Non-accidental head injury to an infant just under 8-weeks-old, of Pakistani heritage, in September 2016. Mother disclosed to a GP practice nurse during a routine appointment in July 2016 that father would be violent towards herself and Child L's older sibling, aged 10-months, if the latter would not stop crying. Mother declined to give consent for any referral for support being fearful of further violence. The specialist nurse for safeguarding children was informed and a referral to children's social care was agreed. During an assessment of Child L's sibling, no concerns were raised and mother retracted her allegations. Child L was born prematurely during a visit to Norwich and placed in neonatal intensive care, first in Norwich and then at the local hospital. Child L was discharged home at age 3-weeks. On 30 August children's social care closed the case due to lack of evidence. On 30 September Child L was admitted to hospital with a large subdural haemorrhage, caused by violent shaking. Key findings: good practice by the GP practice nurse; information elicited from mother by practice nurse became diluted during recording; implications for sharing safeguarding information in the case of out of area births. Recommendations include: to develop practitioner guidance on available options when a victim decides to retract allegations of domestic violence; to develop an abusive head trauma strategy to ensure effective prevention of abusive head injury in babies; to obtain assurance that partner agencies fulfil their statutory obligations to ensure strategy meetings take place when necessary and include all necessary partner agencies.
      
 Title:  Child L1: serious case review. LSCB: Manchester Safeguarding Children Board Author: David Mellor Date of publication: 2018  This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC.  This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above.                            CHILD L1  SERIOUS CASE REVIEW This report has been commissioned and prepared on behalf of Manchester Safeguarding Children Board and is available for publication on the 15th May 2018     Ratified: February 2018 Independent Reviewer: David Mellor  MSCB Child L1 SCR  Page i Contents 1.0 Introduction ......................................................................................................................... 1 2.0 Terms of Reference .............................................................................................................. 1 3.0 Glossary ................................................................................................................................ 2 4.0 Synopsis ................................................................................................................................ 4 5.0 Contribution of Child L1’s family to the serious case review ............................................ 17 6.0 Analysis .............................................................................................................................. 18 7.0 Findings and Recommendations ........................................................................................ 31 Appendix A: Review Process .................................................................................................... 39 References ............................................................................................................................... 40  MSCB Child L1 SCR  Page 1 of 40 1.0 Introduction  1.1 Child L1 was the subject of potentially life threatening injuries when less than two months old whilst in the care of their parents. Whilst pregnant with Child L1, mother had made disclosures to her GP practice of physical abuse by her husband of both herself and Child L1’s elder sibling who was ten months old at that time. Additionally, there were subsequently concerns that Child L1 may have been subject of a non-accidental injury a matter of days before the potentially life threatening injuries were sustained.   1.2 Manchester Safeguarding Children Board (MSCB) decided to conduct a Serious Case Review (SCR) because Child L1 had been seriously harmed and abuse was suspected. The MSCB was also concerned that the risk of serious harm to Child L1 and their elder sibling was not acted upon appropriately and that one or more partner agencies involved in the case considered that its concerns were not taken sufficiently seriously.  1.3 MSCB commissioned David Mellor to be the lead reviewer for this SCR. David is a retired chief police officer and former independent chair of Safeguarding Children and Adults Boards. He has no connection to any of the agencies involved in this case although he served as a police officer in Greater Manchester Police (GMP) from 1990-1999. A review group was established to oversee the SCR and membership of this group and a description of the process by which this SCR was carried out is shown in Appendix A.  2.0 Terms of Reference  2.1 The terms of reference for this SCR are as follows:   The effectiveness of single and multi-agency responses to the disclosure of physical harm to Child L1's elder sibling made by mother on 13th July 2016.   The effectiveness of single and multi-agency responses to the domestic abuse disclosure made by Child L1's mother and her subsequent retraction.   The effectiveness of the multi-agency response to suspected non-accidental injuries to Child L1.   Strategy meetings - the extent to which they took place when required and the effectiveness and inclusiveness of strategy meetings when they were held.   The extent to which safeguarding concerns were appropriately escalated, subject to oversight and differing professional opinions addressed.   MSCB Child L1 SCR  Page 2 of 40 3.0 Glossary  A Child in Need (CiN) is defined under the Children Act 1989 as a child who is unlikely to achieve or maintain a reasonable level of health or development, or whose health and development is likely to be significantly or further impaired, without the provision of services; or a child who is disabled.  Child and Family Assessment (CAFA) The purpose of the assessment is to determine if there is identifiable evidence of risk or identifiable significant harm to the child or whether they are unlikely to achieve or maintain a reasonable standard of health or development or they have a disability.  The Common Assessment Framework (CAF) is a process for gathering and recording information about a child in respect of whom practitioners have concerns in which the needs of the child and how those needs can be met are identified.  Domestic violence and abuse (DVA) is any incident or pattern of incidents of controlling, coercive or threatening behaviour, violence or abuse between those aged 16 or over who are or have been intimate partners or family members regardless of gender or sexuality. This can encompass, but is not limited to, the following types of abuse:   psychological   physical   sexual   financial   emotional.   Controlling behaviour is a range of acts designed to make a person subordinate and/or dependent by isolating them from sources of support, exploiting their resources and capacities for personal gain, depriving them of the means needed for independence, resistance and escape and regulating their everyday behaviour.   Coercive behaviour is a continuing act or a pattern of acts of assault, threats, humiliation and intimidation or other abuse that is used to harm, punish, or frighten their victim.  Independent Domestic Violence Advisor (IDVA) Their main purpose is to address the safety of victims at high risk of harm from intimate partners, ex-partners or family members in order to secure their safety and the safety of their children. Serving as a victim’s primary point of contact, IDVAs normally work with their clients from the point of crisis to assess the level of risk, discuss the range of suitable options and develop safety plans.   Multi-Agency Risk Assessment Conference (MARAC) is a meeting where information is shared on the highest risk domestic abuse cases between representatives of local police, health, child protection, housing practitioners, Independent Domestic Violence Advisors (IDVAs) and other MSCB Child L1 SCR  Page 3 of 40 specialists from the statutory and voluntary sectors. A victim/survivor should be referred to the relevant MARAC if they are an adult (16+) who resides in the area and are at high risk of domestic violence from their adult (16+) partner, ex-partner or family member, regardless of gender or sexuality.   SafeLives DASH (Domestic Abuse, Stalking and 'Honour'-based violence) is a commonly accepted tool which was designed to help front line practitioners identify high risk cases of domestic abuse, stalking and ‘honour’-based violence and to decide which cases should be referred to the Multi Agency Risk Assessment Conference (MARAC) and what other support might be required.   Section 47 Children Act enquiry – Children’s Social Care must carry out an investigation when they have “reasonable cause to suspect that a child who lives, or is found, in their area is suffering, or is likely to suffer significant harm”. The enquiry will involve an assessment of a child’s needs and those caring for the child to meet them.  A Strategy Discussion must be held whenever there is reasonable cause to suspect that a child has suffered or is likely to suffer significant harm. The purpose of the Strategy Discussion is to decide whether a Section 47 Enquiry under the Children Act 1989 is required and if so, to develop a plan of action for the Section 47 Enquiry.   MSCB Child L1 SCR  Page 4 of 40 4.0 Synopsis  4.1 On the afternoon of 13th July 2016 mother attended GP practice 1 for a pertussis or whooping cough vaccination. She was almost seven months pregnant with Child L1 and was accompanied by her 10 month old child – Child L1’s elder sibling (L2). Whilst receiving the vaccination, mother disclosed to the practice nurse that father couldn’t stand Child L1’s elder sibling crying and would hit both her and the child if the latter wouldn’t stop crying. The practice nurse asked mother if she had any bruises and she showed her three finger bruises near the top of her right arm where she said father had grabbed her.  4.2 Mother said that this violence towards her and Child L1’s elder sibling had been going on since the birth of the child. Mother said she did her best to keep the child quiet but that when she was unable to prevent the child crying, father would “take the child off”. She added that she pleaded with father to simply go into another room and leave her to calm Child L1’s elder sibling but this provoked him into hitting mother for “undermining” him in front of the child. Mother told the practice nurse that the child had been bruised by father and that she was frightened of what further harm he might do to the child.  4.3 As stated above, mother was almost seven months pregnant with Child L1 and was described by the practice nurse as “distraught” when contemplating the harm father might also inflict on this child when born. She said that she prayed every night that God would protect her and her children. She went on to say that father did not allow her to use contraception which explained why there was such a short gap between the birth of the first child and the start of her pregnancy with Child L1. She added that father wanted her to have more children but that she didn’t want further children after her second child was born.   4.4 When the practice nurse began to discuss support for mother such as a women’s refuge, this appeared to increase mother’s distress. She began to say that children should grow up with a mother and a father, adding that without father she had nothing. She began to insist that father was essentially a good man, that he loved both her and their child and that she loved him. Mother showed the practice nurse images of father cuddling both of them. She began to beg the practice nurse not to tell anyone about her earlier disclosures. The practice nurse replied that they were obliged to report what had been said in order to protect the child and mother. The practice nurse said that mother became very distressed at this point and began to change the subject.  4.5 Mother declined to give consent to any referral for support in respect of herself and left the GP practice.  4.6 There is no reference to Child L1’s elder sibling’s body being checked for potential non accidental injuries in the GP practice records of this interaction. However, the practice nurse, who now no longer works within Greater Manchester, has contributed to this review through a MSCB Child L1 SCR  Page 5 of 40 telephone interview with the lead reviewer in which they said that mother told them that the child currently had no bruises but, whilst mother was making her disclosures, the nurse had managed to take a look at the child’s arms, legs and back and could see no bruising.  4.7 The practice nurse immediately sought advice from a GP who advised them to ring the safeguarding team at the Central Manchester University Hospitals NHS Foundation Trust (CMFT). The practice nurse also quickly accessed the GP practice’s safeguarding children protocol which they then followed.  4.8 The practice nurse telephoned the CMFT specialist nurse for safeguarding children who recorded a more detailed account of the exchange which had taken place between the practice nurse and mother. (Differences from the practice nurse’s account are shown in italics) The specialist nurse recorded that mother had disclosed that father physically assaulted her every time the child cried. Father was said to ask mother to leave the room and when she refused he hit and punched mother. He was said to have put his hands around her throat. The specialist nurse recorded that mother had showed the practice nurse bruises on her arms where he had assaulted her. Mother also disclosed that father has hit the child many times when she cried. The specialist nurse noted that the practice nurse had not examined the child but mother said the child also had bruises. (Present tense in contrast to practice nurse’s recording which refers to bruising of the child in the past tense) The specialist nurse recorded that mother had begged the practice nurse not to tell anybody as she had nothing in her life except her husband. She had no family or friends in this country. Mother was reported to have come from Pakistan over two years ago. Father is Kurdish and 17 years older than mother. Mother said father was controlling and she stayed at home most of the time. Mother told the practice nurse that she had never previously disclosed the abuse of herself and her child.  4.9 The specialist nurse advised the practice nurse that a referral needed to be made to children’s social care that day as mother had made clear disclosures that not only had father assaulted her numerous times but also assaulted their child. The specialist nurse emphasised the high risk to the child and advised the practice nurse to be really clear about mother’s pregnancy and her high level of anxiety to ensure that the case was managed correctly.   4.10 The specialist nurse also advised the practice nurse to contact the health visitor (who was the 'case holder' for mother and child) but when the practice nurse attempted to do so they were unable to obtain any reply and left a voicemail message requesting the health visitor to contact the GP practice. However, contact was made with the health visitor by the specialist nurse. The health visitor the specialist nurse spoke to documented receiving the telephone call. (Variations in information recorded by the health visitor are shown in italics). The health visitor recorded that the child was not undressed but did not have any visible marks. It was documented that the child may need a child protection medical. Mother was said to be anxious about her disclosures being shared with anyone else, otherwise she said her husband would kill her.  MSCB Child L1 SCR  Page 6 of 40  4.11 The health visitor then contacted the Central midwifery team as they were unable to find any information about mother on the Chameleon hospital electronic information system. The health visitor spoke to the safeguarding midwife who reported no scan or ultrasound information in relation to mother. The health visitor was directed to the Wythenshawe hospital midwifery team which advised that mother was 'booked' at Wythenshawe hospital and had attended all appointments with her last midwifery contact taking place on 4th July 2016. Her expected delivery date was 26th September 2016.  4.12 The health visitor was informed that mother was covered by the Didsbury midwifery team with whom the concerns arising from mother’s disclosures would be shared although it was agreed that the midwifery team would not be asked to visit her that evening as this could put both mother and the midwife at risk.  4.13 The specialist nurse also discussed the case with the named nurse safeguarding children who agreed with the plan to make a referral to children’s social care and also to share the information with the midwifery team.  4.14 After receiving advice from the specialist nurse, the GP practice nurse rang the children’s social care emergency duty service (EDS) and the call was answered by a contact centre officer in the children’s social care contact centre. The details were recorded on a contact screening (child) record at 4.37pm. The record states that “Mother has disclosed that father gets very angry when the baby cries and he has been doing this since the baby has been born. Father also hits the baby and mother. This is the only detail that mother would give and she begged the referrer not to pass this information on. Apparently the father is very controlling and he checks mother’s phone. Referrer did not see any injuries on the child and the mother showed her grab marks on her arm”. Also recorded was the reason why consent had not been obtained for the referral which was stated as “Mother is terrified”. Although there was no reference to mother being pregnant, the record referred to mother, father, and both the child and unborn child. After recording this information, the contact centre officer asked the practice nurse to complete and submit a safeguarding children’s referral form. The practice nurse said they queried whether they needed to make a separate referral to any other agency in respect of mother and was advised that this was unnecessary.   4.15 The contact centre officer classed the incident as 'level 5' which triggered an immediate referral to the EDS. The record created by the contact centre officer would then have been sent to the children’s social care out of hours (OOH) inbox.   4.16 The safeguarding referral was then submitted by the practice nurse. It was timed at 4.47pm on 13th July 2016. Under 'key areas of risk of harm and neglect', the following was recorded: “Father gets very angry when the child cries, he can then proceed to hit child and to hit mother if she tries MSCB Child L1 SCR  Page 7 of 40 to intervene on the child’s behalf. Mother is 9 months pregnant and very stressed and tearful about how she will protect two children. Baby will be a (gender redacted)”. Under 'actions taken or support provided so far' was recorded, “Mother disclosed to myself during a routine consultation that father hits her and the child and has major anger issues”. Under 'what are you requesting from children’s social care?' was recorded “Urgent referral. Safeguarding issues, concerns about safety”.   4.17 At a later point in the referral document the practice nurse recorded that “mother terrified about consequences of her disclosure. At the moment she does not want intervention as she feels her husband cares about her. She has no family support apart from him, and is very isolated. We are unsure about immigration status. He is very controlling and wants to know who is phoning her. Needs to be handled sensitively, as I do not want to escalate the situation. However once disclosure occurred I had no option but to report it”. Under 'family and environmental factors' was recorded “no family support apart from husband”.  4.18 At some point after submitting the safeguarding referral, the practice nurse received a phone call from an EDS social worker. The practice nurse said that the social worker adopted a “very patronising” tone and allegedly said that this referral had placed the social worker in a difficult situation as any visit they made to mother that evening could place her and the child at greater risk than they currently faced. The social worker is said to have questioned why the practice nurse had not referred mother for support in respect of domestic abuse to which the practice nurse responded by describing their attempts to encourage mother to seek support. The social worker said that they intended to seek advice from the police before taking further action in response to the referral.   4.19 This telephone exchange is not included in the children’s social care chronology so it is not possible to present the social worker’s account of this call. However, an exchange of correspondence between GP practice 1 and children’s social care has been shared with this review. A GP wrote to children’s social care to express concern that the practice nurse’s actions in making the safeguarding referral appeared to have been questioned by the EDS social worker. The EDS team manager replied and offered an apology on behalf of the EDS social worker for any miscommunication which may have occurred during his telephone call to the practice nurse, the intention of which was to elicit additional information.  4.20 The practice nurse – who worked one day each week for GP practice 1 - also left information about the case for the GP practice safeguarding lead (as advised by the specialist nurse) who had not been at work that day and arranged for the focused care worker and a GP to discuss the situation the following day. (Focused care workers work with patients and their families in an effort to address the medical issues they present and any underlying issues.)  4.21 At some point during the evening of 13th July 2016 an untimed referral was sent by the EDS social worker to the police. Under 'details of children' only “unborn Child L1” is referred to. Child MSCB Child L1 SCR  Page 8 of 40 L1’s elder sibling is referred to under 'family composition/significant others' along with mother and father. Under 'reason for referral' is recorded “request strategy discussion – to share information and form action plan.” The following additional information is recorded on the referral:  4.22 “Children’s services received contact from health centre detailing that the mother has disclosed that the father gets very angry when the baby cries and he has been doing this since the baby has been born. The father also hits the baby and the mother. This is the only detail the mother would give and she begged the referrer not to pass this information on. Apparently the father is very controlling and he checks the mother's phone. Referrer did not see any injuries on the child and the mother showed grab marks on her arm. (This appears to be a 'cut and paste' from the information included in the contact screening (child) record). Children’s services have called referrer and asked whether they had attempted to signpost mother towards refuge or Manchester Women’s Aid – mother has refused this support and will not accept help. Mother is very isolated – no family / friends. They have tried to speak to the health visitor for 9 month old – Health Visitor not responding. Mother has refused for the health centre to disclose this to anyone else. Family not previously known to children’s services”.   4.23 On 14th July 2016 the police evaluated the request for a strategy meeting. They recorded that concerns had been raised for Child L1’s elder sibling as mother had disclosed that father gets very angry when the baby cries and had been doing this since the birth of the baby. The police also noted that father hits the baby and mother and that the latter had begged the referrer not to pass this information on. Father was noted to be very controlling and checked mother’s phone. The referrer had not seen any injuries on the child and the mother had shown grab marks on her arm. Again this appeared to be a 'cut and paste' from the information included in the contact screening (child) record. The police did not appear to appreciate that mother was pregnant. This was not mentioned in the referral from children’s social care although “unborn Child L1” is the (only) child recorded under “details of children”.  4.24 The police created a public protection investigation (PPI) in order to manage any further actions arising from the information shared by children’s social care. The information transferred from the original referral from children’s social care onto the PPI is said to be broadly similar to the original referral and contain no errors or omissions, although it has not been seen by the lead reviewer. A crime should have been recorded in accordance with national crime recording standards but was not. Various checks were made which disclosed minimal previous contact with father and no contact with mother. There were no previous PPIs. Contact was made with children’s social care to share this information.  4.25 The police declined the request for a strategy meeting on the grounds that both the police and children’s social care held very little prior information about the family. The police suggested that children’s social care complete a single assessment and added that should mother disclose physical MSCB Child L1 SCR  Page 9 of 40 abuse to herself and/or her child, children’s social care should re-refer to the police in order to discuss how to proceed.   4.26 Also on 14th July 2016 the specialist nurse contacted the Multi Agency Safeguarding Hub (MASH) to follow up on the practice nurse’s referral. The specialist nurse was advised that the case had been allocated to children’s social care central locality team 3 based at Longsight. The specialist nurse then contacted the health visitor to request that they urgently contact children’s social care to find out the time of the anticipated strategy meeting in order to ensure that a health visitor was able to attend. The specialist nurse was advised that the case had now been handed over to another health visitor.  4.27 On 15th July 2016 mother’s named midwife at Wythenshawe hospital developed a safeguarding plan which entailed independent domestic violence advisor (IDVA) support being offered to mother. The plan was widely shared and two copies placed in mother’s notes with one copy to be transferred to Child L1’s notes at birth.  4.28 On 18th July 2016 a midwifery domestic abuse support service (MIDASS) IDVA contacted the social worker who had been allocated the case of mother and her child, to offer support to mother should she wish to take it up. (The MIDASS IDVA was allocated to Wythenshawe hospital for a twelve month pilot during 2016/17.)   4.29 On 19th July 2016 the health visitor to whom mother’s case had been allocated contacted the social worker to enquire about the outcome of the strategy meeting. The social worker was on the way to mother and father’s house at the time and acknowledged that they were unsure about how to tackle the situation if father was present. The health visitor mentioned that mother had told the practice nurse that father had threatened to kill her if she told anyone about the abuse. The social worker then said that they would consult with their manager and call the health visitor back. When the social worker called back, they said that the home visit had been cancelled due to the level of risk. This led to the two practitioners developing a plan to invite mother to bring her child to a 9 month development assessment.  4.30 The health visitor also ascertained that the police had declined a strategy meeting and that the social worker was undertaking a children and family assessment (CAFA). The health visitor then contacted the specialist nurse to escalate the matter given that no strategy meeting had been held and mother and her child remained at home with father. The specialist nurse advised that the named nurse had become involved as GP practice 1 had complained about a lack of input into the case from children’s social care. Mention was made of a potential conversation between a GP and a social work team manager and the specialist nurse was to contact the named nurse.  4.31 On 20th July 2016 the health visitor contacted the named nurse and outlined the plan agreed with children’s social care to invite mother and her child for an assessment. The named nurse MSCB Child L1 SCR  Page 10 of 40 expressed support for the plan which had to be amended after the health visitor contacted mother who said that she was unable to attend the relevant children’s centre for the 9 month assessment. In the knowledge that father would be working, it was agreed that the assessment would take place in the family home.  4.32 On 21st July 2016 the health visitor and the social worker conducted the planned joint home visit to conduct the 9 month assessment of the child. “No concerns” were said to have been raised over the home environment although mother appeared to be living in a bedroom as the rest of the house appeared to require building work. An absence of toys was noted. Mother denied making any disclosures to the practice nurse on 13th July 2016. She said she was forced to say what she said by the practice nurse. Mother acknowledged that she did tell the nurse that her child cried a lot, especially if mother left the room, but that is all she said.  4.33 The child was weighed naked which gave the social worker an opportunity to check for bruising. No evidence of injuries was noted. Mother was noted to be very isolated and advice was given about local groups she could access. A referral was made to Sure Start for an outreach worker to reduce mother’s isolation. Mother was advised by the social worker that a CAFA was to be completed which would need to include father. The social worker was to visit again during the following week to complete the CAFA and father was to be told that the source of the concern was anonymous in order to try and minimise the risks to mother. Mother was said to look worried about father finding out about the allegation. The social worker also advised mother that if she chose to remain in a relationship with father then this could be considered to be a cause for concern which could lead to further steps to safeguard her child. The social worker encouraged mother to contact them if she needed support. The health visitor was to try and develop a trusting relationship with mother so that she could feel able to disclose any abuse.  4.34 On 22nd July 2016 children’s social care telephoned the GP to advise of the steps being taken to safeguard mother and her child. The action taken by the social worker and the health visitor were described as above, although mother was said to have minimised rather than retracted the disclosures made to the practice nurse. On the same date a GP attempted to contact mother by phone but received no reply and decided against leaving a voicemail message in case it was picked up by father.  4.35 On the same date the specialist nurse rang the health visitor for an update and was advised of the current plan. During this conversation mother was said to have made disclosures to the practice nurse because she thought the practice nurse was her friend. The specialist nurse later contacted the GP to update them and a discussion took place about the possibility of offering Identification and Referral to Improve Practice (IRIS) support to mother. (IRIS is a general practice based domestic violence and abuse training support and referral programme.) This may have prompted the GP’s telephone call to mother. (See paragraph 4.34)  MSCB Child L1 SCR  Page 11 of 40 4.36 On 6th August 2016 mother gave birth to Child L1 at Norfolk and Norwich University hospital (NNUH). Child L1 was premature (33 week gestation) and of low birth weight and so was transferred to the neonatal intensive care unit (NICU) for observations. Mother was described as “traumatised” following delivery and declined skin to skin contact with Child L1. Mother, father and Child L1’s elder sibling had been visiting father’s elder sister in Norwich at the time mother went into labour.  4.37 Mother was discharged to father’s sister’s address the following day and on 8th August 2016, NNUH contacted Wythenshawe hospital to advise them of the birth and arrange for transfer of Child L1 which took place on 10th August 2016. No safeguarding concerns were noted by NNUH and no safeguarding concerns were shared with NNUH by Wythenshawe hospital.  4.38 The transfer of Child L1 took place at 4pm on 10th August 2016 and the transfer nurse pointed out a Mongolian blue spot at the base of Child L1’s spine to a Wythenshawe hospital counterpart. At 8.15pm the same day mother paid a brief visit to Child L1 but the family made no further visits until 1.30pm on 12th August 2016 when mother made a brief visit and declined to hold Child L1. She advised that the rest of the family were returning to Norwich and would not return until after 14th August. Mother was encouraged to ring Wythenshawe NICU for updates on Child L1.  4.39 Notifications of Child L1’s birth were sent to the GP and health visitor and on 12th August 2016 the health visitor contacted the staff nurse in the Wythenshawe hospital NICU to advise of the current safeguarding and domestic abuse concerns and advised the staff nurse to contact the safeguarding midwife. At this point the Wythenshawe NICU appeared to have been unaware of these earlier safeguarding concerns. Child L1’s birth out of area appears to have been a factor in this although safeguarding alerts are available for all NICU and maternity staff to access. The staff nurse advised the health visitor of the absence of contact by mother and father. The health visitor asked to be kept informed of any developments and details of discharge home. The health visitor also contacted the social worker to update them. The latter advised that an IDVA would shortly be engaging with mother. The social worker also advised that they planned to visit mother and father to commence the CAFA on 15th August 2016 and would use the absence of contact with Child L1 as a pretext for the assessment.  4.40 The same day the health visitor discussed the case in safeguarding supervision with a second specialist nurse for safeguarding children and the current plan was agreed. Also discussed was the possibility of completing a Multi-Agency Risk Assessment Conference (MARAC) risk identification checklist if the opportunity arose. Later the same day the health visitor met the social worker and their team manager by chance. The need to avoid placing mother at greater risk of harm was discussed and the health visitor raised concerns around the increased risks associated with mother having to care for two very young children, the pressure this would place upon the family and how father would respond. The health visitor went on to suggest a professionals meeting with the midwife and hospital IDVA and a plan to support mother whilst Child L1 was on the unit. MSCB Child L1 SCR  Page 12 of 40  4.41 On 15th August 2016 the named midwife contacted the social worker to express concern that neither mother nor father had visited Child L1 or telephoned for updates since 12th August. The social worker advised of the planned home visit and also said a strategy meeting was to be arranged. It was also agreed that a discharge planning meeting would need to take place prior to Child L1’s return home.  4.42 At 6.20pm the same day mother, father and Child L1’s elder sibling visited Child L1 and were seen to be affectionate towards the baby. Similar family visits followed each evening with the exception of 21st August 2016.  4.43 On 18th August 2016 mother was seen by a GP at GP practice 1. She complained of lower abdominal pain following the recent birth of Child L1.  4.44 On 21st August 2016 the health visitor contacted the social worker for an update and was advised that no CAFA visit had taken place as the social worker was awaiting contact from mother and father. The social worker planned a home visit for the forthcoming week and would be accompanied by an interpreter to ensure that mother fully understood what was being communicated.  4.45 On 22nd August 2016 the community midwife was unable to gain access to the family’s home address and left a card to say that they would call again the following day. It appeared that major building work was taking place at the family home. After being unable to gain access again the following day, the community midwife was able to complete a post-natal assessment of mother on 24th August 2016. The midwife noted no visible bruising on mother’s legs although her arms were covered. Mother reported that her mood was good and that she had registered Child L1 with the GP. She denied there were any issues in her relationship with father when asked whilst he was out of the room playing with Child L1’s elder sibling.  4.46 On 23rd August 2016 the health visitor contacted the social worker for an update and was advised that the latter had spoken to both parents and father was now aware of children’s social care involvement due to non-attendance at the NICU and relationship concerns. The family had advised that they had had to return to Norwich to register Child L1’s birth which was why they had not attended the NICU initially. The social worker added that no concerns had been raised since the CAFA commenced which was still being completed and said that there was a possibility that the case would be kept open as a Child in Need (CiN).  4.47 On 25th August 2016 a discharge planning meeting took place at Wythenshawe hospital at which it was decided that Child L1 would be discharged on 27th August allowing mother to stay overnight the previous night to receive support and advice on the care of Child L1 from NICU staff. Despite mother’s previous disclosures being discussed in the discharge planning meeting, no MSCB Child L1 SCR  Page 13 of 40 consideration appeared to be given to any risk to Child L1’s elder sibling in staying alone with father on the night prior to the baby's discharge. Child L1 was noted to have a “clicky hip” which was to be followed up by an outpatient ultrasound appointment. The family was to be supported by home visits by a neonatal midwife initially and subsequently by the health visitor who was to provide the “universal partnership plus” level of service. (Universal partnership plus is the highest level of support provided by health visitors and entails ongoing support, playing a key role in bringing together relevant local services and helping families with continuing complex needs or additional concerns such as safeguarding, domestic abuse or mental health problems.) Mother’s understanding of English was judged not to require the services of an interpreter for the discharge planning meeting.  4.48 On 28th August 2016 a neonatal outreach midwife made a home visit. Safe sleeping guidelines were discussed in detail (Premature babies are at increased risk of sudden infant death). Child L1 was observed to be wearing a hat and swaddled in fleecy blankets and mother was strongly advised against this practice. There was no mattress in baby's cot and Child L1 was nursed on folded towels which necessitated further advice. However, Child L1 appeared well.  4.49 On 30th August 2016 the social worker made a home visit and no concerns were said to have been noted over mother’s care for both children. The next day another health visitor was unable to gain access for the new birth visit and left a card to say that they would return the next day. The health visitor was able to gain access the following day but only after repeatedly knocking for 30 minutes. Whilst attempting to gain access, the health visitor – who had recently been allocated the case – contacted the social worker who advised that such difficulty in obtaining access was a “common occurrence” with this family. Mother and children were seen in a back upstairs bedroom. The health visitor pointed out the absence of stair gates and mother replied that these had been obtained but had yet to be put in place. (This was rectified by the 15th September 2016 health visitor home visit.)  4.50 On the same day the health visitor received a telephone call from the social worker to say that children’s social care were closing the case due to “lack of evidence” and mother and father’s insistence they had been misunderstood. On 2nd September 2016 case closure was confirmed following completion of the CAFA. It was noted that mother would continue to be supported by Sure Start. (According to the children’s social care chronology, the CAFA did not triangulate all the concerns in relation to domestic abuse, physical abuse and both parent’s failure to regularly visit their premature baby in hospital.)  4.51 On the same date the neonatal outreach service discharged Child L1 after a clinic appointment in which L1 was examined and found to be well and putting on weight. Mother requested the service to remain involved with her for longer and requested a further home visit but this request was not acceded to, although a further home visit by the community midwife did take place on 4th September 2016. MSCB Child L1 SCR  Page 14 of 40  4.52 On 6th September 2016 mother visited the GP with a possible urinary tract infection (UTI) and a urine sample obtained and treatment prescribed. No enquiries were made about how the family were coping.  4.53 On 9th September 2016 mother took Child L1 to the GP with “tummy problems”. Treatment was prescribed.  4.54 On 15th September 2016 the health visitor and an outreach worker made a home visit in order to introduce the latter worker and also review Child L1’s weight. Mother said that Child L1 had been getting colic and a discussion took place about how to ease the symptoms. During weighing four small red marks were seen in a cluster on the inside of Child L1’s left ankle. The health visitor also noted darkened skin in the form of a small straight mark above Child L1’s naval. Mother said that the red marks had been caused by the NICU name band which mother had delayed removing. Mother added that these marks had been seen by the GP. The health visitor contacted the GP (GP 3) who confirmed that there was no record of the marks and they did not recall seeing them. The GP agreed to see mother and Child L1 at 2pm the same afternoon. (Child L1’s elder sibling had been seen naked when weighed and no injuries were noted.)  4.55 Mother attended GP practice 1 with Child L1. The GP noted that Child L1 probably had colic. The GP also noted what appeared to be a 3cm long linear bruise on Child L1’s central abdomen running from top to bottom. Three small blanching erythematous (abnormal redness of the skin or mucous membranes due to capillary congestion as in inflammation) marks were also noted around L1's left ankle which appeared to be strawberry nevus (birth mark in the form of a raised red patch). Mother said she had noticed the mark on Child L1’s stomach a couple of days previously but was unsure of what had caused it. She added that father helped out in soothing Child L1 at night and also massaged the child’s stomach. Otherwise Child L1 looked well.  4.56 Given the unexplained bruising in a non-mobile infant and the previous safeguarding concerns, the GP decided that a paediatric assessment was necessary and arrangements were made for Child L1 to be taken to Wythenshawe hospital by their parents. The GP also made a referral to children’s social care.  4.57 When mother and father failed to present Child L1 at Wythenshawe hospital, social worker 3 from the children’s social care EDS contacted the police to share information about the marks noted on Child L1 earlier that day. The police recorded a crime and visited the family home with social worker 3. They noted the red marks on Child L1’s left ankle and a “3cm vertical line above their belly button”. Both parents were said to be co-operative and took Child L1 to Wythenshawe hospital. The police advised social worker 3 to contact the police overnight if any immediate police action was needed once the paediatric assessment had been completed. It is not known why the police did not attend the paediatric assessment.  MSCB Child L1 SCR  Page 15 of 40  4.58 At 8.40pm that evening a child protection medical was completed by a paediatric consultant who noted an irregular linear brown mark (2cm long by 0.1 cm wide) running vertically down Child L1’s abdomen. Mother said that the mark had not changed for three days. The paediatric consultant felt that this was unlikely to be a bruise, but felt that the mark should be observed and a skeletal survey may need to be considered depending upon the evolution of this abdominal mark. The paediatric consultant also noted the strawberry birth marks on Child L1’s ankle and birth marks and a Mongolian blue spot on her back. Child L1 was later admitted to the paediatric ward for blood samples (which did not reveal anything untoward) and observation to check for any change in the mark on their abdomen. Mother was to stay on the ward with Child L1 whilst Child L1’s elder sibling was to stay in the family home with father.  4.59 The paediatric consultant was informed by social worker 3 that mother had made “an allegation of domestic abuse” against father in July 2016 and that children’s social care had completed an investigation following which the case had been closed. Child L1’s neo natal notes were ordered from the Trust library to check whether the Mongolian blue spot had been noted previously.  4.60 The following day – Friday 16th September 2016 - Child L1 was seen at 10.30 am by a second paediatric consultant who noted the linear mark on their abdomen to be non-blanching and neither fading nor changing colour. It was thought the mark was most likely to be a birth mark. The plan was to review Child L1 again the following day and if the mark was not fading L1 would be discharged. Mother continued to stay with Child L1. Father and Child L1’s elder sibling visited that day.  4.61 On Saturday 17th September 2016 Child L1 was seen at 11.45am by another paediatric consultant. According to an advanced nurse practitioner who had seen Child L1 previously, the abdominal mark appeared redder than previously but also appeared to be fading. The paediatric consultant documented a discussion with mother regarding the manner in which Child L1 was secured in their car seat. Although some communication difficulties were noted, mother declined an interpreter. Mother initially said she used a carrier bag to secure the straps in the baby seat but then said she used the clip fastening. She was unable to demonstrate the action by which Child L1 was secured in their car seat. In any event the paediatric consultant concluded that the straps or buckle from the car seat did not fit with the linear mark on Child L1’s abdomen. Mother also stated that Child L1 was never unsupervised with their elder sibling.  4.62 The paediatric consultant planned to liaise with the other paediatric consultants who had examined Child L1 to discuss whether further investigations were needed prior to a strategy meeting with children’s social care. The police were updated and attended the hospital intending to take photographs of the mark but were unable to obtain consent from mother as she had left the hospital to attend a family celebration. The police made reference to a strategy meeting planned MSCB Child L1 SCR  Page 16 of 40 for the next day (Sunday 18th September 2016) which had apparently been deferred until Monday 19th September 2016 to allow for a full skeletal survey to be carried out and the results made available prior to the deferred strategy meeting. The police considered whether there were any safeguarding concerns for Child L1’s elder sibling but decided that that there were none although they documented that this issue could be reviewed following the forthcoming strategy meeting.   4.63 On Sunday 18th September 2016 Child L1 was examined by a paediatric consultant who noted that the linear mark on their abdomen appeared to be fading. There was no change in colouration – which would be typical of a bruise - and so the mark was thought not to be behaving like a bruise. The mark was thought to be vascular in origin. (A bruise is caused when blood vessels break and there is blood visible through the skin. A vascular prominence/mark is when an intact blood vessel is visible through the skin.) The skeletal survey was deferred pending a further discussion with the second paediatric consultant (lead consultant).  4.64 On Monday 19th September 2017 Child L1 was reviewed by a paediatric registrar who saw no evidence of an abdominal mark. The strategy meeting had been deferred until Tuesday 20th September 2016. In the invitation to the health visitor, the meeting was described as a strategy meeting/discharge planning meeting.  4.65 On Tuesday 20th September 2016 Child L1 was reviewed by the second paediatric consultant who concluded that the mark had disappeared from their abdomen. The second paediatric consultant felt that the mark was not a bruise and was possibly of vascular origin. At 2.30pm the same day the strategy meeting took place. Mother attended and again declined an interpreter.   4.66 The marks seen on Child L1’s body were noted to be the linear narrow mark on their abdomen which had been the primary focus of attention; there were also two small brown marks on L1's back, blue discolouration on their back and red marks on their ankle. The marks on the abdomen, the foot and the brown marks on the back were classified as vascular malformations and the blue mark on the back was a Mongolian Blue Spot. Although the mark on the abdomen was classified as a vascular malformation it was unclear what had caused it to appear and it was classed as “unexplained” but not thought to be a non-accidental injury as the mark disappeared rather than changed colour as in bruising. A skeletal scan was considered unnecessary.   4.67 During the meeting information was shared about mother’s 13th July 2016 disclosures. The health visitor disclosed that when they initially saw the marks, mother told her that Child L1 had already seen the GP, which the health visitor said was not true. (Mother had last taken Child L1 to the GP six days prior to the marks being noticed by the health visitor.) It was decided that children’s social care would complete a further CAFA and that Child L1 and their elder sibling would be monitored as CiN with the first meeting to take place within two weeks. The health visitor would continue to encourage mother to engage with Sure Start. Child L1 was discharged into the care of MSCB Child L1 SCR  Page 17 of 40 their parents.  4.68 On 28th September 2016 the health visitor made a home visit during which they reviewed Child L1’s weight. No marks were observed on her unclothed body. Child L1’s elder sibling was being cared for by father and was only seen briefly. The condition of the house remained unchanged. A date for the CiN meeting had yet to be arranged.  4.69 The following day mother and Child L1’s elder sibling visited the GP practice. Mother had had abdominal pains which were thought to be linked to irritable bowel syndrome. Child L1’s elder sibling was taken to the GP to begin their 12 month immunisations.  4.70 On 30th September 2016 Child L1 was admitted to Royal Manchester Children’s Hospital (RMCH) after being found unresponsive at home whilst in the care of their parents. A large subdural haemorrhage was observed on a scan and no explanation was given by mother and father. The medical opinion was that Child L1’s injury had been caused by violent shaking.   5.0 Contribution of Child L1’s family to the serious case review  5.1 At the time of writing both father and mother were subject to police investigation of the injuries sustained by Child L1 on 30th September 2016. The SCR review group took the view that it could be beneficial to invite mother to contribute to the review but that this was not possible whilst she remained subject to a criminal investigation.  5.2 The review has been advised that mother has no family members living in the UK. No information about father’s family in the UK has been shared with the review other than the reference to a sister in Norfolk whom mother and father were visiting when Child L1 was born prematurely.   MSCB Child L1 SCR  Page 18 of 40 6.0 Analysis  6.1 The terms of reference for this SCR are as follows:    The effectiveness of single and multi-agency responses to the disclosure of physical harm to Child L1's elder sibling made by mother on 13th July 2016   The effectiveness of single and multi-agency responses to the domestic abuse disclosure made by Child L1's mother and her subsequent retraction.   The effectiveness of the multi-agency response to suspected non-accidental injuries to Child L1.   Strategy meetings - the extent to which they took place when required and the effectiveness and inclusiveness of strategy meetings when they were held.   The extent to which safeguarding concerns were appropriately escalated, subject to oversight and differing professional opinions addressed.  The effectiveness of single and multi-agency responses to the disclosure of physical harm to Child L1's elder sibling made by mother on 13th July 2016 6.2 Fully documenting mother’s disclosures on 13th July 2016 was no easy task. The disclosures arose unexpectedly during a routine appointment with the practice nurse at GP practice 1. Mother became very emotional as she articulated her fears for both her child and her unborn baby. And once the practice nurse began to steer the conversation towards referring mother and her child for support, mother appeared to have second thoughts and by the end of the conversation was “begging” the practice nurse not to take any further action in respect of her disclosures. She left the GP practice before the practice nurse could carry out anything more than a cursory examination of the unclothed parts of the child’s body.  6.3 In these circumstances the practice nurse was able to obtain sufficient information to identify the following risks to mother, her child and her unborn baby:  Father regularly became angry when the child cried and responded by physically assaulting both mother and the child.   Mother showed the practice nurse bruising to her arm which had the appearance of three fingers. She said that these marks had been caused by father forcefully grabbing her.   Mother disclosed that the child had also sustained bruising as a result of father’s assaults but the child was not examined unclothed in order to check for any current marks.  MSCB Child L1 SCR  Page 19 of 40  Father had put his hands to mother’s throat on one occasion which may have represented an attempted strangulation.   Father was very controlling of mother. He would not allow her to use contraception hence the short gap between the birth of the first child and becoming pregnant with Child L1. He also monitored mother’s phone.   Mother was isolated. She had come to the UK from Pakistan “over two years ago” and had no family or friends in this country. She did not leave the family home very often. Her (unknown) immigration status may have been an additional factor deterring her from seeking help.   Mother presented as extremely anxious about the impending birth of Child L1 as new born babies inevitably cry which seemed likely to anger father and generate further violence.    Mother was said to be anxious about her disclosures being shared with anyone else, fearing that her husband would kill her if he found out. (Threat to kill was only recorded by the health visitor after conversation with specialist nurse)  6.4 Not all of this information appears to have been recorded by the practice nurse. Some of the information was recorded by the specialist nurse from whom they sought advice after mother had left the GP practice. Given the short gap between the practice nurse’s interaction with mother and their subsequent telephone conversation with the specialist nurse, and taking into account the specialist nurse’s experience, it seems reasonable to accord a high degree of reliability to the information recorded by the specialist nurse. The threat to kill was only recorded by the health visitor after their conversation with the specialist nurse on 13th July 2016.  6.5 The safeguarding children referral submitted by the practice nurse should have been completed more fully but addressed several of the risk factors highlighted above with the exception of mother’s bruising, the fact that it had not been possible to fully check her child’s body for bruising, the attempted strangulation of mother, the threat to kill and the refusal of father to allow mother to use contraception although father’s controlling behaviour was referenced. The section entitled 'what are you requesting from children’s social care?' could have been completed more fully and it could have been helpful to state here that it had not been possible to view the child’s unclothed body to check for bruising. It might have been helpful for the practice nurse to have the referral checked over by a colleague more experienced in safeguarding (this was the practice nurse’s first experience of dealing with a safeguarding issue) or possibly the specialist nurse who had been advising. However, the referral provides sufficient information to gain an understanding of the risks faced by mother and her child.   MSCB Child L1 SCR  Page 20 of 40 6.6 One might have expected this referral form to have been the basis for subsequent information sharing between the agencies which would need to consider how best to respond to this case. Such an expectation would be incorrect. Prior to submitting the referral to children’s social care, the practice nurse contacted children’s social care’s contact centre by telephone and the details of the case were recorded by a contact centre officer. Under the heading 'what has happened?' the contact centre officer recorded the following:  6.7 “Mother has disclosed that father gets very angry when the baby cries and he has been doing this since the baby has been born. Father also hits the baby and mother. This is the only detail that mother would give and she begged the referrer not to pass this information on. Apparently the father is very controlling and he checks mother’s phone. Referrer did not see any injuries on the child and the mother showed grab marks on her arm.”  6.8 This summary helpfully included the fact that mother had shown the referrer the grab marks on her arm which was omitted from the subsequent referral form. However, the reference to the referrer not seeing injuries on the child was ambiguous as it did not explain that it had not been possible to see the child unclothed. (Even if the baby had been seen unclothed, the absence of visible bruises is not sufficient reassurance that the baby had not sustained significant injuries) The summary makes no reference to mother’s pregnancy although elsewhere on the contact screening (child) form both the child and the unborn child are listed as 'subject children'.  6.9 The summary of the case recorded on the contact screening (child) form was cut and pasted onto the subsequent referral from children’s social care to the police requesting a strategy meeting and was then cut and pasted into the record created by the police. It therefore assumed much greater importance as a vehicle for information sharing than the original referral from the GP practice nurse which appears to have been filed with the contact screening (child) form and shared no further. Reliance on the summary from the contact screening (child) form appears to have contributed to the police not noting that mother was pregnant which would have diminished the risks the police perceived to be present.  6.10 Some of the police officers involved in the decision making in response to the strategy meeting request from children’s social care contributed to this review and said that had they been aware of mother’s pregnancy, the attempted strangulation and the threat to kill, this would have made their eventual decision not to accede to the request for a strategy meeting much less likely. They argued that the original referral from the GP practice nurse was the source document on which decision making should be based rather than the summary created by the contact centre officer.  6.11 However, sufficient information was shared with the police to indicate that the child and their mother had been subjected to, and remained at risk of, physical violence from father. Given the very young age of the child (ten months) and concern over mother’s ability to safeguard them from father given that she had now distanced herself from her earlier disclosures, the decision to decline MSCB Child L1 SCR  Page 21 of 40 the strategy meeting does not appear to have been a sound decision on the basis of the information the police had recorded.   6.12 When the officers involved in this decision contributed to this review they referred to the volume of requests for strategy meetings received and the difficulty in resourcing all of them. They also made mention of staffing shortages during this period which may have impacted upon decision making in this case. Pressure on decision making arising from heavy demands and limited resources appear to have been an underlying factor in police decision making and at other points in this case. However, a credible threat of physical violence to a very young child from one parent together with serious doubts about the ability of the other parent to safeguard that child should have led to a strategy meeting which would have provided a vehicle for more complete information sharing about the case, a sounder appreciation of the risks involved and a robust plan of action including a child protection medical.  6.13 Having declined the strategy meeting, the advice given by the police to children’s social care that they should refer the case back to the police should mother make any disclosures during the proposed CAFA appears to have been somewhat unrealistic. Mother had already made very serious disclosures which she had then distanced herself from. Making a re-referral conditional upon her repeating those disclosures appeared to be setting a rather high threshold for re-referral.  6.14 There is no evidence that children’s social care questioned or challenged the police decision to decline the strategy meeting. The lack of a strategy meeting was escalated by a health visitor to the specialist nurse. The named nurse became involved at this point. Concerns were also being expressed by the GP safeguarding lead for practice 1. However, it appears that the plan for the health visitor and social worker to see mother and Child L1’s elder sibling for the 9 month assessment whilst father was not present, for children’s social care to conduct a CAFA and for support to be offered to mother to reduce her isolation largely assuaged concerns over the lack of a strategy meeting. Again no challenge to the police decision to decline the strategy meeting appeared to be considered.   6.15 The whole system for safeguarding children consists of a substantial number of points at which decisions are made. However, some decisions appear to be of greater significance than others and have the potential to exert a higher degree of influence over the direction of the case thereafter. A police decision to decline a strategy meeting appears to be one of these types of decisions which appear to send a signal to other partner agencies. The inference partner agencies appear to draw from a police decision to decline a strategy meeting is that if the police do not consider the risks to be of sufficient concern to justify a strategy meeting, then perhaps partner agencies should recalibrate their perception of the risks down a level or two. Another safeguarding decision invested with greater symbolic importance than it probably merits is the view of a paediatric consultant that a mark on a child’s body is not, or is unlikely to be, a non-accidental injury. As seen MSCB Child L1 SCR  Page 22 of 40 earlier, this case also features such a decision which will be discussed in more detail later in this report.   6.16 The 9 month assessment provided the health visitor and social worker with the opportunity to weigh the child naked and establish that there were no signs of bruising. This provided a degree of reassurance to agencies but was not an adequate response to the disclosures mother had made of the baby being hit and having had bruises. There appears to have been a lack of understanding in all agencies about the vulnerability of small babies. Disclosures of physical abuse to babies, even in the absence of bruises, should result in referral for a child protection medical including a skeletal survey.   6.17 GP practice 1 decided to use every subsequent contact with mother to attempt to further engage her and offer support. Mother was expecting her second child in the near future and so further contact with her was expected. The GP who was the safeguarding lead for the practice contributed to the review via a telephone conversation with the lead reviewer and said that the GP practice found it challenging to ensure that every contact with mother was used as an opportunity to engage with her and to explore family functioning. The GP said that the heavy reliance on part time and locum staff together with the demands of the GP practice also being a walk-in centre made it challenging to ensure that all staff were aware of concerns about mother and her children.  6.18 The planned CAFA was interrupted by the premature birth of Child L1 and was not completed until 2nd September 2016 when a decision was taken to close the case. The children’s social care chronology does not provide any details of the meeting with mother and father which must have been an important element in the assessment. It is assumed that this took place on 30th August 2016 when the social worker made a home visit and “noted no concerns over mother’s care for both children” (Paragraph 4.49). This comment excludes any reference to father and in focussing exclusively on “care” for the children, omits any reference to the parents ability to “safeguard” the children. The decision to close the case was inconsistent with earlier indications from children’s social care that the case would be managed as a CiN, and nor did it appear to be consistent with the further concerns which had emerged since mother made her initial disclosures to the GP practice nurse which are set out below:   Mother had claimed that she had been forced to make her disclosures by the practice nurse. This was not a credible position to take and was undermined by the bruising noted by the practice nurse.   Mother remained in a relationship with father which children’s social care advised her was a cause for concern in that she was not prioritising the safeguarding of her children. (This seemed to be a very substantial concern which did not diminish in any way).  MSCB Child L1 SCR  Page 23 of 40  Access for home visits was very challenging. The community midwife made two no access visits and a health visitor made one such visit. The health visitor only gained access on a subsequent occasion after knocking for 30 minutes which the social worker described as a common occurrence for this family. This difficulty in gaining access did not appear consistent with mother’s isolation and her comment to the GP practice nurse that she rarely left the family home.   The family home was undergoing substantial building work and seemed likely to contain potential hazards particularly for Child L1’s elder sibling who would have been mobile by this time. Yet the fixing of a safety gate on the stairs only happened after prompting from practitioners.   The possibility that the premature birth of Child L1 may have been linked to domestic abuse did not appear to have been considered. A 2016 meta-analysis found that domestic violence doubled the risk of preterm birth and low birth weighti. (1)   The absence of visits or telephone contact with Wythenshawe NICU between 10th and 15th August 2016. The reason given by the family for their physical absence from the NICU during this period was the need to return to Norwich to register Child L1’s birth. There was no legal reason to return to Norwich to register the birth although it is accepted that mother and father may not have been aware of this. It is unusual for a mother to leave a premature baby and some indications of attachment issues may have been apparent in mother’s reluctance to have skin to skin contact (Paragraph 4.36). Additionally, her fears for the harm father might inflict on the newly arrived baby, which she articulated to the practice nurse (Paragraph 4.3) may have led her to distance herself from Child L1.   The birth of Child L1 unquestionably increased risk. As a new born baby L1 was certain to cry. Father was said to be unable to stand Child L1’s elder sibling crying which was the trigger for his violence towards the child and mother. The birth of Child L1 appeared to be a source of significant anxiety to mother which seems likely to have affected the behaviour of her very young children.  6.19 According to the children’s social care chronology, the CAFA on which the decision to close the case was based, did not triangulate all the concerns in relation to domestic abuse, physical abuse and both parents’ failure to regularly visit their premature baby in hospital. (Paragraph 4.50) This also raises a question mark about the quality of supervisory oversight of the CAFA.  6.20 The premature birth of Child L1 out of area created some challenges in ensuring that neonatal staff in both Norwich and subsequently Wythenshawe were aware of the prior safeguarding concerns relating to this family. Two copies of the safeguarding plan developed by midwifery had been placed in mother’s notes with one copy to be transferred to Child L1’s notes at birth MSCB Child L1 SCR  Page 24 of 40 (Paragraph 4.27). As Child L1 was born out of area this transfer of the safeguarding plan to the new born baby’s patient notes did not occur. By the time Child L1 was transferred to the Wythenshawe NICU from Norwich, mother had been discharged and was therefore no longer a patient. As a result, mother’s patient notes were not opened by Wythenshawe NICU and so the opportunity to transfer the safeguarding plan from her notes to those of Child L1 was temporarily lost.  6.21 However, had neonatal staff at Wythenshawe checked the safeguarding folder on their shared drive they would have found the safeguarding plan under mother’s name.  The effectiveness of single and multi-agency responses to the domestic abuse disclosure made by Child L1's mother and her subsequent retraction. 6.22 Mother made disclosures of domestic abuse by father to the practice nurse on 13th July 2016 which were very concerning. She alleged that father became angry when her first child cried and hit both her and the child. This had been taking place for the whole of her first child’s life. She showed the practice nurse bruising on her arm which appeared to be an indication that she had been forcibly grabbed. She said that father had put his hands to her neck in an apparent attempt to strangle her or threaten strangulation and had threatened to kill her if she disclosed the abuse. Father was alleged to be very controlling in that he would not allow her to use contraception and monitored her phone. Mother was extremely isolated having come into the UK from Pakistan over two years previously. She said she had no family support in the UK. It was of concern that mother’s (unknown) immigration status may prevent her from seeking support in case this led to her being required to leave the UK. She expressed extreme concern about how the impending arrival of her second child would make the existing situation much more dangerous for her and her children. The risks of domestic abuse she faced therefore appeared high.  6.23 However, once the practice nurse began to suggest support options mother might access which appeared to indicate to her that she, or father, may need to leave the family home, mother began to reconsider her earlier disclosures. She began to present an alternative view of father as loving provider and emphasised the importance of her children having a mother and father. She began to beg the practice nurse not to share her disclosures further and attempted to change the subject.   6.24 The practice nurse was presented with a very challenging dilemma in that mother had quite unexpectedly made disclosures of domestic abuse which were very serious and appeared credible. She had later implored the practice nurse not to take the disclosures any further. The practice nurse took the view that mother was no longer consenting to any referral for support in respect of domestic abuse and focused their attention on the safeguarding concerns for the child and their unborn sibling. Although the practice nurse sought appropriate advice on the steps they needed to take to safeguard the children, they did not appear to seek or appear to be offered advice on further options they could consider to address mother’s disclosures of domestic abuse. The practice nurse asked the contact centre officer whether they needed to complete any additional referral in MSCB Child L1 SCR  Page 25 of 40 respect of the domestic abuse disclosed by mother and was apparently advised that the referral to children’s social care would suffice.  6.25 GP practice 1 is an Identification and Referral to Improve Safety (IRIS) practice. As previously stated IRIS is a general practice based domestic violence and abuse training support and referral programme. Training for the practice had been completed in February 2016 although the practice nurse had not received it. The clinical training focuses on the health impacts of domestic abuse, identification through specific clinical enquiry, appropriate response, referral and recording.  It involves two two-hour sessions for all practice clinical staff, including GPs, doctors in training, practice nurses, nurse practitioners, and health-care assistants. There is a one-hour training session for reception and administration teams which focuses on understanding domestic abuse, confidentiality and facilitating patient care and safety.   6.26 The IRIS advocate educator also provided the GP practice’s patients with emotional and practical support, carried out risk assessments and enabled safety planning.  This advocate educator liaises with the GP practices and provides feedback on the outcome of referrals. Patients of IRIS trained GP practices can they had not received the IRIS training, the practice nurse seems to have given priority to the issue of consent and perceived the absence of consent from mother as a barrier to referring her to any services which support the victims of domestic abuse.    6.27 At the learning event to which practitioners involved in this case were invited there was a discussion of whether the practice nurse could have been supported to complete the SafeLives DASH risk assessment. Practitioners accepted that formally completing the risk assessment in mother’s presence whilst she was initially making her disclosures would not have been feasible. However, practitioners felt that completing the DASH risk assessment was an option even after mother had withdrawn consent to any referral for support. It was felt that this could have been completed after mother had left the GP practice using the information she had disclosed earlier.   6.28 Many important questions from the DASH risk assessment would have been answered in the affirmative such as whether the victim had been injured, felt frightened, was isolated, was pregnant, controlled, financially dependent, whether there had been threats to kill, attempts to strangle and whether the abuser had hurt anyone else including a child in the family. A MARAC referral could have been considered even though it may not have been possible to fully complete the risk assessment, as policy allows a MARAC referral on the grounds of “professional judgement” irrespective of the risk “score” which emerges.   6.29 Representatives of GP practice 1 were present at the practitioner event and questioned whether it was a reasonable expectation of a practice nurse to retrospectively complete a DASH risk assessment in such challenging circumstances. As stated earlier, the practice nurse has contributed to this review.  The practice nurse pointed out that they worked one day per week at the GP practice at the time which they said made it difficult to access all the potential training MSCB Child L1 SCR  Page 26 of 40 required for their role. In any event the IRIS training the GP practice had received emphasised the overriding importance of consent which appears to have strongly influenced the practice nurse’s actions. However, the IRIS process applies only to cases assessed as medium risk and below. High risk cases coming to the attention of GP practices can only be dealt with under the DASH process. However, whilst IRIS training has made GP practices aware of the SafeLives DASH risk identification checklist and the fact that consent is not essential in high risk cases, the training has not previously taken members of GP practices through the process of completing a DASH and making a MARAC referral.     6.30 If it may have been unrealistic to expect the practice nurse to complete a DASH risk assessment, a question for reflection is whether it would have been possible for either children’s social care or the police to have considered completing a DASH risk assessment in these circumstances? The contact screening (child) form completed by children’s social care when the practice nurse initially telephoned the EDS contact centre on 13th July 2016 includes a section on domestic abuse which was not completed by the contact centre officer. The MASH manager has advised this review that the contact centre officer would not be expected to complete the domestic abuse section of the contact screening (child) form but it has not been possible to identify where responsibility for completing this section resides. It is an area which would benefit from greater clarity.   6.31 Had a referral to MARAC been made by the GP practice or any other agency in response to mother’s 13th July 2016 disclosures, an IDVA would have been notified and considered how best to make contact with mother and the case would have been discussed at a MARAC meeting at which a multi-agency action plan would have been developed – although mother may have decided not to engage with it. The MARAC process would have taken place concurrently with the Section 47 enquiry to address the priority issue of the violence to the child.  6.32 A GP appears to have attempted to make contact with mother by telephone to discuss IRIS but having received no reply does not appear to have followed this up subsequently. IDVA support from Wythenshawe hospital appeared to be a feature of subsequent planning and on 12th August 2016 it was said that an IDVA was to be shortly engaging with mother although this did not appear to happen.  6.33 Mother’s fairly rapid distancing of herself from her disclosures to the practice nurse appeared to create confusion for practitioners involved in this case. The way in which mother portrayed the disclosures then began to change over time. Initially her stance was that she did not wish to pursue her disclosures. Later she said she made the disclosures to the practice nurse because she thought the practice nurse was her friend. She also alleged that the practice nurse forced her to make the disclosures. She also minimised and denied the disclosures before appearing to settle on having been misunderstood. (Mother’s first language is Urdu but was considered to have a good understanding of English by practitioners.) There appears to be an absence of single and multi-MSCB Child L1 SCR  Page 27 of 40 agency guidance on how practitioners should respond to disclosures which are retracted or with which the victim does not wish to proceed. The police have a policy for dealing with taking retraction statements from victims of domestic abuse who decide they no longer wish to proceed but this only applies to victims who have made an initial statement of complaint to the police.  The effectiveness of the multi-agency response to suspected non-accidental injuries to Child L1. 6.34 The initial response to the marks noted on Child L1 was highly effective. The health visitor quickly arranged for mother to take Child L1 to the GP practice when the marks were noted. GP 3 made a prompt referral for a child protection medical at Wythenshawe hospital and when mother and father failed to attend with Child L1, children’s social care and the police made a home visit which led to the child being taken to the hospital.  6.35 Thereafter there seemed to be an overriding focus on the opinion of a series of paediatric consultants on whether the mark on Child L1’s abdomen could be non-accidental. Ultimately the paediatric consultants concluded that the mark did not behave as a bruise would be expected to and concluded that although the mark was “unexplained” it was not a non-accidental injury. In this case and many others, undue weight was placed on a consultant paediatrician providing a definitive view on whether an injury is accidental or non-accidental. As stated in Paragraph 6.15 this is the type of safeguarding decision in which great symbolic importance is invested. Clearly it is an important decision because the view of a paediatric consultant that an injury to a child is accidental or non-accidental is likely to have a substantial impact on the future direction of the case. However, the view of the paediatric consultant is often regarded as definitive when in fact it is just one important element in making a judgement about safeguarding concerns.    6.36 The strong focus on whether the mark was non-accidental or not may have obscured the substantial risk factors present in this case which are set out in Paragraphs 6.3 and 6.18. The three paediatric consultants involved attended the practitioner learning event and concurred with the view that a definitive opinion on the origin of the mark on Child L1’s abdomen may have been invested with more significance than was merited. The first paediatric consultant to examine Child L1 reflected that the information about previous safeguarding and domestic abuse concerns which were shared with them by children’s social care was much more limited than the actual level of concerns. The designated doctor safeguarding children for the CCG is a consultant paediatrician and was a member of the SCR review group in this case. The designated doctor safeguarding children reflected that in their experience it is common for the paediatric consultant carrying out a child protection medical to receive insufficient information about relevant safeguarding concerns. The designated doctor safeguarding children felt that this situation had been tolerated to such an extent that it had become accepted practice.  6.37 The paediatric consultants were not well served in their decision making by delays in accessing the paper records of Child L1 to establish whether any of the marks on L1's body had been present at birth. The review has been advised that such hospital patient records are now available MSCB Child L1 SCR  Page 28 of 40 electronically, although any records requested which pre-date the introduction of electronic records in the summer of 2017 remain accessible only as paper records.  6.38 It would have been helpful for a strategy meeting to have been convened on the evening on which the child protection medical took place at Wythenshawe hospital rather than deferring this for five days by which point the hospital was ready to discharge Child L1. The strategy meeting thus became a combined strategy meeting/ hospital discharge planning meeting and clarity of purpose may have been diminished as a result.   6.39 Research indicates that physical abuse is rarely a single event and that many children who suffer inflicted head injury have suffered from previous episodes of physical abuseii.  Therefore it may have been useful for the mark on Child L1’s abdomen to have been viewed as a potential “harbinger” injury, i.e. an injury to a non-mobile child which could precede further potentially more serious injuries. “Harbinger” injury research suggests adopting a lower threshold for requesting a skeletal surveyiii.  In this case a skeletal survey was under consideration by the paediatric consultants for several days before being rejected as an option.  Having said that, the skeletal survey subsequently obtained after Child L1 was admitted to hospital with a subdural haemorrhage just ten days after hospital discharge following the concerns over the mark on their abdomen, disclosed no healing fractures from old injuries.   Strategy meetings - the extent to which they took place when required and the effectiveness and inclusiveness of strategy meetings when they were held. 6.40 Working Together states that a “Local authority children’s social care should convene a strategy discussion to determine the child’s welfare and plan rapid future action if there is reasonable cause to suspect the child is suffering, or is likely to suffer, significant harm”.  6.41 Although the information which accompanied the request for a strategy meeting did not present a sufficiently full picture of the risks presented to mother and Child L1’s elder sibling and omitted that fact that mother was seven months pregnant with her second child, there was sufficient information to conclude that Child L1’s elder sibling was suffering, or likely to suffer, significant harm given that mother had disclosed that father had been physically assaulting a ten month old child since birth because he couldn’t stand the child crying and that mother had been unable to prevent this physical abuse.  6.42 The grounds on which the police declined the strategy meeting were insubstantial and the suggestion that further disclosures from mother should trigger a re-referral to the police seemed unwise given the fact that mother had already made significant disclosures from which she had subsequently emphatically distanced herself. The fact that disclosures had been made relating to injury to a baby should have heightened concern and suggested incomplete aware of the particular vulnerability of babies.  MSCB Child L1 SCR  Page 29 of 40 6.43 There was no challenge or questioning of the police decision to decline a strategy meeting. Whilst concerns were expressed by health practitioners over the absence of a strategy meeting, which were raised with children’s social care, no direct challenge of the police decision appeared to be contemplated. A key component of an effective system for safeguarding is that practitioners feel empowered to challenge partner agencies decisions. It is also important that there is a process available for resolving professional disagreements which practitioners are aware of and have confidence in.  6.44 There were further opportunities to convene a strategy meeting prior to, or at the point of discharge of Child L1 from Wythenshawe NICU (Paragraph 4.47) when additional concerns had arisen over the initial absence of contact between the family and their premature baby and on the evening of 15th September 2016 when the initial paediatric examination of Child L1 took place. (Paragraphs 4.57 – 4.59)  6.45 The purpose of the strategy meeting which took place prior to Child L1’s discharge from hospital after the mark on their abdomen had been monitored for several days appears to have been less than clear. Managers and practitioners who participated in the learning event for this SCR spoke frankly of their confusion over the purpose of this meeting. The meeting was believed to be a review strategy meeting by children’s social care who incorrectly understood an earlier strategy meeting to have taken place; the consultant paediatrician understood the meeting to be a discharge planning meeting; and the health visitor believed the meeting to be a combined strategy/ hospital discharge meeting.  6.46 As in an earlier SCR completed by this lead reviewer for MSCB, the police advised that they receive many requests from children’s social care for strategy meetings and that it was not possible to accede to all such requests because of workload pressures.   The extent to which safeguarding concerns were appropriately escalated, subject to oversight and differing professional opinions addressed 6.47 The GP practice nurse appropriately escalated the disclosures made by mother on 13th July 2016 to GPs, including the GP who was the practice safeguarding lead, the specialist nurse who provided essential advice and guidance given that this was the practice nurse’s first experience of handling a safeguarding concern, and the named nurse.   6.48 When it became clear that the police had declined a strategy meeting following mother’s initial disclosures, the health visitor, specialist nurse, named nurse and GP were involved in expressing their concerns to children’s social care who had initiated the request for a strategy meeting, but, as previously stated, not to the police themselves.  6.49 The CAFA initiated following mother’s initial disclosures was relied upon by children’s social care in making their decision to close the case. Children’s social care acknowledge that the CAFA MSCB Child L1 SCR  Page 30 of 40 insufficiently triangulated the information available and appeared to give insufficient weight to the further indications of risk which had arisen since the 13th July 2016 disclosures by mother. This suggests that managerial oversight may have been less thorough and searching than would be expected.  6.50 The GP practice 1 safeguarding lead has advised this review that when they saw the discharge summary following the paediatric admission to Wythenshawe hospital from 15th-20th September 2016, which they understood to refer to a birthmark which was fading, the GP said they struggled to make sense of this as birth marks do not normally fade over a period of days. However, the GP added that they perhaps felt that as a GP it was not appropriate for them to challenge the judgement of the consultant paediatrician. The GP also observed that one can begin to doubt oneself when a specialist comes to a different conclusion to oneself.  6.51 None of the differing professional opinions resulted in the use, or consideration of the use, of the MSCB protocol for escalating concerns and resolving professional disagreements.    MSCB Child L1 SCR  Page 31 of 40 7.0 Findings and Recommendations  Good practice 7.1 The GP practice nurse did well to elicit a significant amount of information from mother about the risks she, her child and unborn child faced from father in quite challenging circumstances in that mother, whilst in a state of distress, made a series of disclosures before beginning to distance herself from them. As previously stated the practice nurse has advised this review that addressing the 13th July 2016 disclosures was their first professional experience of taking action to safeguard a child.   7.2 The GP practice nurse also received excellent support and advice from the specialist nurse and from the GP practice generally.  7.3 At times there appeared to be a vacuum in leadership in this case as the police declined the initial strategy meeting request and children’s social care closed the case after a less than satisfactory CAFA had been completed. To a large extent, health visitors 2 and 3 stepped in to fill that vacuum and provide a lead to ensure information was shared (particularly with maternity services), to obtain updates and prompt action to be taken.  7.4 The development of a safeguarding plan for mother and her unborn child by maternity services was an appropriate response to mother’s 13th July 2016 disclosures.   7.5 The response to the unexplained mark on Child L1’s abdomen by the health visitor and the GP practice was prompt and effective, and after the parents did not present Child L1 at Wythenshawe hospital, the joint home visit by children’s social care and the police was purposeful.  The process by which the disclosures made by Child L1’s mother became diluted which contributed to less than satisfactory decision making 7.6 The information elicited from mother by the practice nurse on 13th July 2016 presented a very concerning picture of the risks that mother, her child and unborn child faced from father. However, this risk information became “diluted” during the process by which it was recorded and shared which was a contributory factor in the police decision to decline a strategy meeting.  7.7 Although the inexperienced GP practice nurse did well to obtain the information they did from mother in the circumstances, the safeguarding referral they completed did not fully reflect the seriousness of the situation and could have been more specific in stating what children’s social care were being asked to do.  7.8 Surprisingly the safeguarding referral is not treated as the source document which is the basis of information sharing thereafter. Of much greater significance is what is recorded within the children’s social care contact centre. The summary recorded by the contact centre officer from MSCB Child L1 SCR  Page 32 of 40 telephone contact with the GP practice nurse became the definitive account of the case which was shared with EDS, the children’s social care locality team and the police and unfortunately that summary omitted reference to mother’s pregnancy.   7.9 SCR review group members commented that partner agencies making a safeguarding referral to children’s social care are actively encouraged to ring the details through to the contact centre prior to submitting the safeguarding referral. If it is indeed standard practice for safeguarding referrals to be rung through to the contact centre and before being submitted as a formal safeguarding referral, then it appears unwise to place greater reliance on the information recorded by the contact centre officer than on the information contained in the formal safeguarding referral. In this case the information recorded in the formal safeguarding referral provided a more accurate account of the circumstances than the record created by the contact centre officer. It seems likely that the formal safeguarding referral completed by the practitioner involved in the case would generally be a more reliable source of accurate information than the record of a telephone call with that practitioner written down by a contact centre officer. No disrespect to the professional competence of contact centre officers is intended in making this observation.   7.10 Several practitioners who contributed to the learning event for this SCR expressed the opinion that they would feel more secure making decisions on the basis of the formal safeguarding referral which they described as the 'source' document. This seems a reasonable position to adopt. One way forward may be to attach the original safeguarding referral to all relevant communications about the case. In any event, it is suggested that MSCB request children’s social care to review the practice by which they record and disseminate information arising from safeguarding referrals to ensure that what is recorded and shared is as accurate and comprehensive as possible.  Recommendation 1 That MSCB request children’s social care to review the practice by which they record and disseminate information from safeguarding children referrals in order to ensure that what is recorded and shared with partner agencies is as accurate and comprehensive as possible.  Strategy discussions/meetings 7.11 Notwithstanding the deficiencies in the information shared, the grounds on which the strategy meeting was declined by the police do not stand up to scrutiny and the threshold the police suggested for re-referral back to them made any re-referral unlikely.  7.12 Workload pressures and staffing levels appeared to be factors in the decision to decline this strategy meeting. However, strategy meetings are important. The absence of a strategy meeting resulted in a lack of direction in this case. The police disengaged and children’s social care’s response lacked urgency and direction. A leadership vacuum developed which the health visitor service admirably attempted to fill by active engagement in the case, efforts to prompt children’s social care and effective information sharing. MSCB Child L1 SCR  Page 33 of 40  7.13 In a safeguarding system in which pressures on partner agencies are likely to remain at a high level, it is important to take steps to ensure that strategy discussions take place when they are needed and include all relevant partner agencies. It is suggested that greater use is made of video and teleconferencing to hold virtual strategy meetings. MSCB may wish to encourage agencies to adopt this approach and monitor the impact.   Recommendation 2 That MSCB obtains assurance that partner agencies fulfil their statutory obligations to ensure strategy meetings take place when necessary and are inclusive of all necessary partner agencies.   Response to disclosure of domestic abuse by mother 7.14 Once mother declined offers of support from domestic abuse services offered to her by the GP practice nurse on 13th July 2016, and then began to distance herself from her disclosures, the GP practice nurse took the view that absence of consent prevented them from taking mother’s disclosures of domestic abuse further. The practice nurse concentrated on taking action necessary to safeguard Child L1’s elder sibling by completing and submitting the safeguarding children referral. It is interesting to note that whilst the practice nurse was able to readily access advice on safeguarding Child L1’s elder sibling, an equivalent source of advice on domestic abuse did not appear to be available at that time.  7.15 The nurse’s GP practice is an IRIS practice. Paragraphs 6.25 and 6.26 describe the key elements of IRIS. It appears to have been a very successful vehicle for raising awareness of domestic abuse within GP practices across Manchester. The practitioners who attended the learning event felt that the IRIS training for GP practices emphasised the overriding importance to gain consent to refer to the IRIS service which appears to have strongly influenced the practice nurse’s actions, although they had not personally accessed the IRIS training. (Paragraph 6.29) As stated earlier the IRIS process applies only to cases assessed as medium risk and below. Mother’s case appeared likely to be considered a high risk case (Paragraph 6.28 suggests that many of the DASH check list questions would have been answered in the affirmative). High risk cases can only be dealt with under the DASH process. However, although the IRIS training is said to be very clear that consent is not required for a MARAC referral, attendees have not been shown how to complete the DASH risk identification checklist. This may have led to a lack of confidence in, and familiarity with the DASH process which was evident from the comments of members of GP practice 1 who contributed to the practitioner learning event.  7.16 It is understood that future IRIS training and refresher training for Manchester GP practices will ensure that attendees are taken through completion of the DASH checklist, along with the learning from this SCR and the emphasis that the DASH checklist can be completed with or without the patient.  MSCB Child L1 SCR  Page 34 of 40 7.17 This review suggests that multi-agency and single agency policies on domestic abuse may lack clarity on the steps for practitioners to consider when victims make domestic abuse disclosures and then decide that they do not wish to pursue or decide they wish to retract their allegations. This is not an uncommon feature of domestic abuse cases and the police have a policy for obtaining retraction statements from victims of domestic abuse who have previously made a formal statement but subsequently decided to withdraw it. The policy advises on the need for officers to consider whether the victim was withdrawing their allegation of their own free will and to further consider the victim’s support needs. However, in this case mother began to distance herself from her disclosures a very short time after making them. As previously stated where the victim is considered to be at high risk of domestic abuse, a MARAC referral can be considered irrespective of whether the victim consents although obtaining victim consent is considered highly desirable. Where a case falls below the high risk threshold, there appears to be an absence of guidance for practitioners. It would be helpful to make use of the learning from this case to develop guidance for practitioner on options available to them should a victim decide not to pursue or decide to retract allegations of domestic abuse.  Recommendation 3 That MSCB shares this SCR overview report with Manchester Community Safety Partnership and requests that partnership consider developing practitioner guidance on options available to them when a victim decides not to pursue, or retracts allegations of domestic abuse. This will also be integrated into the IRIS training programme.  7.18 It would be helpful if any such revised practitioner guidance could be completed in time to accompany the dissemination of learning from this case.  7.19 Manchester Clinical Commissioning Group commissions the IRIS service and will seek assurance that the IRIS GP practice training adequately equips GP practice staff to complete DASH risk assessments and make MARAC referrals. (See Paragraph 7.16)     7.20 In this case the domestic abuse section of the contact screening (child) form completed as a result of the telephone conversation between the GP practice nurse and the contact centre officer was left blank. (Paragraph 6.30) It is unclear where responsibility lies for completion of the domestic abuse section of the contact screening (child) form where a safeguarding children referral includes concerns of domestic abuse. It is suggested that MSCB obtain clarity on this issue.  Recommendation 4 That MSCB request children’s social care to reinforce the importance of completion of the domestic abuse section of the contact screening (child) form where a safeguarding children referral includes concerns of domestic abuse.   MSCB Child L1 SCR  Page 35 of 40 7.21 This review has been advised that a new model for addressing domestic abuse known as 'Safe and Together'iv is being implemented across Manchester which may have helped practitioners respond to mother’s disclosures in a different way. The focus of 'Safe and Together' is that systems should support keeping children with the non-offending parent in cases in which domestic abuse is alleged. The 'Safe and Together' approach characterises existing practice as inadvertently blaming the non-offending parent and holding them to account for safeguarding their children from the behaviour of the offending parent whilst failing to hold the offending parent to account for their behaviour. 'Safe and Together' consists of processes of mapping perpetrator patterns of behaviour and mapping the non-offending parent’s protective strategies in order to develop the strongest possible partnership with that non-offending parent in order to enhance the safety and wellbeing of the child or children of the family.  7.22 In this case mother appeared to begin to distance herself from her disclosures on 13th July 2016 when options for providing support to her and Child L1’s elder sibling began to be discussed with her. Her comment that children should have a mother and a father (Paragraph 4.4) implies she may have been fearful that she and her child may have needed to leave the family home if she continued to make disclosures. MSCB may wish to monitor the impact of the 'Safe and Together' programme on efforts to safeguard children from the frequently harmful effects of domestic abuse.   Role of GP practices in addressing safeguarding children and domestic abuse concerns 7.23 In the weeks that followed mother’s 13th July 2016 disclosures, it was clear to GP practice 1 that they were going to have further contact with mother given the impending birth of Child L1. The safeguarding lead for the GP practice saw these further contacts as opportunities to reach out to mother, check on her welfare and that of her children and possibly encourage her to repeat her disclosures. This approach does not appear to have been successful. Several contacts with mother did take place but opportunities to offer support to mother were often not taken. The GP safeguarding lead for the practice has contributed to this review and observed that internal communication within the practice was complicated by the practice also being a walk in centre which meant that there was less “down time” for informal information exchange. The GP safeguarding lead identified the practice’s heavy reliance on part time staff and locums as another factor. Additionally, the GP practice did not seem to be drawn into multi-agency plans for supporting mother and safeguarding her children.    7.24 The lack of strategy discussions generally in this case and the absence of involvement of the GP practice in the only strategy discussion which did take place may well be factors in the lack of engagement of the GP practice in multi-agency working. However, one would have expected it to have been possible to ensure that every contact with mother was seen as an opportunity to support her by flagging her patient record and coding those of Child L1 and their elder sibling but the review has received no evidence that this was done.  MSCB Child L1 SCR  Page 36 of 40 7.25 The challenge of fully engaging GP practices in the safeguarding children agenda is not a new one. However, the involvement of GP practice 1 in contributing to the learning from this SCR has been impressive. The MSCB may wish to reflect upon how the learning from this review should inform efforts to further engage GP practices in the safeguarding children system.  Out of Area births – implications for sharing safeguarding information  7.26 Out of area births such as Child L1’s premature birth in Norwich appear to represent a challenge to systems for sharing safeguarding information. No evidence has been provided to this review that Norwich University Hospital requested mother’s records and so would have been unaware of her previous disclosures.  By the time Child L1 was repatriated to Wythenshawe hospital’s neonatal unit, mother was no longer a patient so her patient records which contained the safeguarding plan for Child L1 were not referred to.  The neonatal unit only became aware of the safeguarding concerns when contacted by the health visitor. The review has been advised that steps have been taken to prevent this situation recurring by advising maternity staff in cases where a new born baby is repatriated from an out of area hospital to check the mother’s patient records and to also to check the safeguarding file on the hospital’s shared drive in which they would also have found a copy of the safeguarding plan under mother’s name. The MSCB may wish to obtain assurance that systems by which Manchester maternity services access safeguarding information in respect of out of area births are robust and adhered to by staff. The MSCB may also wish to share a copy of this SCR overview report with Norfolk LSCB so that they are aware of the role played by Norwich University Hospital in this case.   Recommendation 5 That MSCB obtains assurance that systems by which maternity services in Manchester access safeguarding information in respect of out of area births are robust and adhered to by staff.  Recommendation 6 That MSCB shares a copy of this SCR overview report with Norfolk LSCB so that the latter board is aware of the role played by Norwich University Hospital in this case.   The response to the unexplained mark on Child L1 7.27 The marks discovered on Child L1’s body, particularly the mark on their abdomen, promptly led to a child protection medical. Child L1 was admitted to Wythenshawe hospital for five days in order that the development of the mark on their abdomen could be observed to clarify whether it was a birthmark, a bruise or a mark of vascular origin. As stated earlier the outcome of this careful examination of the mark by three paediatric consultants appeared to become the sole focus of professional concern whilst the wider risk picture, of which the suspicious mark was just one important element, received much less attention.   7.28 All three paediatric consultants contributed to the SCR practitioner learning event and the first paediatric consultant to examine Child L1 remarked on the very limited information they received MSCB Child L1 SCR  Page 37 of 40 from children’s social care about previous and current safeguarding concerns about Child L1 and their elder sibling. (Paragraph 6.36) The designated doctor safeguarding children for the CCG has advised this review that in their experience, a paucity of safeguarding information has become the accepted norm for paediatric consultants embarking upon a child protection medical. This is an undesirable state of affairs because a lack of information about safeguarding risks puts the consultant at a disadvantage when communicating with the parents and also makes it less likely that the presence of a harbinger injury will be considered. (Paragraph 6.39)  7.29 The MSCB may wish to enquire how widespread is the problem of paediatric consultants being provided with insufficient information about safeguarding concerns ahead of child protection medicals in order to consider what action to take.  Recommendation 7 That MSCB enquires how widespread is the problem of paediatric consultants being provided with insufficient information about safeguarding concerns ahead of child protection medicals in order to consider what action to take.  Comprehensiveness of Child and Family Assessments 7.30 The CAFA which was the basis for children’s social care decision to close the case in respect of Child L1 and their elder sibling was insufficiently comprehensive with continuing and fresh concerns appearing not to be fully taken into account. The inadequacy of the CAFA appears to have gone unchallenged. MSCB may wish to request children’s social care to make use of the learning from this case in their process for quality assuring CAFA completion.  Recommendation 8 That MSCB requests children’s social care to make use of the learning from this case to challenge the quality assurance process for CAFA completion.  Lack of challenge 7.31 Effective safeguarding systems need practitioners to be prepared to challenge decisions in a constructive manner and processes for resolving professional disagreements.   7.32 There is no evidence that the police were challenged on their decision to decline the strategy meeting following mother’s disclosures on 13th July 2016 despite the fact that several agencies expressed surprise that no strategy meeting was taking place. Had there been a challenge, it seems likely that some of the risk information which had not been shared with the police, particularly the fact that mother was seven months pregnant, may have led to the police decision to be reviewed. An effective safeguarding system need practitioners who are prepared to challenge decisions in a constructive manner together with processes for resolving professional disagreements. MSCB may wish to reflect on the absence of challenge to the police decision to decline a strategy meeting in this case. And given the fact that several agencies expressed concern about the police decision yet MSCB Child L1 SCR  Page 38 of 40 none of them directly approached the police, GMP and partner agencies may wish to reflect on the extent to which they are open to and invite challenge from partner agencies.  Preventing abusive head trauma in babies 7.33 Abusive head trauma which is most commonly known as shaken baby syndrome is the leading cause of death and long term disability for babies who are harmedv.  Research suggests a demonstrable relationship between the normal period of peak crying in babies and the incidence of babies subject to abusive head trauma (AHT). There is a higher level of cases of AHT in the first month of life, a peak at 6 weeks of age and a decline in cases during the third to fifth month of a baby’s life.   7.34 When Child L1 sustained abusive head trauma they were just short of eight weeks old and had been suffering from colic which would have caused an increase in their crying. Excessive crying in babies can be difficult to manage for parents and they need to be advised on how to manage episodes of prolonged crying. In light of this case, MSCB may wish to obtain assurance that the local strategy to prevent abusive head trauma in babies is as effective as possible.  Recommendation 9  That MSCB seeks to influence the developing Greater Manchester abusive head trauma strategy in order to ensure the strategy to prevent abusive head trauma in babies is as effective as possible.  Longstanding concerns 7.35 When this report was presented to the subgroup of MSCB which, amongst other things, is responsible for scrutinising Serious Case Review reports, concern was expressed that several of the areas of learning arising from this review had also featured in earlier Serious Case Reviews.  Issues such as strategy discussions not taking place when justified, lack of challenge to partner agency decisions and the provision of incomplete safeguarding information to paediatric consultants were considered to be longstanding concerns. Previous attempts to effect improvements in these areas were considered to have been less than successful. The subgroup touched upon the particular challenges faced by partner agencies operating in Manchester but concluded that there needed to be a renewed and sustained effort to address these longstanding challenges.   MSCB Child L1 SCR  Page 39 of 40 Appendix A: Review Process  Process by which SCR conducted and membership of the SCR review group A review group of senior managers from partner agencies was established to oversee this SCR, which was chaired by the independent lead reviewer. The membership of the review group was as follows:  Consultant Paediatrician, Central Manchester University Hospitals NHS Foundation Trust  Service Manager, Manchester Children’s Services  Detective Inspector, Greater Manchester Police  Head of Nursing – Safeguarding, University Hospital of South Manchester NHS Foundation Trust   Named Nurse – Safeguarding Children, Central Manchester University Hospitals NHS Foundation Trust  Acting Designated Nurse – Safeguarding Children, Manchester Health and      Care Commissioning  Policy and Performance Officer, MSB  Business Support Officer, MSB  David Mellor, Independent Lead Reviewer.  It was decided to adopt a systems approach to conducting this SCR. The systems approach helps identify which factors in the work environment support good practice, and which create unsafe conditions in which unsatisfactory safeguarding practice is more likely. This approach supports an analysis that goes beyond identifying what happened to explain why it did so – recognising that actions or decisions will usually have seemed sensible at the time they were taken. It is a collaborative approach to case reviews in that those directly involved in the case are centrally and actively involved in the analysis and development of recommendations.  Specifically, it was decided to adopt the Welsh concise child practice review methodologyvi which focusses on recent practice and places strong emphasis on engagement in the SCR of practitioners and managers involved in the case.  Chronologies which described and analysed relevant contacts with Child L1 and their family were completed by the following agencies:  Central Manchester University Hospitals NHS Foundation Trust  Greater Manchester Police  Manchester City Council Children’s Services  NHS Manchester Clinical Commissioning Groups  University Hospital of South Manchester NHS Foundation Trust.  MSCB Child L1 SCR  Page 40 of 40 The review group analysed the chronologies and identified issues to explore with practitioners and managers at the learning event facilitated by the lead reviewer which was extremely well attended by representatives of the various disciplines involved in this case.   The lead reviewer then developed a draft report which reflected the chronologies and the contributions of practitioners and managers who had attended the learning event. Two key practitioners who had since left their positions contributed to the review via telephone conversations with the lead reviewer.  With the assistance of the SCR review group, the report was further developed into a final version and presented to MSCB.  It has not proved possible to engage mother or father in this SCR as at the time of writing they are both subject to an ongoing police investigation into the injuries sustained by Child L1. Contact with Child L1 or their elder sibling was not appropriate because of their very young age. References i Retrieved from http://onlinelibrary.wiley.com/doi/10.1111/1471-0528.13928/full  ii Retrieved from https://www.nspcc.org.uk/services-and-resources/research-and-resources/2014/head-spinal-injuries-core-info/?_t_id=1B2M2Y8AsgTpgAmY7PhCfg%3d%3d&_t_q=head+injuries&_t_tags=language%3aen%2csiteid%3a7f1b9313-bf5e-4415-abf6-aaf87298c667&_t_ip=10.99.66.5&_t_hit.id=Nspcc_Web_Models_Pages_ResearchReportsPage/_33e039c9-f723-4883-bbb2-87dfa5f1d4d4_en-GB&_t_hit.pos=1  iii G/THUR/CPD3 Harbinger injuries in serious physical abuse H. Smith1, V. Coupes2.1Central Manchester and Manchester Children's Hospitals, Manchester, UK; 2Fairfield General Hospital, Bury, Manchester, UK  iv Retrieved from http://endingviolence.com/our-programs/safe-together/safe-together-overview/Safe and Together    v Abusive head trauma: mechanisms, triggers and the case for prevention – presentation by Dr S. Smith March 2017. vi https://www.nspcc.org.uk/preventing-abuse/child-protection-system/wales/child-practice-reviews/                                                       