safeguarding and substantial experience in conductingSerious Case Reviews. The other members of the SCR panel were:OrganisationDesignationNHS Berkshire EastDesignated PaediatricianRoyal Borough of Windsorand Maidenhead CouncilHead of Services to Childrenand Young PeopleRoyal Borough of Windsorand Maidenhead CouncilHead of Safeguarding andSpecialist ServicesThames Valley PoliceDetective Chief InspectorThames Valley ProbationTrustSenior Probation Officer,Berks East Community HealthServiceAssistant Director (Children)The work of the SCR panel was supported by the Windsor andMaidenhead Safeguarding Children Board Manager and the LSCBSecretary. A health overview report was prepared by theDesignated Nurse for Safeguarding on behalf of NHS Berkshirewhich commissions the health services involved with the family.52.5The purpose of the SCR is set out in Working Together as follows:to draw together a full picture of the services provided for thechildren and their familyto establish what lessons are to be learned from the case aboutthe way in which local professionals and organisations workindividually and together to safeguard and promote the welfare ofchildrento identify clearly what those lessons are both within and betweenagencies, how and within what timescales they will be acted on,and what is expected to change as a resultto improve intra-agency and inter-agency working and bettersafeguard and promote the welfare of children2.6Given the specific circumstances of the case the terms of referenceof the SCR asked it to consider whether lessons could be learnt inthe following areas:historical information on the family members about factors thatmay have impacted on the parenting capacity of the mother orthe fatherthe quality of assessment of circumstance relating to thechildren and their familyfactors that helped or hindered the engagement with thefamily;how well agencies identified and responded to children’sinjuries and other indicators of harmthe extent of, and professional understanding of, the supportfrom the extended familythe advice that was given and the services offered to theparents concerning adoption issuesrisk factors in the family known to agencies during the periodunder reviewwhether staff and managers dealing with the family had therequisite skills, knowledge and experience to respond to thecircumstances presented by the familywhether sufficient attention was given to issues relating thereunification of EY and his mother following the period when hewas in foster care6Given the circumstances of the death of EY the terms of referenceasked the SCR to consider whether his death could have beenprevented.3Family involvement in the SCR3.1The SCR panel agreed that because of the concurrent criminalinvestigation into the death of EY it would not be possible to involvethe mother or the children or other family members because of therisk of prejudicing the criminal investigation and trial. The LSCB willkeep this decision under review and will seek to obtain the views offamily members about the services that were provided to the familywhen it is possible to do so. Any further learning arising from this willbe considered by the LSCB.4Key events in the case history4.1Only very limited information about the family history of the motherand father was obtained by agencies. There is no information in anyagency record to indicate any concern about abuse or poor parentingof children in the family history of either of the parents. The motherand the father were in a relationship. There was a considerable agedifference between them. The father stated that there was nointention for the relationship to be permanent or for the couple tohave children.4.2The mother gave birth to the first child in the family at the father’shome, with no medical or nursing attention. She was aged 21. Shehad received no antenatal care and stated that she did not know thatshe was pregnant. She has no recorded history of mental illness,learning disability or drug misuse. The mother said that she hadsuspected that she was pregnant about a week before the birth, butdid not tell anyone or do anything about it. The child’s maternalgrandparents were notified about the birth of OY by the hospital soonafter the birth. Initially the parents considered relinquishing OY to beadopted but they very quickly changed their minds and took himhome.4.3Despitetheunusualcircumstancesofthepregnancyandtheconcerning circumstances of the birth only very limited assessmentswere undertaken by midwives, health visitors and the local authority7socialworker.Therewereneversubsequentlyanysignificantconcerns about the care provided to OY.4.4EY was born in similar circumstances to his brother almost a yearlater. By this time the mother lived in her own flat. On this occasionthe mother admitted suspecting that she was pregnant but she didnot tell anyone or seek any medical attention. The father said laterthat he suspected that the mother was pregnant, but that she deniedthis. EY’s parents wanted him to be accommodated by the localauthority and said that they wanted him to be adopted. His fathermaintained this view consistently. Members of the mother’s familywere not informed about the birth of EY until he was nearly sevenmonths old.4.5The mother stated that she was ambivalent about relinquishing EYfor adoption. He lived with foster carers for nearly seven monthsduring which time he was noted to be a healthy child who developednormally. During this period the mother had adoption counsellingwith the aim of enabling her to come to a properly considereddecision about EY’s future. Little progress was made by the localauthority in implementing the planned adoption. EY’s father only sawhim once during this period, at a meeting to plan his placement. EY’smother saw him twice during the first five weeks of his life, on bothoccasions this was linked to planning and review meetings held abouthim. During the next month she visited him on seven occasions. Thiswas the only time when there was any significant contact betweenthe mother and EY prior to her decision to look after him. In thefollowing 18 weeks she visited him only twice, with gaps of almost 10weeks between the visits.4.6When EY was 28 weeks old the social worker informed the mother’sfamily about the birth of EY. The aim of this was to assist inprogressing the proposed adoption, but the local authority alsobelieved that the mother and her family could provide a suitablehome for EY. At this point the mother and her family decided thatshe should look after him. After a short series of visits by the motherto his foster home, EY was placed in his mother’s care. The visitswere only observed by the foster carer.84.7There were no grounds for the local authority to prevent themother from assuming care of EY, but the complexity of thebackground and the evidence that the mother had shown verylittlepositiveinterestinEYindicatedtheneedforcarefulmonitoring of his health and development and the care that hewas provided after his placement with his mother. At this pointthere should have been a coordinated child in need plan linked toa similar plan for his health needs. The local authority closed thecase after two visits and the health visiting service offered only itscore service i.e. the mother was left to take EY to health clinicsand to seek advice from her health visitor or GP if she wished.4.8Four weeks after he moved to live with his mother, on her finalvisit, the social worker noted scratches on EY’s face. The socialworker accepted the mother’s explanation that these scratcheshadbeencausedbyEY’sbrother.Thiswasaconcerningpresentationwhichmighthavebeenanindicationofpoorparenting or abuse.4.9Four weeks after this EY’s GP noted bruises on his face and headwhile he was undertaking a developmental check. When EY’smother was asked about this she stated that these had beencaused by his older brother. At this point it was also noted thatEY’s weight had not increased since he had last been to a childhealth clinic. The GP did not realise that this coincided with theperiod when he had been in the care of his mother because he didnot have access to his medical records and he did not notice thereferences to this in EY’s Personal Child Health Record.4.10Over the following eight weeks staff at a children’s centre notedscratches and bruises on several more occasions. The mother haddeceived the staff and other parents at the centre by giving him afalse surname and telling them that EY was in fact the child of hercousin. She claimed the bruises were caused by his four year oldsister, a child who did not exist. Other parents pointed out thebruises and also expressed concern about EY. Professionals foundthe injuries concerning, but they did not refer them to the localauthority to investigate.94.11When the children’s centre sought advice from the local authoritythe centre coordinator spoke to an unqualified member of staffwithout realising this. She was unhappy with the advice given, butdid not challenge it. The systems in place in the local authority forscreening calls were not clear to other professionals.4.12The day before he was admitted to hospital with the very seriousinjury that caused his death, EY was seen by a health visitor in achild health clinic. She had not met EY or his mother before. Thehealth visitor noticed bruises on his face which the mother saidhad been caused by a fall the previous day. The health visitor wasconcerned about EY and noted her intention to speak to hisallocated health visitor. Despite the very limited time that she hadwith EY the health visitor had enough information to have madethe decision to refer EY to the local authority. At the veryminimum she should have sought the advice of the health trust’snamed nurse for safeguarding or another senior colleague.4.13When he was brought to hospital EY had bruises on his face, head,chest, back and legs. Doctors recognised that he had suffered avery serious head injury. The post-mortem findings show that EY’sdeath was caused by this injury. They also revealed that EY hadsuffered a number of fractures that predate his death by at leasttwo weeks. It is not possible to date these injuries more preciselyso some or all of them may be older than this.4.14However, taking only the two week period before he suffered theinjuriesthatcausedhisdeaththeagencyrecordslistthreeepisodes in which bruising was noted or discussed. None of theseincidents was reported to the local authority. If that had happenedor EY had been referred for a paediatric assessment the bruiseswould have been investigated. Given EY’s age and vulnerability itis very likely that a full child protection medical examination wouldhave been undertaken. In the circumstances this would very likelyhave included a skeletal survey (an x-ray of the whole body). Thiswould in turn have very likely identified the older fracture injuriesand this would have led to action being taken to protect EY.5Conclusions of the SCR and key lessons learnt5.1The conclusions of the SCR are that 1) over the long term the10potential risks to EY were underestimated 2) when he moved to livewith his mother he should have been closely monitored because ofthe concerns about the circumstances of his birth, and his mother’sfailure to visit him for long periods when he had been looked after3)inthetwoweeksbeforehisdeathprofessionalsmissedopportunities to intervene which, if they had been taken, are verylikely to have led to the detection of serious injuries and are verylikely to have prevented his death.5.2There were a number of missed opportunities to identify and assessthe bruising observed on EY. These presentations were highlysuspicious. EY’s age and circumstances marked him out as beingextremelyvulnerable.Theprofessionalsinvolvedshouldhaveresponded differently and the bruises should have been reported tothe local authority so that child protection enquiries could beundertaken. At the very least professionals should have takenadvice from a member of staff or a professional advisor withexpertiseinchildprotectionorreferredEYforapaediatricassessment.5.3Taking the case history as a whole there are important lessons forthe work of organisations work to safeguard and promote thewelfare of children. These relate to 1) the training, skills andknowledge of individual professionals and teams of staff who wereinvolved 2) the wider organisational arrangements that existedwithin agencies and 3) working arrangements between agenciesand the sharing of information.Concealed and denied pregnancy5.4Staffandprofessionalsinalltheagenciesinvolvedfailedtorecognise the significance of concealed or denied pregnancy. Whenthere has been a concealed or denied pregnancy the circumstancessurrounding it need to be recorded and investigated in detail bymidwives, health visitors, GPs and social workers and all otherprofessionals who come into contact with the children and parents.This should always include consideration of the psychological andpsychiatric status of the parents.5.5When a pregnancy is denied or concealed or a woman presents at avery late point in her pregnancy for antenatal care it is usually the11result of parental learning difficulty, drug misuse or mental illness.These were not features that were present in this case and this isone of the reasons why there was less concern than there shouldhave been. In these unusual circumstances a detailed assessmentshould still have taken place.5.6Communications between midwifery services and health staff suchasGPsandhealthvisitorswerenotsufficientlydetailedandspecific. They did not consistently make clear the concealed natureof the pregnancies and the lack of antenatal care that the motherhad received. This contributed to the fact that GPs and healthvisitors did not recognise the significance of the history.5.7In this case the mother had two concealed pregnancies and thisshould have further served to alert the professionals involved to thepotential concern. Information about the circumstances of the twopregnancies was not linked together consistently. This reduced thecapacity of some professionals to recognise the added significanceof a second episode.Initial and new birth assessments5.8The new birth health assessment in relation to OY was very limitedand failed to seek out information about the concealed pregnancyor wider family factors that might have impacted on his health.5.9The initial social care assessments of OY were of limited value. Theyalso failed to seek out information about the concealed pregnancyorwiderfamilyfactors.The complexityofEY’scircumstancesmerited a social work core assessment. Although there was noproceduretorequirethisoncehewasalookedafterchild,professionaljudgementshouldhaveidentifiedthecaseasacomplex one which merited a fuller assessment.5.10Professionals failed to involve the children’s father and members ofthe extended family fully. Better engagement would have improvedthe assessment of risk and need.Re-unification of children5.11Professionalsunderestimatedtherisksassociatedwiththere-unification of a child with parents after a considerable period ofsubstitute care (or as in this case when a parent has never had12responsibilityforthechild).Thedevelopmentalneedsoftheindividual child, the meaning for the parents of the individual childand the child’s history of attachment need to be evaluated in detaileven when there is no obvious indication of risk. There is a valuablebody of research which shows that the reunification of children withtheir parent or parents after a prolonged separation is complexwork which needs to be carefully planned and monitored.The ability of professionals to recognise abuse and comply withchild protection procedures and guidance5.12There was a lack of curiosity about scratches on the face of aninfant.Thisshouldhavebeenrecognisedasanunusualandpotentiallyconcerningpresentation.Thebruisesobservedbyprofessionals should have been considered as highly suspicious andconcerning given the age and vulnerability of the child.5.13Professionals in three different settings – the GP practice, thechildren’s centre and a child health clinic – did not comply with thechild protection procedures and the training that they had receivedand did not report suspicious injuries to the local authority socialcare service. They were faced with a confident and convincingparent who denied having harmed her child and gave explanationsthat professionals found plausible to different degrees. Professionalsneed to have the skill and confidence to take the action required toprotect children when faced with such circumstances.5.14If professionals in the health service are not sure that a referral tothe local authority is required then they must consider alternativessuch making as referral for an urgent paediatric opinion or takingadvice from a named professional or another more experiencedcolleague.5.15Key information about EY was held in his Personal Child HealthRecord. This included significant history that might have affectedthe way in which professionals responded, including the fact that EYhad been a looked after child for the first few months of his life. Thedesign of that document and the way in which some importantinformation about his history was recorded in it meant that it wasnot obviously noticeable to staff referring quickly to the record.Arrangements for transferring and sharing information135.16There were delays in transferring and summarising the GP recordson some family members. This may have impacted in a significantwayonthedecisionsandactionsofprofessionals.Currentarrangements for the transfer of GP records are not fit for purposein relation to the needs of vulnerable children. The delays that arecommonplacemeanthattheserviceofferedbyGPsmaybeseriously impaired and some children may be placed at risk. Thereare also often delays in summarising records once they arrive at GPpractices.CurrentarrangementsmakeGPsprofessionallyvulnerable.5.17The health visitors who were involved with EY prior to and after hisdischarge from care did not share all of the relevant informationabout him with one another and did not ensure that his GP knewthat he had been a looked after child. The health care of childrenwho are discharged from being looked after needs to be bettercoordinated. All of the health professionals who will be involvedwith a child and its family need to be informed about the relevanthistory and know which other professionals are involved with thechild. The role of the looked after children health team should bereviewed to take this into account.Capacity of organisations and other organisational arrangements5.18The caseloads of health visitors in East Berkshire exceeded nationalrecommended levels and the review found that this limited the timethat staff had to make visits, to undertake assessments and topracticeinareflectiveway.Healthvisitingteamsarealsoresponsibleforprovidingchildhealthclinicsinarangeofcommunity settings. These are popular and very busy and staff mayhave only a very limited contact time with each child. Staff workingin these clinics have limited access to records about the childrenthey see and rely on the information contained in the Personal ChildHealth Record.5.19Children’s centres have been developed rapidly in order to make arange of services accessible to children and their families. The staffworking in the children’s centre attended by EY and his motherlacked experience in running and managing a service used by largenumbersofchildrenandhadreceivedinsufficienttrainingon14safeguarding children.5.20Services such as child health clinics and children’s centres havebeen developed with a view to maximising the accessibility ofservices to families. This is an important and positive objective ofpolicy and service development. As a result of the SCR it has beenrecognised that the setting in which staff work can enhance orimpair the ability of professionals to recognise risks to and meet theneeds of vulnerable children. The same applies to the clinicalrecords and other information systems that are available to staff.5.21The social worker who was primarily responsible for EY’s case wasnewly qualified and inexperienced. She was allocated this casebecause it was believed to be a straightforward piece of work. Thisunderestimated its potential complexity, given the concealment oftwo pregnancies. Newly qualified social work staff dealing withchildren’s cases require a high level of supervision tailored to theirindividuallevel ofcompetence, skillandknowledge. Thiswasabsent in this case.Learning the lessons of the SCR and the implementation ofrecommendations6.1The findings of the SCR and the recommendations that flow fromthem have been adopted by Windsor and Maidenhead LSCB. TheLSCB has produced an action plan that sets out the actions needed,who is to be responsible for taking them and the timescales forcompletion. Many of these recommendations have already beenfully or partly implemented. The LSCB will oversee implementationover the coming months to ensure that lessons are learnt andpractice improves. The full detail of these recommendations is setout in the action plan that accompanies this document.