Serious injury of a 4-month-old baby boy in February 2012. EN12 was admitted to hospital with significant and chronic bleeds to the head and fractures to his ribs, shoulder blade and legs. Father was sentenced to three years, three months in prison; mother accepted a caution. EN12 is the subject of ongoing care proceedings; he has been placed with foster carers and plans for adoption are being sought. Father was well known to children's social care whilst he was in relationships with two previous partners. In 2003 father was suspected of causing bruising to his eldest daughter who was subsequently made the subject of a child protection plan. In 2009, he was suspected of harming his second child, who was subsequently made subject to a child in need plan. Paternal history of drug and alcohol misuse and offending. Maternal history of physically abusive relationships. Identifies learning, including: the challenge for health organisations in identifying and tracking men who have dangerous histories as information is held on the files of their female victims and not easily accessible; and the need for recognition of the impact that parents can have on professionals and how this can affect their practice and ability to challenge and confront parents. Makes various recommendations for children's social care, police and health services.
      
 Title:  Serious case review final report in respect of EN12. LSCB: Nottinghamshire Safeguarding Children Board Author: Glenys Johnston Date of publication: 2014  This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC.  This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above.                                     Nottinghamshire Safeguarding Children Board   Serious Case Review Final Report  in respect of  EN12   May 2013                                                         Glenys Johnston OBE         Independent Overview Author   (Published July 2014)  CONTENTS         Page Introduction           3 The Facts          11 Relevant ethnic, cultural or other equalities issues   12 Analysis          12 Learning from previous SCRs and research    23 Learning that has arisen during the Review    23 Organisational context issues      25 Conclusions         26 Recommendations        28            2  1.0 Introduction 1.1 The circumstances that led to the Serious Case Review 1.1.1 EN12 is a white British baby who was born eleven weeks prematurely in October 2011.  He weighed 1.5kgs. Due to his prematurity he remained in hospital for several weeks following his birth and was discharged home on 3rd January 2012.  On 15th February 2012, he was admitted to Queen’s Medical Centre.  Upon medical examination he was found to have the following injuries: significant and chronic bleeds to the head with swelling of the scalp, 9th and 10th right rib fractures (healing),  right shoulder blade fracture (healing), right upper leg fracture (new), right lower leg (healing). These multiple non accidental injuries were thought to be as old as six weeks, therefore being caused during the period EN12 had been at home since being discharged from hospital, following his birth. 1.1.2  Joint police and children’s social care enquiries were commenced and restrictions were put in place to manage contact between EN12 and his parents.  Having received treatment for his injuries EN12 was discharged from hospital and placed with foster carers and care proceedings were initiated.  1.1.3  The review was concluded and approved by the NSCB full board in May 2013. However, the publication of the report was delayed pending completion of criminal proceedings against the parents. In March 2014, father was convicted of two offences and sentenced to three year three months in prison. He was also served with a barring order preventing him from working with children in the future. The mother accepted a caution.   1.1.4  EN is safe and doing well in a settled permanent placement.  1.2 Decision to hold the SCR 1.2.1 The Nottinghamshire Safeguarding Children Board (NSCB) Standing Serious Case Review sub-group discussed the circumstances of the case on 21st March 2012.  The sub-group noted that at that stage, there was no reasonable explanation for the injuries sustained and medical opinion indicated they were non accidental, furthermore it was reported that EN12 would possibly have permanent and substantive disabilities as a result of the injuries.  It was noted by the subgroup that police enquiries were continuing.    1.2.2 The sub-group recommended, on the basis of the available information, that a serious case review (SCR) should be undertaken. On 2nd April 2012 Chris Few, the independent chair of the NSCB, decided that the case should be subject to a SCR as the circumstances met the criteria outlined in paragraph 8.11 of Chapter 8 of Working Together to Safeguard Children 2010, i.e.  ‘a child has sustained a potentially life threatening injury or serious and permanent impairment of physical and/or mental health and development through neglect or abuse’, and the case gives rise to concerns about the way in which local professionals and services worked together to safeguard and promote the welfare of children. This includes inter-agency and/or inter-disciplinary working.    3  1.3 Subjects of the review 1.3.1 The subjects of this review are: • Subject child: EN12 • Mother:  M-EN • Father: F-EN  1.4 Scope of the review 1.4.1 This review covers the period from 16th May 2011, the date M-EN booked as pregnant with her GP, until 17th February 2012, the date a strategy meeting was held, following EN12 being admitted to the hospital and non accidental injuries being found.    1.4.2 In addition, relevant information outside the above period has been reviewed and included where appropriate.  1.5 SCR Timescales 1.5.1 The decision to conduct a SCR was made on 2nd April 2012 and it was anticipated that it would be concluded and forwarded to Ofsted by October 2nd 2012. Since the review was initiated the arrangements for submission of reports has been amended and Local Safeguarding Children Boards (LSCBs) are no longer required to send SCR documents to Ofsted for evaluation at the completion of the SCR.  Copies of relevant documents have been provided to the Department for Education (DfE), prior to publication in accordance with current requirements. Ofsted will ask for evidence of learning from SCRs at the start of unannounced inspections of arrangements to protect children. 1.6 Purpose 1.6.1 The purpose of this SCR is, in accordance with Working Together to Safeguard Children 2010, to: • establish what lessons are to be learned from the case about the way in which local professionals and organisations work individually and together to safeguard and promote the welfare of children; • identify clearly what those lessons are both within and between agencies, how and within what timescales they will be acted on, and what is expected to change as a result; and • improve intra- and inter-agency working and better safeguard and promote the welfare of children.  1.6.2 SCRs are not inquiries into how a child died or was seriously harmed, or into who is culpable. These are matters for coroners and criminal courts, respectively, to determine as appropriate.  1.7 Overview report author 1.7.1 The author of this Overview Report is an independent social work consultant with considerable experience of safeguarding, including chairing the Leicester, Leicestershire and 4  Rutland joint LSCB for six years.  The author has undertaken a number of SCRs and acted as an Ofsted Additional Inspector on Joint Area Reviews, Safeguarding and Looked after Children Inspections, Unannounced Inspections of Referral and Contact Arrangements and Child Protection Inspections and has evaluated SCRs for Ofsted.  The author has also chaired a Domestic Homicide Review for a local authority council and its partners.   1.8 The SCR panel and commissioners 1.8.1 The SCR panel comprised senior managers from relevant agencies and representatives from NSCB who provided support and advice: Job title Agency Head of Housing Broxtowe Borough Council  Service Director, Children’s Social Care  Nottinghamshire County Council Associate Director of Social Care  Nottinghamshire Healthcare NHS Trust Director of Quality & Patient Safety  NHS Nottinghamshire County Medical Director Nottingham University Hospitals NHS Trust Superintendent, Head of Public Protection  Nottinghamshire Police Designated Doctor  NHS Nottinghamshire County  Group Manager, Safeguarding & Independent Review Nottinghamshire County Council NSCB Manager  Nottinghamshire County Council  1.8.2 This SCR was well managed and there were no avoidable delays during the process. The Serious Case Review Panel was independently chaired by David Ashcroft, Independent Social Work Consultant and included an appropriate range of agencies. Mr Ashcroft is highly experienced in SCRs as both overview author and panel chair. 5  1.8.3 Serious Case Review Panel meetings were held on 20th July, 3rd September, 14th September and 10th October so that the panel could satisfy itself as to the robustness of the process, consider the reports and confirm the recommendations and action plans.  1.8.4 The Serious Case Review Panels were regularly attended by all members with the exception of Nottingham University Hospitals who did not attend two meetings on 3rd September and 10th October 2012. The Overview Author attended all meetings. The agenda for each meeting was appropriate, there was a good level of debate and appropriately robust challenge, themes were identified and recorded as they emerged and the minutes and actions were promptly circulated and the latter closely monitored. Following receipt of the first versions of the Individual Management Reviews (IMRs) a very helpful response was provided by the NSCB Board Manager and Panel Chair to each author that led to a consistently good standard of reports. 1.8.5 A number of recommendations have been identified and have been incorporated into an integrated action plan. The NSCB Standing Serious Case Review sub-group will monitor the plan on a quarterly basis until they are all implemented and the Performance and Quality sub-group will monitor the impact of the recommendations. 1.8.6 . The NSCB reviewed the Overview Report and integrated action plan on November 5th 2012.  Final sign off of the Overview Report was delayed to enable contributions to the review to be sought from both parents, pending the completion of criminal investigations, and to allow further work to be carried out.  The criminal investigation subsequently led to criminal proceedings being instigated against both parents.  The NSCB Independent Chair, having taken account of advice from the police, decided that sign off the review should not be deferred and on 1st May 2013 the NSCB agreed the review and Overview Report had been completed to their satisfaction.  1.9 Individual Management Reviews  1.9.1 The following organisations have been involved in the SCR and have submitted chronologies and IMRs as part of the SCR process, meeting the requirements set out in Working Together to Safeguard Children (2010). They have been authorised by their agencies and scrutinised and challenged by the Serious Case Review Panel on two occasions. • Broxtowe Borough Council  • Nottinghamshire County Council Children’s Social Care • Nottinghamshire Healthcare NHS Trust • NHS Nottinghamshire County GP Contracted Services • Nottingham University Hospitals NHS Trust  • Nottinghamshire Police  • A Health Overview report was prepared by the Designated Doctor for NHS Nottinghamshire County     6  Information reports were also provided by: • Women’s Aid Integrated Services  • East Midlands Ambulance Service  1.9.2 All agencies formally contributing to the SCR commissioned an appropriate manager, officer, or independent person to be the author of the IMR. These managers or officers have had no direct involvement with the family, or the immediate line management of any of the practitioner(s) involved.  1.10 The involvement of the family 1.10.1 The Serious Case Review Panel agreed that the review would benefit from the involvement of family members.  At the commencement of the review both parents were notified that a review was underway however, due to ongoing criminal proceedings contributions by the parents to the review have not been sought. 1.10.2 Family members have an important perspective to bring to the review to assist NSCB in gaining the best possible understanding of what happened, why, and importantly what, if anything, might have prevented  the events.   1.10.3 The outcome of the review has been shared with family members before publication of the SCR Final Report.  1.11 Involvement of organisations in other LSCB areas 1.11.1 None 1.12 Criminal Investigations and Proceedings 1.12.1 The investigation by the police resulted in criminal proceedings against both parents being pursued. 1.13 Expert Opinion 1.13.1 None has been deemed necessary 1.14 Related parallel reviews  1.14.1 None 1.15 Public and Media Interest 1.15.1 Public and media interest will be managed by Nottinghamshire County Council which will take the lead in relation to the SCR on behalf of the NSCB.   1.15.2 Information relating to the young person, family members and professionals involved in the case (with the exception of the NSCB Chair, SCR Panel Chair and the Overview Report author) will be anonymised by NSCB before being submitted to any external organisation or body (including DfE) 7  1.15.3 This review will be published in line with current Government guidelines.  1.15.4 Freedom of Information requests relating to this case will be handled in the first instance by the NSCB Board Manager.  1.16. Legal advice 1.16.1 It was agreed that legal advice, if required, would be sought from Nottinghamshire County Council Legal Services in the first instance.  1.17 Liaison with DfE and extension to timescales 1.17.1 The DfE have been updated by the NSCB Manager throughout the course of the review.  In September 2012 the Serious Case Review Panel Chair consulted the NSCB Chair requesting a short extension to original timescales to allow further work on the SCR Final Report and this was agreed. The DfE and Ofsted have been notified of the publication of this report, together with the National Panel of Independent experts.  1.18 Key Issues:  1.18.1 In order to reach a view on whether this incident could have been predicted and/or prevented and to guide IMR authors and ensure that significant areas of practice are reviewed, the following specific issues or questions have been addressed:    i. Identify and evaluate the effectiveness of information sharing, multi-agency working, and compliance with local and statutory guidance.  Particular attention should be given to the following periods of time;   • Pre-birth, following M-EN booking as pregnant with her GP.  • The period which EN12 stayed in hospital after his birth until his discharge. • The period following EN12’s discharge from hospital until the strategy meeting on 17th February 2012.  ii. Identify and evaluate the frequency, nature and quality of professionals’ contact with the subjects of this review.   This should include the period pre-birth.  Following his birth was EN12 seen, observed and examined as necessary and were the responses of his birth family recorded and analysed?   iii. Were the services provided sensitive to the needs and vulnerabilities of EN12 and the potential impact on his parents? In particular his prematurity, age and health requirements.    8  iv. What were the key relevant points/opportunities for assessment and decision making?  Were assessments, decisions and actions made in an informed and professional way?   i. Were risk factors appropriately identified and responded to in a way that met the needs of the child?   ii. Were staff aware of the issues of domestic violence and if so were the assessments of the impact of domestic violence child focussed  iii. Was the assessment of parenting capacity of sufficient quality and did it consider the attachment between mother, father, and EN12, the quality of the relationship between the parents, the impact of their relationship upon the children and other significant behaviours that influenced their parenting. iv. Did actions accord with assessments, information available and decisions made?  v. Was the step down process appropriate and how did it affect the outcome for EN12? vi. Were there obstacles to professionals being able to engage with parents and protect the baby? vii. Were appropriate services and interventions offered or provided?  v. Was historical information available and was it accessed and used to inform assessments.  In particular the previous allegations involving F-EN and his previous partners’ children  vi. Is there evidence that staff had access to and used their relevant own agency guidance, NSCB interagency child protection procedures and guidance    vii. Were relevant organisations and professionals involved at points in the case where they should have been?   viii. Was there oversight and accountability for decision making, including managerial supervision?   ix. Was practice sensitive to gender, race, disability, cultural, linguistic and religious identity of those involved?    x. Were practitioners knowledgeable and had they undertaken relevant training about domestic abuse, potential indicators of child abuse or neglect and what to do if they had concerns.  In particular were they aware of the significance of bruising in non mobile babies?  xi. Were there any organisational problems/issues that affected the outcome of this case?   9  1.19 Feedback 1.19.1 Each agency is responsible for identifying how they provide feedback to staff involved in the case and for ensuring that organisational learning is disseminated appropriately..  The NSCB will ensure that the broader themes identified during the review are communicated effectively.  1.20 Actions taken since the events that led to the injuries to EN12 on 15th February 2012 1.20.1 EN12 is the subject of ongoing care proceedings; is placed with foster carers and plans for permanent care through adoption, are being progressed.  1.21 EN12 A Pen Picture 1.21.1 It is difficult to describe EN12 from the information contained in the IMRs and case records. He was obviously a poorly, vulnerable child with tubes attached to his face but apart from one comment by a Housing Officer, that he was “cute”, no sense of him as a baby or his relationship with his parents was gathered.  1.22 Genogram and agency involvement with EN12 and his family  1.22.1 A generic genogram was produced as part of the review however a decision was made by the panel, following feedback by Ofsted regarding a previous SCR, that IMRs would not include individual genograms.  Each IMR contains an account of what that agency knew of the family at the time of their involvement however individual agency genograms can provide a useful way of representing this information and the panel agreed that the use of genograms would be reviewed for any subsequent SCRs. 1.22.2 Each agency created a chronology setting out their involvement with EN12 and his family.  The chronologies were combined to create an integrated chronology in order to aide the review of key events.    1.23 Scope of the SCR 1.23.1 It was agreed at the outset that the review would focus on the following periods: 1. Phase 1 Pre-birth, following M-EN booking as pregnant with her GP.  2. Phase 2 The period which EN12 stayed in hospital after his birth up until his discharge.  3. Phase 3 The period following EN’s discharge from hospital until the strategy meeting on 17th February 2012.    10  2.00 The facts   2.1 EN12’s parents both had a history of difficulties. Children’s Social Care (CSC) had involvement with two previous partners of F-EN and their children.   2.2  In 2003 F-EN was suspected of causing bruising to his first daughter (HalfSib1) soon after her birth; he denied being responsible for the injuries. She was the subject of a child protection plan between September 2003 and March 2004.  2.3 In 2008 and 2009 CSC were involved with another partner (M-HalfSib2) of F-EN and their child (HalfSib2); the mother accepted refuge from his violence. It was subsequently suspected that M-HalfSib2 had suffered abuse during and after her pregnancy and that F-EN had also been abusive towards HalfSib2. CSC was involved through a Child in Need (CIN) plan until September 2009.   2.4 In both the above cases F-EN’s relationship with the mothers was discontinued prior to CSC’s withdrawal but he continued to have some contact.  2.5 F-EN’s alcohol and drug use was periodically problematic and he had been disqualified for driving whilst under their influence. In early June 2011 he suffered a seizure.  2.6 M-EN had been involved with partners who abused her and she had reported to the police incidents of physical assault and harassment which she later withdrew.    2.7 FE-N and M-EN first knew each other at secondary school; following her arrest for the injuries to EN12 in February 2012, M-EN told police officers that they began a relationship in October 2010 after making contact on Facebook. In 2011, at the time of the incidents included in this review, they were both in their mid 20s.  2.8 It is not known whether F-EN was employed; M-EN had a job but it is not known what this was.  2.9 Apart from his known criminal history, only a partial picture has been built about F-EN, in particular his relationship and contact with his other children.  2.10 The home circumstances are unclear, it is understood that F-EN and M-EN co-habited from November 2010, and at one point, August 2011, they lived with F-EN’s mother. There are no records within the IMRs of home conditions apart from mention of more than one Staffordshire Bull Terrier, which were kept in a back room.  2.11 Little is known of maternal or paternal grandparents or siblings and the parents’ relationship with them other, than an assault on F-EN by his mother’s lodger, who objected to F-EN’s behaviour to his mother and a minor mention that maternal grandmother described her daughter as sensitive to perceived criticism and that at times they fell out with each other.  2.12 There is nothing known about the level of support from family and friends. 11  3.0 Relevant ethnic, cultural or other equalities issues and whether these are relevant to the behaviours and approach taken by the organisations and professionals involved.  3.1 EN12 and his parents are white British there were no identified issues in respect of cultural or linguistic identity. His vulnerability was recognised well and latterly his risks of disability are considered. There is limited evidence within the records to support the assessment, analysis and planning of his additional needs and those of the family. Some information in IMRs indicates that the area in which the family lived has a culture of resistance to statutory services. There is almost no information in relation to family relationships and any support within the community and wider network of family and friends.    4.0 Analysis  4.1 Phase 1 Pre-birth, following M-EN booking, as pregnant, with her GP.  Summary of key events a. In early June 2011 F-EN suffered a seizure; it is not known whether there was any exploration of his relationships with partners in the context of his alcohol use. b. On 30th July 2011 M-EN reported to the police that her partner, F-EN, had assaulted her resulting in her sustaining eye and neck injuries. On 9th August 2011 this incident was notified by the police to the CSC Team Support Worker based within the police Domestic Abuse team, her role was to screen domestic abuse notifications and pass them to CSC. Although the risk was appropriately judged by the police to be ‘medium’, the level of detail provided by them is unclear. M-EN avoided contact with the police following this incident.  c. Despite having some knowledge of F-EN’s previous abuse to his partners M-EN did not take this assault seriously. d. M-EN’s antenatal care was uneventful and she attended regularly. However, M-EN was not spoken to about domestic abuse on each occasion that she attended for ante-natal care appointments. She was always accompanied by F-EN. e. During her labour M-EN asked for F-EN to leave the labour suite. M-EN was described as very tearful and did not want F-EN to return to the delivery room.  F-EN was described by M-EN as verbally abusive, rubbing a sandwich in her face and being generally unkind, she also said he had taken her mobile phone away, had put his hands round her throat and threatened to kill her and the baby. These events were not observed by hospital staff but were reported to hospital staff by M-EN at the time. 4.2 Analysis 4.2.1 The above information indicates a number of risk factors, for example the incidents during pregnancy and labour, the history of abuse by F-EN to two previous partners and their children, known by some agencies, although not to health professionals, M-EN’s avoidance of contact with the police, her denial about domestic abuse to F-EN’s previous partners and the minimisation of the risks of domestic abuse to herself.   12  4.2.2. The recording of information in health systems against patient records presents difficulties for health professionals around tracking abusive men whereas accounts of past abuse are held on the patient record for the victim. 4.2.3. The domestic abuse notification by the police to CSC on 9th August 2011, regarding the assault on M-EN by F-EN was not processed appropriately by CSC. The notification was sent by email but was not picked up, and the reasons for this are not known. The notification was therefore not entered onto Framework-I, the CSC electronic recording system.  This was a missed opportunity to share information about a vulnerable pregnant woman with a known abusing partner and it did not become known to CSC until the later strategy meeting on 7th November 2011. However, the level of risk given to the notification was ‘medium’ and this would not have led to child protection enquiries but may have led to further consideration and assessment based on what else was known by CSC.  Child protection referrals by the police are made through a separate process to CSC.  Since this incident the process for reviewing domestic violence notifications between the police and CSC has been revised as part of the development of a Multi Agency Safeguarding Hub (MASH). 4.2.4 There was insufficient exploration of domestic abuse by health during the pregnancy. Although the expectation that midwives and other health professionals will ask all expectant mothers about domestic abuse is covered by policy and training, it appears that practice amongst midwives is inconsistent. The NUH IMR states “M-EN was booked by community midwife on 22nd. She was accompanied by F-EN”. There is no record of enquiry about domestic abuse or violence. F-EN was present throughout the consultation. In this circumstance it may be difficult for a health professional to make such a positive enquiry (or for an expectant mother to make a disclosure). The template used by most, but not all, midwifes at booking includes a tick box to denote questions about domestic abuse ‘not asked as other present’. The community midwife reported that this was ticked for M-EN at the booking visit. The template used for follow up visits through pregnancy has a similar tick-box, but this is completed by a smaller proportion of midwives.  The community midwife was aware of good practice in asking about domestic abuse, but described that an opportunity to speak with M-EN alone did not arise.  4.2.5 It is also possible that even had M-EN been given this opportunity she may not have chosen to share her concerns out of fear of her partner or of statutory intervention. 4.2.6 The hospital, unlike some in other authorities, does not operate a “red dot” procedure, in which pregnant women are able to mark urine sample containers, indicating they wish to speak to a midwife alone (or similar method to promote disclosure). 4.2.7 Pregnancy can be an especially vulnerable period for women who suffer domestic abuse. In a review of medical records for more than 2,800 women Janet M. Leone, PhD, of Syracuse University in New York, and colleagues found that 3.7% had reported violence from their partner during the prenatal period and, even after adjusting for social demographic variables associated with pregnancy trauma and placental abruption, these reports indicated significant risk to women. 9% of women suffer physical or sexual violence by a male partner and between 40% and 59% of those women continue to experience violence once they become pregnant. Domestic abuse during pregnancy is 13  also associated with adverse pregnancy outcomes including premature birth and having a low birth weight baby. 4.2.8 Little was gathered about F-EN during pregnancy by health, for example his views about the pregnancy and forthcoming baby or his drug and alcohol misuse. This issue is well documented in the Health Overview report which concluded that this was a missed opportunity to assess the relationship between the couple and their view about the forthcoming baby. 4.2.9 The police control room used a graded response system to determine the priority and speed of response to incidents. The graded response process did not take account of the particular risks posed by domestic violence towards pregnant women and their unborn babies and this led to the incident not being given a higher priority. 4.2.10 Good efforts were, however, made by both health and the police to contact M-EN when she missed the occasional ante-natal appointment or appeared to be deliberately avoiding contact for example when she had made allegations of domestic abuse to the police and then withdrew them. 4.2.11 The above issues have been addressed well in the police and health IMRs with appropriate recommendations.   4.3 Phase 2 The period which EN12 stayed in hospital after his birth up until his discharge.   4.3.1 Summary of key events a. Following his birth EN12 who was 11 weeks premature remained in hospital.  Due to the continuing need for intensive medical and nursing care and supervision, he remained an inpatient on the neonatal unit.  He remained a highly vulnerable premature baby, who required continuous oxygen and specialist feeding.  b. On 1st November 2011 M-EN insisted on being discharged from hospital, this was agreed on condition that she returned daily for checks to be made on her health. c. Following the incident during labour, several discussions took place between health professionals within the hospital and the community, about the nature of the concerns.  d. The community midwife reported that M-EN was very quiet during visits to her home and she suspected that telephone calls were being monitored by F-EN. e. On 2nd November 2011concerns arose that M-EN had not returned to the hospital as agreed, the police were asked to undertake a safe and well check but this was later cancelled when it is understood that M-EN was on her way. However, she failed to arrive.  f. On 3rd November 2011 Nottingham University Hospitals’ Domestic Abuse Liaison Nurse referred her concerns about F-EN’s behaviour during M-EN’s labour (three days earlier) to CSC this included threatening to kill M-EN and EN12 and forcing food into M-EN’s mouth and M-EN having asked F-EN to leave her room). This information was also communicated to the police by CSC. 14  g. On 4th November 2011 the case was allocated to SW1 to undertake an Initial Assessment. The same day a strategy discussion was held between CSC and the police and it was agreed that the police would undertake a safe and well check the same day. h. On 7th November 2011 a multi-agency strategy meeting was held at Nottingham University Hospitals. It was convened and chaired by CSC (TM1). Also present were the NUH Domestic Abuse Liaison Nurse (who had made the referral to CSC on 3rd November), the police, the Health Visitor, the midwife, the safeguarding nurse, and the NCH family co-ordinator. In all seven people attended from four agencies. Information on the events in the labour suite (M-EN’s allegation of abuse) and hospital was shared by the NUH representatives. Information regarding suspected domestic abuse by F-EN was shared with the meeting by the police, including abuse to his two previous partners, and the abuse reported by M-EN on 30th July 2011 that had been subject of the email notification on 9th August 2011. i. At the strategy meeting police shared details of a further earlier incident in which F-EN had sustained a stab wound in an argument with his mother’s lodger at the family home. The meeting considered the risk of violence, not only to M-EN and EN12 but also to professionals providing care and support to the family.  Agreement was reached that an assessment of the level of risk was required under section 47 of the Children Act. It was also agreed that there was no role for the police Child Abuse Investigation Unit (CAIU) or any other part of the police force at this stage. There is a narrative account of events but no inclusion of an analysis of risk or an overall strategy. No decisions or actions, including commencing s47 enquiries, were recorded by the chair, other than that a further strategy discussion should take place. The minutes (or notes) of the strategy meeting were not written up by the chair until 23rd November when they were put on the CSC electronic recording system; however, no minutes from this meeting were distributed.  j. On 24th November a Multi-agency Risk Assessment Conference (MARAC) meeting was held, during which risks to M-EN and EN12 were discussed.  Details of the incident reported to the police on 30th July 2011 and the incident on the Labour Suite in October 2011 were provided. The police entry in the crime report regarding the incident in July 2011 assessed the case as medium risk. CSC were represented by TM3 who did not appear to have been made aware prior to the meeting of the information about domestic abuse in July 2011 (disclosed by the police at the strategy meeting of 7th November). TM3 was not the line manager of the case so was unfamiliar with the details.  k. The outcome of the MARAC meeting was an agreement that a housing officer would undertake a welfare visit to M-EN, and that the Women’s Aid Integrated Service (WAIS) would provide M-EN with advice and information on safety and housing, once it was assessed as safe to do so. It is unclear whether this issue of safety related to M-EN or professionals. l. It is unclear how and to whom the minutes were distributed. The process for the distribution of minutes is that they are generated by Women’s Aid workers and distributed to all relevant agencies. In the case of health agencies the minutes follow the above practice and are sent to the representative from NHCT. That representative should then distribute the information to the relevant practitioner in the area but on this occasion the minutes were not communicated to HV1, which would have heightened her awareness of the safeguarding risks to M-EN and EN12. 15  m. Visits to EN12 were monitored during this period by hospital staff; no concerns were recorded about the parents other than F-EN occasionally smelling of alcohol.  EN12 was considered to be developing well and his medical dependency was reducing. n. The combined chronology indicates that on 29th November 2011 a telephone strategy discussion took place between the police CAIU and TM1. The CSC record states that the police informed TM1 that the case had been referred to the domestic abuse unit the previous week and chased up. They also advised that if M-EN did not make a disclosure of domestic abuse then there was little that the police would be able to do and would therefore close the case. The police have no record of this discussion. What does appear to have happened the same day is that the case was allocated to SW1 to undertake s47 enquiries, the reasons for this delay are unclear but from the records it would appear that the SW1 did not do as he had been previously instructed.  o. On 5th December 2011 Police made the decision that there was insufficient evidence to charge F-EN with the abuse to M-EN as she was not prepared to substantiate her original complaint and the incidents in hospital were not witnessed by staff. p. On 7th December 2011 supervision took place between TM1 and SW1. It was agreed that SW1 would: visit the neo natal unit to meet the parents; undertake a home visit to check preparation for EN12’s discharge; undertake agency checks; contact the police; complete s47 enquiries and convene a discharge plan and unless there were any additional concerns the case would progress to a CIN plan. The core assessment commenced the same day and SW1 met the parents in hospital and explained that the reasons for CSC’s involvement were due to F-EN’s domestic violence with previous partners.  M-EN and F-EN were advised that CSC would be involved in the discharge meeting to be followed by a CIN meeting. Both parents were agreeable. q. On 23rd December HV1 cancelled a home visit. r. On 29th December 2011 a discharge planning meeting was held at the hospital and attended by SW1. It was discussed that the parents had refused to come in for transitional care over the weekend so the resuscitation training had not been completed and EN12 would not be allowed home.   The plan was to discharge EN12 home on 2nd January 2012. The case record and the minutes of the meeting confirmed that SW1 reported that he was unlikely to take any further action until the review meeting on the 27th January 2012 unless there was a ‘request for additional support in the case of non-engagement from family or any reports of domestic violence’. The records of this meeting were not put on the CSC electronic recording system until 14th February 2012 when the case was written up for closure. s. The CSC core assessment indicates that there was a home visit by SW1 on 29th December. SW1 said that the discharge meeting of 29th December had gone well but he would be collecting more information due to his suspicions that the parents were not fully engaged t. On 3rd January 2012 the hospital neonatal unit telephoned SW1 to express their concern that the parents were not spending time with EN12, as part of the transitional care arrangements, prior to his planned discharge and as a result, the discharge date had been postponed. u. On 3rd January 2012 EN12 was discharged home due to CSC advising NUH that they could not prevent this as there were no grounds to do so.  16  4.4 Analysis 4.4.1 There was an appropriate referral to CSC by the neonatal unit at Nottingham University Hospitals on 3rd November 2011, it included concerns about the incidents during M-EN’s labour however, the referral was made three days after the events, which is of concern. Although EN12 was in a safe place it was important that he had regular contact with his parents, especially his mother, to establish an early bond and attachment. This is more difficult to achieve when a baby is premature, unwell and attached to apparatus and cannot be cuddled but it is important for their later relationship. There was no assessment of M-EN’s attachment to her son but if she was being put under pressure by F-EN to go home early and not to visit regularly, this would have an impact on her contact with and attachment to her baby. 4.4.2 Following the referral the case was promptly allocated by CSC but the allocation did not include a discussion with, or clear directions to, the social worker. Given the strategy meeting planned for three days later clear instructions should have been given about the possibility that this would become a child protection case. The fact that EN12 was still in hospital is thought to have reduced any sense of urgency.   4.4.3 The strategy meeting of 7th November was poorly chaired and recorded. The relatively inexperienced team manager found the task of chairing and recording the meeting a challenge; the minutes of the meeting were insufficiently detailed, not put on the CSC recording system promptly and not distributed; each agency had their own notes but this led to a variation in their understanding of what actions would be taken. It appears the meeting agreed that CSC should commence s47 enquiries, which, given the information shared at the meeting and F-EN’s previous history was an appropriate decision however, it is not clear what information was communicated to SW1 by TM1, following the meeting. There was also a lack of challenge by agencies, in regard to the absence of the minutes. 4.4.4 Following the strategy meeting there was a lack of effective management oversight of the case by TM1 and the case ‘drifted’ without focus. Child protection enquiries did not commence and the original concerns appeared to become seen as less serious, despite not being supported by a full and proper analysis. It is possible that the concerns became viewed as less serious as there were generally positive reports about the parents from health but SW1 failed to explore the validity of the concerns with the family and other professionals. The outcome was that the case became deemed by CSC as a CIN case and, despite concerns by other professionals; there was no use of the escalation procedures to challenge this and the reasons are not explored in the IMRs 4.4.5 The MARAC meeting on 24th November 2012 was appropriately minuted and covered the relevant history. The minutes include actions for several agencies but these are not as clear as they could be and they lack timescales for completion. The actions address the risks to the victim, M-EN, rather than the risks to EN12 and although it is understood that MARAC is a victim focussed system, children are also potential victims and it would be better practice if the MARAC discussions and records included a focus on risks to children. It is of note that it was not considered safe for CSC or WAIS to visit the family but it is not clear whether this was because their visits might put M-EN at further risk or whether they would be at risk from F-EN. The police were asked to assess the situation but what they were assessing is 17  unclear. S47 child protection enquiries should have commenced after the strategy meeting and the fact that this had not happened should have been recognised. 4.4.6 The minutes were not distributed efficiently, in particular HV1 did not receive them which was a missed opportunity to raise her awareness about the risks to M-EN and EN12, it is however, my understanding that some recent recommendations from an internal review of MARAC arrangements have addressed these issues. 4.4.7 The instructions from TM1 to SW1 on 7th December 2011 were appropriate in terms of his conducting s47 enquiries but SW1 did not follow them and although the recording of his discussion with the parents is scant it indicates that he did not complete a thorough assessment and gave M-EN and F-EN an opinion as to what would happen, without having undertaken an assessment. 4.4.8 There is no evidence from the records why the visit of 23rd December 2011 was cancelled by HV1 however, the cancellation was regrettable as it may have been an opportunity for HV1 to assess whether M-EN & F-EN were putting the needs of EN12 first.   4.4.9 The home visit by SW1 on 29th December 2011, which is mentioned in the core assessment, was not recorded on CSC’s recording system and it is my view that it did not take place and the date in fact refers to the discharge planning meeting which SW1 did attend. 4.4.10 The discharge planning meeting of 29th December 2011 was not a comprehensive multi-agency meeting and there was insufficient focus on the safeguarding of the baby, as opposed to his physical health care. Indeed SW1 is recorded as stating that there were no safeguarding concerns, despite the strategy meeting of 7th November, the MARAC discussion, the s47 enquiries and the core assessment, all of which should have collated and evaluated the safeguarding concerns and the known information held by different agencies.  This was a missed opportunity to share information and develop a clear multi-agency plan for his safety. The Health Overview Report author explained at the Serious Case Review Panel that although multi-agency discharge planning is well developed within paediatric services those in neo natal units are less familiar with safeguarding arrangements and the need for a collaborative approach to the discharge of babies including the involvement of CSC if they are working with the child’s case.  4.4.11 The practice of SW1 was poor, his visits were infrequent, the quality of his assessments (initial and core) were inadequate, lacking sufficient analysis and evidenced based conclusions. There is no evidence that he accessed historical information contained in archived paper files. He did not gather appropriate background information such as a history of the parent’s own childhood experiences, relationships between family members, parenting capacity, reasons for the abuse of the previous children, risks and protective factors were not explored and in addition, due to the infrequency of visiting, EN12 was rarely seen. None of this was appropriately challenged by TM1. The reasons for this are explored in the CSC IMR and include factors such as her inexperience and limited preparation for her new role as a manager. She also trusted SW1’s ability, partly because he appeared confident and knowledgeable but also because she was struggling with her role and the demands it involved. When interviewed as part of this review SW1 and TM1 both reported that they had felt overwhelmed by their work and this probably affected their practice. There is also a 18  possibility, although this is not evidenced within the review, that he may have been frightened by the Staffordshire Bull terriers kept by the family and may have been influenced by the MARAC minutes of 24th November 2011 which recorded that CSC should not visit until the police informed them that it was safe to do so. There is no evidence that these issues or the reasons for his poor practice were explored in supervision. 4.4.12 There was a delay in initiating s47 enquiries after the 29th November when SW1 was instructed to undertake this work. The first recorded meeting was on 7th December 2011 when SW1 saw M-EN and F-EN on the neo-natal ward but the records indicate that this was an unsatisfactory meeting, there is no reference to an assessment of risk (or any other assessment) and no explicit expectation about CSC becoming involved and what that would involve; it was a very passive stance from the outset compounded by insufficient and inaccurate information about F-EN’s history. There are references to SW1 acknowledging that he needed to gather more information but he did not pursue this by seeing the family or the baby. Overall the content of the records was scant and there were significant gaps.  4.4.13 During this period the health of EN12 was regularly monitored by health professional and he appeared to be thriving. However, the involvement of his parents was also monitored and found to be of concern and an appropriate decision was made to postpone his discharge home until there was confidence in the parent’s ability to cope with their son’s health needs (providing access to oxygen, gastric feeding and the prevention of infection).  4.5. Phase 3 The period following EN’s discharge from hospital on 3rd January 2012 until the strategy meeting on 17th February 2012 4.5.1 Summary of key events a. On 5th January 2012, during supervision between TM1 and SW1, it was confirmed that although EN12’s parents had spent only a matter of hours in the hospital, learning how to care for him at home, he had been discharged. It was also identified that concerns about the dogs and family support networks had not been explored. It was agreed that SW1 would undertake a home visit to collect information about family members, discuss the control of the dogs and complete a core assessment. b. On 5th January 2012 SW1 undertook the home visit agreed in supervision. F-EN was at the gym and M-EN was asleep, following a sleepless night, she acknowledged she and FE-N were both feeling stressed. There is no record of EN12 being seen or that SW1 checked on where the dogs were kept and made any judgment himself about the safety of these arrangements.  Indeed, SW1 subsequently asked the Continuing Care Sister to check where the dogs were kept, when she made her next visit, as he did not know, but clearly realised this could be significant. c. On 6th January 2012 there is evidence of clear communication of the discharge summary from the hospital, including the issues of violent outbursts and history of domestic abuse. The record was entered on health electronic recording system on the same day. d. On 10th January 2012 SW1 telephoned the hospital and spoke to the Family Care Sister; she had visited on the 9th January 2012 and acknowledged she had not seen beyond the living room. SW1 asked her to check where the dogs stayed, when she visited the following week. 19  e. On 12th January 2012 EN12’s medical care was reviewed by the hospital and no concerns were identified. f. On 16th January 2012 the core assessment by SW1 was completed, his analysis of risk was that domestic violence was unlikely given the ‘intense input by other professionals’. There was no information about F-EN’s history of violence or the incidents observed in hospital and no evidence of discussions with other services regarding the assessment of risk. The core assessment recommended no further action and the case to be reviewed only if there were further incidents of domestic violence or non engagement. g. On 17th January 2012 there was a supervision discussion between TM2 and SW1 during which it was reported that EN12 was doing well and that his parents were engaging with professionals; a handover meeting (from hospital staff to community staff) was to be held on the 27th January 2012. The decision (in supervision) was that there was no role for CSC and the case was to be stepped down to a Common Assessment Framework plan (CAF) after the discharge meeting. h. On 27th January 2012 a discharge handover meeting was held, CSC did not attend. There were very positive reports to TM2 from health (during a telephone conversation in which TM2 informed the hospital that SW1 was unable to attend the meeting) about the care of EN12, since his discharge from hospital. CSC informed the hospital that CSC would be closing the case.  M-EN stated she was unclear about whether CSC remained involved as the social worker had not visited for 2 weeks. i. On 31st January 2012 CSC closed the case though this is not formally recorded on the electronic recording system until 14th February 2012.  j. On13th February 2012 a step down CIN plan was completed by SW1 the records state that this was with the Family Care Sister, HV2 and the CPN. However, there was no actual meeting. The plan was for HV2 to continue monitoring EN12 who would require oxygen support for an extended period. No role was identified for CSC as no child protection issues had been identified and family was being supported by health. There was no challenge by any agency to this plan, despite the shared information about the incidents of domestic abuse between M-EN and F-EN.  k. On 13th February 2012 marks on EN12’s face were noticed by HV2.  There were discussions about causation between health professionals. M-EN was advised to take EN12 to the Emergency Department at the hospital but failed to do so. l. On 14th February 2012 the practice manager at the GP surgery telephoned SW1 about the bruising and he visited the family with HV2 and then accompanied the parents to the hospital for further examination. m. On the same day HV2 noticed bruising to M-EN’s arm, who said it had been caused accidentally, there was not further exploration of this by HV2.  n. On 14th February 2012 EN12 was admitted to hospital; however there was no strategy discussion until the 16th February 2012 when one took place between DSerg2 and TM2 who agreed that s47 enquiries should commence and neither parent should have unsupervised contact with EN12. o. On 16th February 2012 the consultant paediatrician spoke to TM2 and confirmed his diagnosis that the injury was the result of a ‘vigorous hand grab/hold’. Following this discussion TM2 began a series of telephone calls. She instructed SW1 to attend the hospital to speak to the parents about the concerns. There was not an initial strategy discussion at this stage with the police because TM2 thought that the CAIU would be 20  on voicemail outside daytime office hours. However, it is apparent that the police subsequently made telephone contact with TM2 that evening, in response to the email that she had sent to the CAIU. p. On 17th February 2012 a strategy meeting was held. The meeting discussed the extent of agency involvement over a number of years and the following issues; F-EN’s violent history, including the injuries in September 2003 to another child of F-EN’s who, at the age of three weeks, was found to have bruising to her back and remained subject of a child protection plan until 2004; his convictions of common assault on a previous partner; the numerous calls to the police by previous partners due to domestic violence; in 2010, F-EN  being significantly injured after an incident at his mother’s home when his mother’s lodger objected to the way F-EN was behaving towards his mother; the injuries to M-EN’s eye and  neck in July 2011 when she was pregnant with EN12 and that the explanation for the injury to M-EN’s arm, seen by the Health Visitor on 14th February 2012, had been accepted without appropriate exploration. q. Following an immediate internal review by CSC the case was re-allocated to SW2. CSC also took steps to address the failings SW1 was given notice to leave the service in reflection of the service not being satisfied with his capability as a practitioner and TM1 was transferred from her team manager role.    4.6 Analysis 4.6.1 Following EN12’s discharge there is some evidence of more rigorous management of SW1 by TM1, as by this point her concerns about his practice overall had been raised. Her instructions in supervision on 5th January 2012 confirm that she identified that no risk assessment had been completed before EN12’s discharged, despite the fact that the parents had not attended the ‘transitional care’ arrangements at the hospital and SW1 had not explored EN12’s vulnerability to infection, concerns about the dogs and their supervision and the extent of any support networks available to the family. Her instructions to SW1 to complete a home visit the same day was appropriate but the records indicate that SW1’s visit was superficial and lacked challenge or any exploration of the issues and there is no record of this being picked up later by TM1. In addition, although SW1 had been told to report back to TM1 following the meeting there is no record of a discussion.  In addition, the SW delegated to colleagues in other agencies, checks that he should have carried out himself. 4.6.2 The outcome of this lack of focus and information was the absence of a clearly thought out multi-agency plan with appropriate decisions, clearly articulated monitoring arrangements and contingency arrangements, should all not be well. 4.6.3 It is not known whether HV2 promptly read and considered the hospital discharge summary of 6th January 2012 as the paper copy was not signed and dated until the 14th February 2012.  4.6.4 SW1 closed the case on 31st January but there was delay in line manager authorising this action until 14th February. Had she “signed off” the case closure promptly it is possible 21  that she would have identified the absence of a step down meeting and a multi-agency plan, which she could have addressed at an earlier stage.  4.6.5 EN12’s health needs were monitored, he was weighed and his development considered, positive interaction with his mother was seen and he received his universal immunisations, there were no indications of concerns about his development health or clinical safety. 4.6.6 When the bruising to EN12 was seen on 13th February 2012 it took from 2.00pm on 13th February 2012 until 7.00 pm on 14th February 2012 for him to be seen at the hospital as M-EN did not follow the inappropriate advice given by health professionals. Although the GP practice was appropriately concerned about the bruising there were serious delays in their reporting this to CSC and their advice for M-EN to take the baby to hospital herself placed EN12 at considerable risk. 4.6.7 Following the referral by the GP’s practice manager regarding the bruising there were also delays in convening a strategy meeting. Although TM2 had the information from the GP practice and further information received from the hospital safeguarding nurse on 15th February 2012 (about her concerns that the bruises were indicative of abuse) TM2 appeared to be waiting for the consultant paediatrician to confirm non accidental injuries to EN12 before convening a strategy meeting. TM2 also erroneously assumed that police in the CAIU were not available out of hours so the discussion with the police was not held promptly. The confirmation of the paediatric assessment was shared with CSC on the afternoon of 16th February 2012 when the consultant paediatrician spoke to TM2 and confirmed his diagnosis that the injury was the result of a ‘vigorous hand grab/hold’ and it is evident that the police CAIU was available out of hours as they later contacted TM2 in response to the email she had sent. Nevertheless by the time these events had taken place time had passed. 4.6.8 It is significant that despite several agencies knowing about the bruising, no-one took the initiative to accelerate the strategy meeting; this raises the question whether there is a clear understanding about the significance of bruising to non-mobile babies across all agencies and if the significance is understood, what actions to take in referring the matter to the police and CSC.  4.6.9 The delay in convening a strategy discussion between 14th and 16th February meant that M-EN and F-EN were allowed unsupervised contact with their son in hospital which placed him at considerable risk. It appears to have been assumed that EN12 would be safe in hospital but this did not take into account that his father had not been previously inhibited in his behaviour in a hospital when M-EN was in labour. The strategy discussion should have been held immediately and a risk management plan agreed to cover access to EN12. 4.6.10 There was a failure to follow step down (de-escalation) procedures before the case was closed and to complete a multi-agency CiN plan. A plan appears to have been completed by SW1 on 13th February 2012, after the case had been closed to CSC, presumably as part of the case closure process. A multi-agency meeting did not take place at this point. A meeting would have provided an opportunity to identify any gaps in information and look at the quality of the assessments and judgments before making a more informed plan and identifying any further actions. However, by this point EN12 had tragically 22  been injured. The focus of the plan appears to be that unless there were further triggers there were no child protection issues and this is clearly an unsound judgement. 4.6.11 The record of the strategy meeting of 17th February was insufficiently thorough, there is no record of the decisions made, other than ‘full police intelligence has been requested by social care’ and it is not clear whether the minutes of the meeting were circulated.  5.0 Learning from previous SCRs and research 5.1 The need for heightened concern about any bruising in any pre-mobile baby (up to the age of around six months) is explained through an understanding of the child’s physical development. Because physical self control and independent movement is very limited in young babies,   it is extremely difficult for them to bruise themselves.  Any bruising is likely to come from external sources. The younger the baby the more serious should be the concerns about how and why even very tiny bruises on any part of the child are caused (Research Report based on a consideration of a small sample of SCRs DFE-RR110 May 2011) 5.2 Sheffield LSCB and Nottingham City LSCB undertook a SCR in September 2008 (Child A) this review identified the real challenges faced in trying to collate information about men who are, or were, in a number of different relationships with women and their children. 5.3 In January 2012, twins had been discharged from the neonatal unit at Nottingham University Hospitals NHS Trust and within weeks had sustained non-accidental injuries. A SCR by another LSCB made several recommendations to improve practice (notably interagency communication and decision-making) around risk assessment and discharge, although the issues were not the same as those identified in this SCR it has become apparent in the course of this review that Nottinghamshire was not aware of the SCR and this issue needs further consideration to ensure that where services are accessed by different authorities an awareness of any SCRs is shared.   6.0 Learning that has arisen during the Review  1. The importance of all agencies understanding the significance of bruising on non-mobile babies and in these cases the importance of referring these situations promptly to CSC with full and accurate information.  2. The importance of all agencies recording accurately and promptly and accessing and giving proper weight to promptly recovered historical records.  3. The importance of agencies having a shared responsibility for the protection of children including convening or prompting the convening of strategy meetings.  4. The importance of health professionals considering the social and safeguarding needs of children as well as their health and medical needs.  23  5. The challenge for health organisations in identifying men who have dangerous histories because their information is held on the files of their female partners and cannot easily be brought together.  6. The importance of clearly recording multi-agency meetings, for example strategy meetings, including the decisions and actions to be undertake and not changing these without consulting the professionals who were party to the original decisions and distributing the minutes promptly to all attendees and relevant professionals who were not at the meeting.  7. The importance of intra and inter-agency respectful challenge to practice, delay or decisions.  8. The importance of seeing parents alone and raising, throughout pregnancy, domestic abuse as an issue and exploring their own childhood experiences.  9. The importance of professionals establishing trusting relationship, based on a frank discussion about the concerns of the professionals, with vulnerable parents that facilitates their openness and honesty about their circumstances.  10. The need for professionals to assess and interpret parental avoidance and failed appointments.  11. The need for professionals to base their decision about risk on the circumstances not on whether the police determine that there is sufficient evidence to prosecute.  12. The importance of sound, reflective, supportive, challenging supervision to ensure practitioners in this challenging area of work make good decisions, plan carefully and carry out agreed actions.  13. The need to recognise the potential impact that parents can have on professionals and how this can affect their practice and ability to challenge and confront parents. Intimidation, when present, may be explicit or implicit and may be a perception rather than a reality but should always be explored.  14. The impact on practice of organisational pressures that can lead to high workloads; high levels of staff turnover, including the appointment of new managers who take time to develop their supervisory skills and the use of temporary or agency staff whose competence takes time to be evaluated. In these ‘unstable’ situations senior managers need systems for ensuring that the organisation has a robust oversight of front-line practice by ensuring effective oversight of all levels of the management chain between senior management and front-line practice.      24  7.0 Organisational context issues  7.1 The IMRs review well their particular agency context and the following information is likely to have had a bearing on practice. 7.2 Nottinghamshire Healthcare NHS Trust describes how prior to handing over responsibility for the case to HV2 she had been covering two caseloads on a part-time basis. When HV2 returned to work on 9th January 2012 it was on the basis of a phased return following an extended period of sick leave and that day HV1 had to leave was work on compassionate grounds. This resulted in no verbal handover of any clients on the caseload.                  7.3 Nottingham University Hospitals NHS Trust states that it was not atypically busy during EN12‘s stay and there were no significant, relevant staffing issues (number or competency). It was not a period of significant organisational change, nor did financial constraints impact on EN12’s care (or that of M-EN). However, the IMR makes the point that neonatal unit relies heavily on the NUH Safeguarding Team for advice and support (including active involvement in, for example, Strategy and Discharge Planning meetings). This reliance may have been perceived to limit the need for neonatal unit staff to maintain their own levels of expertise in such difficult areas of practice, even though individual staff have undertaken the required training.                 7.4 The IMR for NHS Nottinghamshire County GP Contracted Services indicates no particular problems within the practice and states that the volume of work specific to general practice in this case was not onerous for any of the subjects involved. However, it does point out that the NSCB Safeguarding Children procedures were updated in June 2012 to clarify responsibilities to refer concerns around unexplained bruising in non-mobile babies. Although practice staff were aware on interview of the LSCB Safeguarding Children procedures and had had training in November 2010, they were not aware of the updated advice regarding bruising.   7.5 The Health Overview Report sets out the national changes to health services but more importantly looks at the local context as follows; following a joint OFSTED and CQC inspection in Nottinghamshire in March 2010, the Local Authority Children’s Services provision was graded ‘inadequate’. The subsequent inspection of September 2011 identified that the service had significantly improved and graded the service as adequate with good capacity to improve.  The author suggests that in these circumstances confidence within and between agencies may take time to be fully restored. 7.6 The IMR for Nottinghamshire Police states that there was no significant contextual information that has noticeably impacted on the ability of Nottinghamshire Police to act prior to and following the serious injuries to EN12. 7.7 The Children’s Social Care IMR provides valuable contextual information which can be summarised as follows. The service was managing high levels of contacts from external services about children whose situations did not meet the department’s thresholds and the quality of information from some external agencies was poor. The quality and timeliness of assessments were also inconsistent and of particular relevance to this case is that in December 2011 there was a delay in completing initial assessments and action was being taken to improve performance, resulting in considerable pressure on team managers. The 25  quality of assessments was also an issue “recent audits had identified that about half of assessments were good or better whilst about ten per cent were inadequate”. Added to this there were high workloads combined with a significant level of turnover of staff and difficulties in attracting and retaining highly competent social workers, as a result and as a temporary measure, agency staff had had to be employed. In addition, when interviewed as part of this review, SW1 described having felt overwhelmed by having several cases allocated at once. As part of this review TM1 said that on reflection she had not questioned SW1’s willingness to take on additional work and had simply thought that he had wanted to be helpful. She also reported that she had felt overwhelmed by the demands being placed upon her. Although she was an experienced practitioner she was in her first management role for which she felt had had limited induction, although senior managers in CSC have challenged this view and provided details of the induction process. TM1 acknowledges that she was not as effective as she could have been in identifying issues in regard to the management of EN12’s case. The reliance on agency or temporary post holders is also seen as an influence, placing additional demands on first line managers who were working hard to improve standards and achieve better key performance indicators, for example in regard to the completion of assessments.   8.0 Conclusions 8.1 EN12 was undoubtedly a very vulnerable baby by virtue of: • His father’s previous history of abusing partners and their children, his criminal behaviour and misuse of alcohol and drugs. • His mother’s previous relationships with abusive partners, her minimisation of the abuse FE-N previously committed, her reluctance to accept the risks to her and EN12 by him and the impact of his control on her. She also appeared to have little family support. • His prematurity and health needs which presented risks in themselves and a challenge to his parents. 8.2 In summary, he was a baby in need of multi-agency protection but some weak practice, a number of mistakes, delays, some poor recording and distribution of minutes  and a lack of rigorous management oversight led to insufficient recognition of the potential risks he faced. 8.3 By the time EN12 was conceived, information was known by the police and CSC about F-EN’s history and on the whole this was shared with other professionals at various points.  8.4 There was insufficiently consistent exploration of domestic abuse by health professionals prior to EN12’s birth and insufficient opportunities created to see M-EN alone to give her an opportunity to express any concerns about F-EN.  8.5 There were significant failures in the practice of SW1 and TM1. SW1 did not sufficiently consider the historical information known about F-EN and apply this intelligently to the circumstances that arose. The quality of his assessments were  inadequate; there was no information about the parent’s own life history, their home circumstances, their capacity to 26  parent their baby and the extent of family and friends’ support. There were insufficiently regular visits by SW1 to EN12 and his family and to see his mother alone. He did not establish an effective relationship with EN12’s parents; it is unclear whether they were ever told why professionals were concerned and there was no challenging of M-EN’s denial that F-EN posed a risk. SW1 failed to follow instructions from his manager and his recording of events was poor. Prior to the case being transferred to TM2 there was a lack of effective case management by TM1. 8.6 There was a lack of recognition by the police control room staff in relation to the heightened risks faced by pregnant women and this affected the grading of risk which they attributed to the case and in turn affected the speed with which they responded.   8.7 There was, at times, a lack of accuracy about events that made some decisions difficult to conclude quickly, for example, police actions in relation to the reported concerns about the incidents during M-EN’s labour. There was also inconsistency in the information about the parents’ visits to the hospital. 8.8 The quality of observations during home visits by some professionals was insufficiently clear and child focussed.  Despite some regular visits by health professionals, EN12 was  not seen sufficiently frequently by CSC. 8.9 HV2 and the GP recognised that bruising to non-mobile babies should always be considered suspicious but their delay in reporting this to CSC was a serious failure. Following this delay there was also a delay in convening the strategy meeting of 17th February 2012, which left EN12 exposed to risk. 8.10 Overall, the quality of recording was inconsistent and in some cases poor, some records by CSC, as previously mentioned, were not maintained appropriately and the recording by health professionals lacked analysis. Agency and inter-agency procedures were not consistently complied with by CSC due to a lack of strong management and practice and in the GP practice, where there appeared to be a reluctance to voice their concern, to either the parents or other professionals, that the bruising to EN12, a non-mobile baby, was possibly and probably the result of non accidental injury especially given the known risk factors in the history of the F-EN. As a result of their reluctance, their referral to CSC was delayed.  8.11 The use of assessment tools was limited by CSC due to SW1 being a temporary agency worker who over claimed his knowledge and competence and was not challenged by his manager who was also new to management.  Prior to appointing SW1 CSC had taken up references which were good and indicated appropriate previous experience to carry out the role.  8.12 Multi-agency meetings were poorly recorded and communicated partly due to the difficulties of chairing and minuting meetings, especially by a relatively inexperienced manager in CSC but also due to the lack of clarity about the distribution of minutes to agencies, attendees and non-attendees and the onward distribution of minutes within organisations. 27  8.13 Concerns about decisions by CSC, for example not to proceed with s47 enquiries, but to consider EN12 as a child in need, were not appropriate and were not challenged by other agencies. 8.14 At this point it is important to reflect on the impact of the context within which organisations were working, covered in Section 7 above, in order to gain an understanding of the possible reasons for missed opportunities and practice failings. Some of the organisational issues described did have a detrimental impact on the management of the case; including the pressure on key health visitors, the demands on CSC and the management of an agency worker by an inexperienced team manager in CSC. 8.15 In conclusion, had better use been made of all the historical information known about EN12’s parents and the previous child protection concerns to other children, to inform a holistic, multi-agency assessment, this would have led to a prediction of the possibility of harm to EN12. There were serious failings in some areas of practice, however, what cannot be concluded, with all certainty, is that had these failings not occurred and a child protection plan had been put in place the injuries would have been prevented. Even with a child protection plan, the parents may have continued not to engage in an open and honest relationship with professionals and to minimise and conceal the risks to EN12.    9.0 Recommendations 9.1 Many of the weaknesses identified in this review were failures to comply with existing procedures, poor professional practice and to apply the learning from previous SCRs, and research. The IMRs include relevant actions to deal with the areas of learning identified for each organisation and in addition the NSCB should: 9.2 : 1. Deliver dissemination events on the learning from this SCR to professionals, following its publication. 2. Carry out a review to ascertain the appropriate options for further action or referral by professionals where there is bruising to non-mobile babies and identify any barriers that prevent them following procedures effectively.  3. Satisfy itself that MARAC arrangements ensure that there is appropriate focus on the protection of children, and that there are robust arrangements to ensure that safeguarding processes are triggered from MARAC discussions and decisions.   4. Ensure that strategy meetings are fully recorded and the agreed actions are promptly distributed to all attendees and invitees and copied to GPs.  5. Review any multi agency guidance and training to ensure staff in all agencies work effectively with intimidating, resistant and avoidant parents and carers.   6. Ensure that all agencies who are involved in SCRs with other LSCBs share any appropriate learning with NSCB. 28   7. Ensure that all agencies involved with this case explore with their staff the reasons for any barriers to using the escalation process and address these individually or organisationally.  .           29  1  EN12 Serious Case Review Recommendations   Broxtowe Borough Council 1. Training to be given to all front line staff to help them recognise the forms and types of Domestic Violence/Abuse.  2. Training to be given to all front line staff on how to signpost/refer appropriately when Domestic Violence/Abuse has been identified/disclosed.  3. Develop a rolling programme of safeguarding children refresher training for all front line staff  4. Policy and procedures should be amended so that staff are aware of their role in contributing to the safeguarding of vulnerable babies/children when they are discharged from hospital to reside in local authority properties.    Children’s Social Care  1. Managers should ensure that the induction and work allocation arrangements for temporary (including agency) social workers are being applied to ensure that any claimed experience and knowledge is assessed.  2. Senior managers should ensure that the processes for the induction and support of team managers either taking on acting up arrangements or their first management role are being applied effectively.  3. The oversight and approval of s47 enquiries should only be authorised by managers who have been approved by the service for having the skills and knowledge required.  4. Formal enquiries and assessments undertaken under s47 of the Children Act 1989 should only be allocated to practitioners who have been approved by the service for having the skills and knowledge required.  5. Managers should establish how well embedded the practice of team managers providing case direction is from the point of allocation and during the conduct of the case through to closure or transfer.   6. Managers should ensure that the circumstances under which the information provided from the police on the 9th August 2011 was received and processed are clarified and understood for the purpose of learning and improvement to practice; to ensure that information about reported abuse and violence concerning women who are pregnant or are a parent are routinely entered 2  into all the relevant information systems used for conducting enquiries and assessments about children.   Health Overview Report  1. Where a professional has considered it important to place an alert on a child’s record this will prompt the professional to consider the role of the wider Primary Care Team in the support and safeguarding of the child.  2. Safeguarding and hearing the voice of the child needs to be embedded in the everyday practices of those working with babies and families on the neonatal unit (NNU) including ensuring that discharge arrangements from the NNU include all agencies involved and specifically consider the safeguarding of babies.    Nottinghamshire Healthcare Trust  1. When invited to a strategy meeting health practitioners should ensure they obtain all available safeguarding information regarding the subjects and complete the identified recommendations following the meeting  2.        Health practitioners need to be reminded of their joint responsibility with children’s social care to ensure cases are progressed appropriately. Staff must use the NSCB (2012) procedures to support the escalation of cases where appropriate   3.       When caring for babies with significant health needs, health practitioners should be competent in the use of the appropriate assessment tools e.g. the Health Needs Assessment Tool, Common Assessment Framework when developing a plan of care.   4.       Managers of Child & Family Teams, Allied Health Professionals and Emotional Health Well Being Teams need to receive training in safeguarding supervision to ensure safeguarding advice is provided and recorded in an appropriate and timely manner.   NHS Nottinghamshire County, GP Contracted Services  1.        GPs should be reminded that when vulnerable children are discharged from hospital to the community it would be good practice to make contact with the family.   2. That a review is undertaken to monitor compliance with the guidance on issuing safeguarding alerts on children’s records.  3.        A reminder is sent to GPs to flag significant adult issues which may impact on parenting capacity.   3   Nottinghamshire Police  1. Revisit internal procedures to clarify the grading response to domestic incidents and Station Support Officers’ responsibilities.    2. Where domestic abuse is reported directly at the police station officers must ensure all the necessary system checks (including CATS) are completed.   3. Revisit procedures to ensure criteria for police referral to Social Care includes where the domestic violence incident involves a pregnant woman.     Nottingham University Hospitals  1. NUH should lead work with partner agencies to explore a standardised template for communication (eg SBAR), which have been shown to improve the quality of information flow and safety in other areas of multi-team working.     2. NUH should review where records are held and stored with due regard for information governance, but also bearing in mind the hazards of decision- making with incomplete information.   3. The template for DPM should include a requirement to review previous Strategy Meeting and / or MARAC notes.   4. NUH should develop Standard Operating Procedures (SoP) to ensure that all relevant departments are represented with sufficient seniority and expertise at DPMs. Notes of DPM must be ‘ratified’ by the responsible Consultant(s) before discharge.    5. The departments of paediatrics and neonatology should review record keeping, and consider a mandatory template which requires that a ‘problem’ remains active until positively ‘resolved’.  6. Routine Enquiries about Safeguarding and Domestic Violence should be strengthened to facilitate disclosure when always accompanied by partner.  7. Safeguarding and Domestic Violence training should be reviewed and strengthened re how to manage ever-present father or partner.    8. Safeguarding and Domestic Violence training should be revised to emphasise that the criminal ‘standard of proof’ is not required for robust actions to safeguard the well-being of children.  9. Safeguarding and Domestic Violence training should be revised to emphasise the importance of establishing the frequency and nature of contacts with all children in extended and ‘multiple’ families.   10. Discharge Standard Operating Procedures (SoP) - checklist - should be reviewed to ensure that it supports 7, 8 & 9.  4  11. NUH should review training for specialist registrars (and information readily available to them) to ensure that they are aware of the correct procedures in the event of GP (or other) referral of suspected non-life threatening NAI.  12. NUH should consider mechanisms to promote ‘think family’ in adult services, where the diagnosis may have implications for child safety and or well-being or need .             Overview Report  1. Deliver dissemination events on the learning from this SCR to professionals, following its publication.  2. Carry out a review to ascertain the appropriate options for further action or referral by professionals where there is bruising to non-mobile babies and identify any barriers that prevent them following procedures effectively.  3. Satisfy itself that MARAC arrangements ensure that there is appropriate focus on the protection of children, and that there are robust arrangements to ensure that safeguarding processes are triggered from MARAC discussions and decisions.   4. Ensure that strategy meetings are fully recorded and the agreed actions are promptly distributed to all attendees and invitees and copied to GPs.  5. Review any multi agency guidance and training to ensure staff in all agencies work effectively with intimidating, resistant and avoidant parents and carers.   6. Ensure that all agencies who are involved in SCRs with other LSCBs share any appropriate learning with NSCB.  7. Ensure that all agencies involved with this case explore with their staff the  reasons for any barriers to using the escalation process and address these individually or organisationally.   Summary update  There were a total of 67 actions across partner agencies arising from the recommendations.  As at the date of publication (22 July 2014), 64 of those actions have been completed.  3 of the actions remain ongoing:  One relating to the standardising of discharge from hospital planning processes – this work has been commenced  One relating to the provision of inter-agency training around work with intimidating, resistant and avoidant parents and carers – this is being incorporated into future training programmes  5   One relating to embedding the use of escalation processes – this is being tested over coming months          