Serious unexplained head injury of an infant, under 4-weeks-old. Mother was found guilty of causing or allowing her baby to suffer serious physical harm. Baby Q was removed to permanent care of an approved family member. Identifies issues including: family's transient living arrangements; lack of engagement with antenatal care; substance misuse; domestic abuse; maternal depression; and high levels of parental anxiety. Identifies lessons learned including: importance of midwives and health visitors co-planning and coordinating their response; and need for routinely and confidentially asking parents about domestic abuse, mental health and substance misuse. Makes recommendations including: agencies need to put in place a mechanism to reduce the risk of confusion caused by recording the same case under multiple surnames; Blackpool Safeguarding Children Board should ensure that parents and children living in temporary accommodation are able to register with a GP; and there should be full consultation with other agencies before a diagnosis is changed from one of suspected non-accidental injury to medical cause.
      
 Title:  Serious case review: Baby Q. LSCB: Blackpool Safeguarding Children Board Author: Jane Wiffin Date of publication: 2015  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.                          1   Serious Case Review  Blackpool Safeguarding Children Board  Baby Q  Author of Report: Jane Wiffin  6th February 2015     2  CONTENTS          Page SECTION ONE – INTRODUCTION AND BACKGROUND   Reason for conducting the review 3 Family Involvement  3 Family members known to agencies during the period under review 3 Brief Chronology of professional Involvement  4 SECTION TWO – ANALYSIS OF AGENCY INVOLVEMENT  GP Services  7 Midwifery Services  7 Health Visiting Services  10 Children’s Social Care 11 Paediatric Care 13 Police  16 SECTION THREE: CONCLUSIONS AND RECOMMENDATIONS   Overall Conclusion  17 Notable Practice  17 Lessons Learned  18 APPENDIX 24    3  SECTION ONE – INTRODUCTION AND BACKGROUND   Reason for conducting the review 1.1. Baby Q was taken to hospital and found to have an unexplained head injury. Baby Q and parents had been taken by ambulance to the hospital because the Health Visitor had visited and found Baby Q pale, floppy and unresponsive. At hospital the parents could provide no explanation for the injuries.  Baby Q was subsequently moved to Hospital 3 for specialist care. Following discharge from hospital Baby Q was initially placed with foster carers and progressed well: Baby Q is now placed permanently with a family member who has been assessed by the Local Authority. Baby Q’s Mother subsequently pleaded guilty to causing /allowing Baby Q to suffer serious physical harm contrary to Section 5(1) & (7) Domestic Violence Crime and Victims Act 2004 and has received a custodial sentence.  1.2. Blackpool Safeguarding Children’s Board initiated this serious case review which has been written by Jane Wiffin, who is Independent of all agencies, and overseen by a panel of senior managers from representative agencies in Blackpool who had no contact with this family prior to the Review. Information about the methodology used, the process followed, and those involved is contained the appendix.   1.3. This report has been fully anonymised to protect the privacy of Baby Q and the family; the dates on which the events took place have been excluded to reduce the possibility that Baby Q could be identified.  Family Involvement  1.4. Family Involvement in a Serious Case Review is important; representatives from the review Panel met with Baby Q’s Mother at the end of the Review process and she provided information about her contact with professionals. Much of this information was consistent with the existing conclusions and recommendations regarding practice. It was not possible to meet with Baby Q’s Father. The family were notified early in the process that a Serious Case Review would be taking place and were advised of its purpose.   Family members known to agencies during the period under review: 1.5.              Father, age 24 Mother, age 27      BABY Q 4  Brief Chronology of professional Involvement  1.6. In her second interim report called ‘The Child’s Journey’1 Professor Munro identified the importance of an analysis of the child’s journey through services and the associated professional response. In the case of Baby Q that journey was extremely brief as the critical incident leading to this review took place when Baby Q was under 1 month old. This brief chronology of events provides a summary of professional contact with Baby Q and the parents over a period of approximately a year: the narrative does not address why this happened or what will be done to improve practice as this is covered in parts 2 and 3. Effective practice is also highlighted in these sections.   1.7. Baby Q’s Mother’s early contact with services was prior to her moving to Blackpool. A few months before she was pregnant she sought help from her GP because she said she was experiencing low mood and did not want to go out; she also disclosed some physical and emotional abuse from her partner. At this time she told her GP that she did not want any support beyond the prescribing of anti-depressant medication. This background information was not available to agencies in Blackpool. There was limited information known by agencies about the background of Mother or Father.  1.8. Baby Q’s Mother saw her GP when she was first pregnant, and the GP made a referral for antenatal care in the Wirral. This referral provided information about Mother’s low mood, but not the earlier disclosure of domestic abuse.  Mother was seen for early antenatal care in the Wirral, and she informed the Community Midwives she would be moving to Blackpool. Mother had no further contact with the Midwifery service in the Wirral and Blackpool Midwifery services received information from the Wirral about Mother’s pregnancy when requested in the third trimester.   When Mother was interviewed as part of this review she said she thought that the Wirral Midwives would contact Blackpool Midwives and they would contact her in due course. Mother told the Review that she had not known how to contact the Blackpool Community Midwives because when she had tried to register with a number of Doctor’s surgeries she said she had been told she could not do so because she did not have a permanent address. Mother said she was told to contact the “out of hours” service if there was an emergency.   1.9. When Mother was in the last two months of her pregnancy she contacted the out of hours Doctor’s service because of abdominal pain. She was seen and advised to go to hospital 2 which she did late at night and was seen by Community Midwife 1 and reviewed by Obstetrician 1. A plan of action regarding immediate antenatal checks and a referral to the Community Midwives was formulated, and she was assessed as medically well. Community Midwife 2 was asked to contact the previous area who said they had no information of concern; they did not inform Community Midwife 2 of the issues regarding Mother’s low mood contained within the early antenatal referral. Mother discharged herself later that night, but before she left the hospital Community Midwife 3                                                       1 Munro, E. (2011) ‘Review of child protection: interim report - the child's journey’ https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/206993/DFE-00010-2011.pdf  5  made sure that the Midwifery team had Mother’s correct contact details and provided her with information and contact details for the Community Midwifery team.   1.10. Community Midwife 1 made a referral to the Specialist Midwife because of Mother had told her she occasionally used cannabis and the Community Midwife considered that Mother was potentially vulnerable because of her lack of engagement with antenatal care. The Specialist Midwife was concerned because she could not make contact with Mother and consequently she made a referral to Children’s Social Care. Children’s Social Care carried out an Initial Assessment2 and during this process Mother and Father were interviewed by Social Worker 1, who concluded that the parents had moved into appropriate accommodation and had made preparations for the birth of the baby. No concerns were noted. The decision was that the case would close and the Specialist Midwife was informed verbally of this outcome.   1.11. Mother subsequently engaged in antenatal care for the last part of her pregnancy and the birth of Baby Q was routine, Father was present and Mother was observed in hospital to be engaging with Baby Q and breastfeeding. Baby Q was visited seven times at home in the postnatal period by Midwives and Health Visitors who recognised that these new parents needed some additional support because they presented as anxious to professionals.   1.12. During the three weeks after Baby Q was born, Baby Q was taken to hospital twice by the parents. The first admission was because Baby Q was reported by the parents to have been coughing up blood. Medical staff observed no bleeding or blood and the outcome was a diagnosis of over-feeding. The Parents were reported to have been very anxious at this time. Health Visitor 1 and the Community Midwifery team were told about the admission to hospital and the parent’s anxieties, and both followed up with home visits.   When Mother was interviewed as part of this review she said she had felt anxious about this incident and worried about how the bleeding had been caused.  1.13. The second admission to hospital was because Baby Q was found to have a laceration to the mouth by the Health Visitor who asked the parents to seek medical advice and Mother took Baby Q to hospital 2. Baby Q was assessed by Doctor 5 later that evening as having an unexplained injury, and as Baby Q was a non-mobile baby, a referral was made to Children’s Social Care Emergency Duty Service, who made initial enquiries and held a Strategy Discussion with the Police. It was agreed further enquiries would be undertaken the next day and that there would be a further Strategy Discussion. Baby Q was kept overnight in Hospital to be further assessed, and Mother returned home. Baby Q was seen the next morning to further assess the injury which was diagnosed by Doctor 8 as being a cut which was exacerbated by dry skin and deep skin creases. Doctor 8 recognised that these parents were anxious and made the assumption that Children’s Social Care were going to be offering services. Doctor 8 organised for there to be an early                                                       2  An Initial Assessment is defined as a brief assessment to consider the needs of a child and is underpinned by national guidance:    Department of Health (2000) ‘Framework for the Assessment of Children in Need’ London HMSO 6  follow up appointment. Baby Q was discharged home, and Health Visitor 1 and the Midwifery team were informed of the admission and outcome. They both carried out follow up home visits.   1.14. Following contact from the hospital on the day of Baby Q’s admission, Children’s Social Care undertook safeguarding checks and discussions were held with the Police, who had undertaken their own inquiries directly with Doctor 8. The health assessment at the hospital determined that this injury was accidental and after discussion regarding the available information, Children’s Social Care and the Police agreed that there was no need for the planned Strategy Discussion to take place and no further action was necessary.    1.15. Health Visitor 1 carried out a pre-arranged home visit a week later and found Baby Q to be unresponsive and immediately called an ambulance. The Health Visitor told the ambulance staff that there had been previous safeguarding concerns about the family. Baby Q was taken to Hospital 2 and received critical care before being transferred to Hospital 3 because there were significant concerns about the extent of the injuries. A CT scan and x-rays showed a significant head injury and evidence of recent rib fractures.    1.16. The parents were interviewed by the Police and could not provide an explanation for what had happened and were arrested. During her Police interview Mother alleged that she had been the victim of domestic abuse from Baby Q’s father.     7  SECTION TWO – ANALYSIS OF AGENCY INVOLVEMENT  GP Services  The Wirral 2.1. Mother sought advice from her GP in Area 1, just before she was pregnant, about feeling low in mood and described domestic abuse from her partner. Counselling was offered, she was prescribed antidepressants and these were monitored regularly.  Mother went to her GP when she was pregnant and an antenatal referral was completed.  The information regarding her low mood was included but the information regarding allegations of domestic abuse was not.  This runs contrary to the requirements to address early vulnerabilities of parents and to consider the implications for the unborn child as outlined in The Healthy Child Programme3 and GP requirements4. Despite enquiries being undertaken it has not been possible to establish why this was the case; however the implications for future practice are addressed through the recommendations in section 3.  Blackpool 2.2.  Neither Mother nor Baby Q was seen at a GP Practice in Blackpool.   Mother reported in interview during the Review process that she had been told she could not register with a Doctor in Blackpool because she did not have a permanent address. Mother reported that her own Father tried to help, without success. This is addressed through the recommendations in section 3.   Midwifery Services  The Wirral 2.3. Mother had her first antenatal appointment in the Wirral and she opted to take up the specialist screening offered. She informed the Midwives that she would be moving to Blackpool where she would access antenatal care. There is no evidence that information was shared with the Midwives in Blackpool as would be expected, or that a follow up appointment was offered to Mother to check whether she had actually moved, which would also have been expected practice. This is addressed in the conclusion and recommendations in section 3 of this report.  The GP antenatal referral contained information about Mother’s low mood and treatment, but this information was not shared with the Blackpool Community Midwife who telephoned to seek information about Mother. It is not clear why this was the case, but this was a missed opportunity to                                                       3  Department of Health (2009) ‘Healthy Child Programme; Pregnancy and the first five years of life’  https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/167998/Health_Child_Programme.pdf  4. Royal college of General Practitioners (2012) ‘Responding to domestic abuse: Guidance for general practices’ http://www.rcgp.org.uk/clinical-and-research/clinical-resources/~/media/Files/CIRC/Clinical%20Priorities/Domestic%20Violence/RCGP-Responding%20to%20abuse%20in%20domestic%20violence-January-2013.ashx  8  form a fuller picture of this Mother, about whom there were early concerns. This is addressed in the conclusions and recommendations in section 3.  Blackpool 2.4. Mother received an appropriate response from Midwifery services in Blackpool when she became known to them.   Mother’s lack of early antenatal care meant she did not have the full schedule of expected appointments with the Midwives, but when contact was made she received antenatal care in line with expected requirements.   2.5. In line with the ‘Healthy Child Programme’5 and routine reporting requirements the Community Midwife asked Baby Q’s Mother about domestic abuse, substance misuse and depression/mental health issues. Records note Mother had stated domestic abuse was not an issue but she did acknowledge she was an occasional cannabis user. It is important that all women are asked about domestic abuse, at key points in the antenatal and postnatal period and this is addressed as a key issue in section 3.   2.6. It was effective practice that Midwife 2 contacted the hospital where Mother previously lived to request background information. She was told that there had been no Children’s Social Care involvement and she was not informed about information on the antenatal form regarding Mother’s discussion with her GP about experiencing low mood. It was effective practice that Community Midwife made a referral to the Specialist Midwife for additional support. The Specialist Midwife made significant attempts by a variety of methods to contact and locate Mother, but was unsuccessful. She was concerned and took prompt action.   2.7. The Specialist Midwife made a referral to Children’s Social Care regarding unborn Baby Q and clearly outlined her concerns of non-engagement, parental transience, cannabis use and the state of the outside of the property. The Specialist Midwife liaised well with Social Worker 1 about the progress of the referral. It was appropriate that there was direct telephone contact between the Specialist Midwife and Social Worker 1 when the assessment was finished, and the Community Midwife was clear about the outcome. This discussion does not appear to have focused upon the reason for poor engagement during the antenatal period. Mother had provided different accounts at the time and a fuller sharing of the assessment information may have helped with cross-referencing this information.  Following this discussion Mother’s level of need was assessed as being routine.  2.8. There is no evidence about whether Mother was ever asked again by the Community Midwives regarding domestic abuse in line with the Healthy Child Programme, and Mother reported in interview as part of this Review that she could not recall being asked. Although she had previously said that this was not an issue, it would be expected that routine enquiries regarding domestic abuse were undertaken at each midwifery appointment. If the circumstances prevented a Midwife from asking a pregnant women                                                       5  Department of Health (2009) ‘Healthy Child Programme; Pregnancy and the first five years of life’  https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/167998/Health_Child_Programme.pdf 9  it is expected that this is clearly recorded and followed up at the next appointment, and this did not happen. There is also no evidence that these midwifery appointments addressed whether Mother or Father used alcohol or illegal substances in line with the Healthy Child Programme6; this is a significant risk factor for parental and baby wellbeing. The Community Midwife did clarify that Mother had ceased to smoke tobacco whilst pregnant, and Mother was made aware of the importance of this. Overall, given the concerns regarding poor engagement with antenatal care and some vulnerability which led to the Initial Assessment, it would have been appropriate to have a planned approach to Mother’s postnatal care and support. This is addressed in section 3.  2.9.  It was good practice that Mother was assessed as needing additional Midwifery support promptly after Baby Q was born and the high level of home visits offered reflected the additional support needed. This increased provision was prompted by parental anxiety and awareness by the Community Midwifery team that Mother had not engaged fully in antenatal care. It is unfortunate that the opportunity for there to be early liaison between the Midwives and the Health Visitors was lost because of Mother’s lack of early antenatal care, as this would normally be planned at 28 weeks into the pregnancy. This meant that the Health Visitor was not aware of early concerns. These were shared after the second admission to hospital. The current electronic system now automatically notifies health-visiting services of antenatal booking as soon as it happens, regardless of the stage of pregnancy.  Following a restructure, the specialist midwives are now part of the safeguarding team and notify the safeguarding team and health visitor services of all unborn babies they are working with.    2.10. Mother, Father and Baby Q received four home visits from Midwives post birth and during this time there were concerns about Mother’s emotional well-being, but not about the care of Baby Q. The Community Midwife was told by Mother that Father was involved in the care of Baby Q but the Community Midwife remained aware that it was taking time for Mother to adapt to parenthood. There is no evidence that Mother was asked follow up questions about domestic abuse as would be expected, and Mother said when interviewed as part of the Review that she could not recall being asked. During some visits Father was in another area of the family home and in these circumstances asking about domestic abuse would not have been appropriate. However, it would be expected that this would have been clearly recorded in the notes and a plan of action for future routine asking about domestic abuse formulated. This is addressed in section 3.  Given the concerns about Mother’s lack of confidence and parental anxiety, alongside two hospital admissions in quick succession, the early help offered by midwifery services was effective practice. Mother also received appropriate support regarding breastfeeding in line with the Healthy Child Programme7.                                                          6  Department of Health (2009) ‘Healthy Child Programme; Pregnancy and the first five years of life’  https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/167998/Health_Child_Programme.pdf  7 Department of Health (2009) ‘Healthy Child Programme; Pregnancy and the first five years of life’  https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/167998/Health_Child_Programme.pdf 10  Health Visiting Services  2.11. Baby Q and the parents received a good service from the Health Visitor. The family were offered “Universal Partnership Plus”8 Health Visiting Support services in recognition of the parents’ early anxieties and the pattern of visiting by the Health Visitor was consistent with this level of provision. The Health Visitor had no opportunity to explore any anxieties, or ask routine questions about domestic abuse, substance misuse or mental health issues because on each home visit she was presented with a new crisis and she responded to these quickly and effectively.   2.12. At her first visit the Health Visitor found that Baby Q had a cut to the mouth and appropriately advised that Baby Q should be taken to see a health professional. The Health Visitor initially attempted to arrange for a General Practitioner (GP) to see Baby Q; however, this was not possible and the reason given was that Baby Q was not yet registered with a General Practitioner. This is not usual practice, but it has not been possible to establish whether this was actually the case and why this message might have been given, despite enquiries. Arrangements were made for Baby Q to be seen by a Paediatrician at the local hospital.   2.13. The Health Visitor was subsequently informed by Health Visitor Liaison that Doctor 8 had discharged Baby Q home with a plan for an early follow up in two weeks’ time. Appropriately, she followed this up with a number of professionals. This included the Acting Safeguarding Lead. The Health Visitor recorded in her notes that the Safeguarding Lead had said that the laceration had been quite nasty and that Doctor 8 had assessed that this was not a child protection concern. The Lead suggested that the case might be discussed at the next safeguarding meeting. The Health Visitor also spoke with the Community Midwife who informed her of Mother’s lack of early antenatal care.  The discharge notice from the hospital received by the Health Visitor noted that Children’s Social Care was going to be involved with the family; however, this was not the case. The Health Visitor could have contacted Children’s Social Care to follow this up and clarify what support was to be offered as she was also planning to offer the parents further support from the Health Visitor Assistant.  It is not clear why this did not happen (and has not been possible to establish this because the Health Visitor is no longer in post), but the Health Visitor did appropriately put in place a plan to offer further health-visiting support. There is now the Multi Agency Safeguarding Hub (MASH) in place in Blackpool that has been established to support effective information sharing across agencies.  2.14. The Health Visitor organised a further visit to the family a week after contact with Health Visitor Liaison to offer the parent’s additional support and a Health Visitor Assistant accompanied her. The Health Visitor found that Baby Q was unresponsive and she immediately called an ambulance, making sure they were aware of the most recent admission to hospital and that there had been questions about safeguarding. The prompt actions by the Health Visitor during this visit may well have saved Baby Q’s life.                                                       8  Department of Health (2009) ‘Healthy Child Programme; Pregnancy and the first five years of life’  https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/167998/Health_Child_Programme.pdf 11  Children’s Social Care  2.15. Children’s Social Care had two periods of involvement with Baby Q and Baby Q’s parent’s.   2.16.  The first period of involvement was prior to Baby Q’s birth when Children’s Social Care received a referral from the Specialist Midwife. This was responded to promptly and the Midwife was informed of the plan for an Initial Assessment, in line with national guidelines. The assessment was delayed because the parents had moved from the address on the referral form - unknown to the Specialist Midwife. There was good liaison between agencies and the parents’ new address was identified and passed to Children’s Social Care. Once Children’s Social Care had the new address the parents were seen and an Initial Assessment was carried out in line with national expectations regarding timescales9. Due to an administrative error, Social Worker 1 was unaware that there were some concerns about cannabis use. Although the information regarding cannabis misuse had been included in the referral sent to Children’s Social Care by the midwife the information had not been copied into the referral episode. The referral document had then been uploaded into the documents section of the child’s file but not into the referral episode. This error is unusual, and there is no evidence that this is characteristic of usual practice. It does, however, serve as a reminder of the importance of accurate recording.  2.17. Social worker 1 reported that parents engaged well during the assessment. Their accommodation was considered appropriate and both parents were able to demonstrate the preparations they had made, physically and emotionally, for the new baby. Mother or Father was not asked about substance misuse or any history of mental health concerns. This is outside expected practice as outlined in Blackpool’s guidance for undertaking an assessment. This was not picked up through management oversight.   Mother reported in the interview undertaken as part of this Review that she was asked about Domestic Abuse, but Father was also present.  2.18. Given the available information, it was appropriate that the Initial Assessment recommended that the case be closed. However, the conclusion of the assessment was influenced by parents’ self-reporting and offered little evidence of cross-referencing of information with what other agencies knew. For example, there was no evidence to support what the parents said about their attempts to access antenatal care and did not reflect the early concerns of the Specialist Midwife. This would not necessarily have had an impact on the outcome of this Initial Assessment; however, effective assessment of risk and need cannot be achieved when there is an over reliance on parental ‘self-report’.  This is addressed in section 3.   2.19. The outcome of the Initial Assessment was shared with the Specialist Midwife through a telephone call. It is good practice to share the outcome of the assessment with any agency that is likely to have an ongoing role with the family. In this case, the conversation between practitioners did not highlight gaps in information and although it                                                       9  Department of Health (2000) ‘Framework for the Assessment of Children in Need’ London HMSO 12  is not currently part of expected routine practice or required by Guidance it may have been helpful to clarify whether sharing the written conclusion of the assessment would have been helpful.   2.20. The second period of involvement with Children’s Social Care was when Doctor 5 contacted the ‘Out of Hours’ Emergency Duty Social Worker to report that Baby Q had a laceration to his mouth and was a non-mobile baby. The Emergency Duty Social Worker appropriately convened a Strategy Discussion, did some preliminary checks regarding the family and liaised with the police in line with national10 and local policy and procedures11.   2.21. The Duty and Assessment Team continued the enquiries the next day. Social Worker 3 was allocated the task of convening a Strategy Meeting. In preparation for this Social Worker 3 made the following checks:   Checking whether the family were previously known to Children’s Social Care. Because Baby Q’s was known by each of his parents’ surnames at different times, both prior to and after his birth, Baby Q was not initially identified in the records. This has highlighted a potential hazard in case management of unborn and newly born babies. This is addressed in section 3.   Liaising with the Hospital. Social Worker 2 attempted to contact the safeguarding lead at the hospital, as is expected practice. Unfortunately, she was on leave and so Social Worker 2 contacted the ward directly. At this time, she spoke to a student nurse who read from the records and told her that Baby Q had been discharged because Doctor 8 had assessed that the injury was caused by dry skin and that this was not a safeguarding issue. In this situation it would have been appropriate to ask to speak directly to the Doctor who had been in charge of Baby Q’s care and had carried out the medical assessment.    Discussion with the police: Social Worker 2 and Police Officer 1 are located in the same office; in their discussion about the case it was confirmed that Doctor 8 did not consider that this was a safeguarding issue because the medical assessment was that the laceration had been caused by very dry skin. The Police confirmed they had had a discussion with Doctor 8 about his assessment of the injury and that they would be taking no further action.   2.22. Social Worker 2 discussed the outcome of these preliminary checks with the Team Manager and it was agreed that given the available information a Strategy Discussion was not warranted and the case would close. In the context of working arrangements at the time, this was appropriate, but this meant that there was no multi-agency meeting to explore the circumstances of Baby Q. In this case, given the lack of discussion about the alternate diagnosis, consideration should have been given to continuing with the                                                       10  Department for  Education (2013) ‘Working Together to Safeguard Children’ https://www.gov.uk/government/publications/working-together-to-safeguard-children  11  http://panlancashirescb.proceduresonline.com  13  Strategy Discussion. Agencies in Blackpool need to consider how to effectively manage circumstances where there is an initial medical concern about an unexplained injury to a non-mobile baby which is considered to be a potential non- accidental injury and guidance from a senior medical practitioner suggests that there is a purely medical cause, without there being discussion regarding this.  This is addressed in section 3.    Paediatric Care  2.23. Baby Q attended Hospital 2 three times and was seen by Paediatricians on each occasion.   2.24. When Baby Q was brought to hospital aged one week old, the parents reported to the ambulance crew that Baby Q had been “coughing up blood”. No blood was recorded to have been seen by either the ambulance crew or the medical professionals who cared for Baby Q. The outcome was a medical diagnosis of over-feeding. Baby Q was discharged home and a letter was sent to Mother’s GP. In line with expected practice, the Health Visitor and Midwife were informed of the admission to hospital and that the parents had presented as anxious.  2.25. Six days later, Baby Q was brought to the Accident and Emergency Department by Mother with a laceration to the mouth on the advice of the Health Visitor and was seen by Doctor 5. He assessed this as an unexplained injury in a non-mobile baby and in line with National Institute of Clinical Excellence (NICE) Guidance12 and the local 13 and national14 safeguarding procedures appropriately suggested that Baby Q be admitted to hospital to be reviewed by the admitting Consultant the following day. A referral was appropriately made to Children’s Social Care and the plan was for medical photographs of the laceration to be taken the next day. This plan was agreed by Doctor 6 and was consistent with the requirements of the NICE Guidance.  It would have been helpful if Doctor 5 had clearly outlined in writing what actions he expected to be undertake the next day with regards to the safeguarding aspects of Baby Q’s care. This would be expected practice.  2.26. The care of Baby Q was handed over to Doctor 8 the next day by the Registrars on the ward. Doctor 8 had no contact with Doctor 5 who had been on duty the night before and he was informed by a more junior Doctor that this was an unexplained injury which needed assessment. Doctor 8 was aware that this had been described as a potential safeguarding concern and that Children’s Social Care and the Police were involved but he did not understand that Children’s Services had already convened a Strategy Discussion.   2.27. Doctor 8 undertook a medical assessment of Baby Q and diagnosed a cut which was exacerbated by deep skin creases caused by dry skin. He did not consider there was any medical evidence that this was a non-accidental injury, and assessed that the injury was                                                       12  NICE (2009) ‘When to suspect child maltreatment’ http://guidance.nice.org.uk/CG89  13  http://panlancashirescb.proceduresonline.com  14  Department for Education (2013) ‘Working together to safeguard children’  www.gov.uk/government/publications/working-together-to-safeguard-children  14  consistent with the explanation provided by Father. There was a lack of cross referencing with earlier information recorded by Hospital 2 that Mother and Father said that they could not see how the injury could have been caused as they had described. This cast doubt on their explanation which should have prompted further enquiries in line with NICE Guidance regarding Child maltreatment.   2.28. Doctor 8 interviewed the parents, and he recorded in Baby Q’s notes that they were “cooperative, caring and honest”. This reliance on how parents appear is not consistent with an effective assessment of safeguarding concerns as outlined in the NICE Guidance15. Doctor 8 did recognise that these parents were vulnerable and he offered them an early follow up clinic appointment. He recorded that “I readily accept that this cut was caused accidentally – probably during feeding – Dad inexperienced happy for baby to go home”.  In making this decision, Doctor 8 did not have a conversation with Doctor 5 and this is not consistent with the Lord Laming Recommendations16 where Lord Laming highlighted the importance of there being direct discussion between Doctors where there is an alternate diagnosis to possible deliberate harm. There was no evidence that Doctor 8 had any discussions with other agencies prior to making the decision to discharge Baby Q home or to inform the decision making. Given that Doctor 5 had considered the laceration to be a possible unexplained injury to a non-mobile baby and had alerted statutory agencies to this, it is of concern that Doctor 8 did not liaise with his medical colleague, the Police, the Health Visitor or Children’s Social Care before making the decision that this was a medical issue. This action was not consistent with either the Lord Laming Recommendations 17 regarding a different diagnosis between deliberate harm to a medical cause nor is it consistent with NICE Guidance regarding assessing deliberate harm to children18.  2.29. NICE Guidance19 regarding recognising safeguarding concerns makes it clear that health professionals should suspect maltreatment where they see an injury in a non-mobile baby. In order to exclude maltreatment they should consider the explanation provided in terms of its plausibility, and also gather information from other agencies. In this case it was recorded that both parents said that they were not clear how the injury to Baby Q occurred, although they thought it might be caused by Father’s nail catching Baby Q’s mouth whilst feeding. This explanation may have been plausible with the presence of very dry skin, but how this cut was actually caused remains unknown. The information available to this review suggests that Doctor 8 gave weight to the attitude and presentation of the parents, rather than the potential vulnerability of Baby Q or the actual cause of the laceration.                                                        15  NICE (2009) ‘When to suspect child maltreatment’ http://guidance.nice.org.uk/CG89 16  Laming (2003) ‘The Victoria Climbié Inquiry’ https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/273183/5730.pdf   17  NICE (2009) ‘When to suspect child maltreatment’ http://guidance.nice.org.uk/CG89 18  Laming (2003) ‘The Victoria Climbié Inquiry’  https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/273183/5730.pdf  19  NICE (2009) ‘When to suspect child maltreatment’ http://guidance.nice.org.uk/CG89 15  2.30. A recurring lesson in effective safeguarding practice (which includes ensuring the wellbeing of babies and children) is to focus on what actually happened to the child, rather than just on the attitude or presentation of the parents. The Guidance from NICE20 regarding recognising safeguarding concerns helpfully differentiates between “considering”, and “suspecting”, child maltreatment. It is helpful because it accepts that there is a grey area where professionals like doctors and health visitors may be dealing with a situation where they are concerned about parents, but do not believe the issue to be one of safeguarding. The grey area is described as “considering” and, after a period of enquiry this should change to either “suspecting” or “excluding” child maltreatment. The guidance highlights the importance of a clear process in moving from considering to either suspecting or excluding, and this should include; listening, observation, seeking explanations and recording. The guidance also states that decision makers should do one or more of the following:  a) Discuss your concerns with a more experienced colleague, a community paediatrician, a child and adolescent mental health service colleague, or a named or designated professional for safeguarding children   b) Gather collateral information from other agencies and health disciplines, having used professional judgement about whether to explain the need to gather this information for an overall assessment of the child   c) ensure review of the child or young person at a date appropriate to the safeguarding concern, looking out for repeated presentations of this or any other alerting features” (NICE 2009).   During the review Mother stated that she had concerns about how Baby Q had sustained the laceration to his mouth, however she did not share these concerns with the professionals she was in contact with at the time. Professionals should be minded to ensure that parents are given the opportunity to share any concerns they may have and are encouraged to seek further medical attention if necessary.  2.31. The handover process did not make clear that a plan to establish whether safeguarding concerns could be excluded had already been formulated. The Victoria Climbié Inquiry21 highlighted the importance of a clear process regarding the diagnosis of possible deliberate harm to a child. The Inquiry recommended that when a change in medical opinion occurs in relation to the diagnosis of possible deliberate harm to a child, discussions between the involved health professionals should take place and where concerns exist about deliberate harm as an alternative to a purely medical one, the diagnosis of deliberate harm must not be rejected without full discussion and if necessary obtaining a further opinion. This did not happen in this case. The process for establishing or excluding safeguarding concerns, and also the handover of safeguarding                                                       20  NICE (2009) ‘When to suspect child maltreatment’ http://guidance.nice.org.uk/CG89 21  Laming (2003) ‘The Victoria Climbié Inquiry’  https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/273183/5730.pdf  16  concerns from one Consultant to another, needs to be clearer and more robust. This is addressed in section 3.   The Police  2.32. The Police were involved when they received a referral from Children’s Services Emergency Duty Team and they undertook appropriate enquires in line with existing national22 and local23 guidance regarding a non-mobile baby with an unexplained injury. Police officer 1 checked the police national computer and found the parents had no previous convictions. Police officer 1 contacted Doctor 8 and was informed that this was not a non-accidental injury and Baby Q was to be discharged home. Police Officer 1 reported this to her Senior Officer, who asked that this be clarified. Police Officer 1 spoke to Doctor 8 who reported that it had not been possible for Doctor 5 to complete a full assessment, which Doctor 8 had been able to do the next day, and Doctor 8 said that the injury was accidental, exacerbated by dry skin. Doctor 8 was asked to fax over the medical records to confirm this, which was done. The notes received did not provide information about the parent’s doubts about how the laceration could have been caused and the Police were not made aware that this was the second admission to hospital in a short period of time. Police Officer 1 had a discussion with Social Worker 2 and it was agreed that there was no further need for a Strategy Meeting. Given the available information this decision was in line with accepted practice standards. It is good practice that Police Officer 1 explored decision making regarding the laceration with Doctor 8, but there should have been greater exploration of this between the Police and Children’s Social Care and it is clearly important to raise awareness within these agencies of the potential risks posed by medical decisions taken in isolation. This is addressed in section 3.                                                         22 Department for Education (2013) ‘Working together to safeguard children’  https://www.gov.uk/government/publications/working-together-to-safeguard-children  23 http://panlancashirescb.proceduresonline.com  17  SECTION THREE: CONCLUSIONS AND RECOMMENDATIONS   Overall Conclusion   3.1 Baby Q was seriously injured whilst in the care of both parents at the age of three weeks. There was no evidence available to the professionals that visited the parental home that either parent might physically harm Baby Q.  Midwifery and Health Visiting Professionals did recognise the parent’s vulnerability and offered additional support. This resulted in seven visits during the first three weeks of Baby Q’s life.   3.2 The second hospital admission for Baby Q was a potential missed opportunity to explore the circumstances of Baby Q in more detail, given that this was an injury to a non-mobile baby, which was initially considered as a potential safeguarding concern. There were no immediate concerns about the presentation of the parents or their response to the needs of Baby Q. The injury was assessed as accidental and exacerbated by dry skin, the move from safeguarding concerns happened without consultation with the original assessing Doctor, or any other professionals. The planned strategy Meeting did not take place and so all available information was not evaluated in a multi-agency context. This was not effective safeguarding practice.  3.3 The conclusion of this review is that there was little evidence that indicated that the harm to Baby Q could have been predicted or prevented.  There are lessons that can be learned, and these are outlined below alongside some notable practice and recommendations.    Notable Practice  3.4 The Community Midwife recognised Mother’s vulnerability because of reported substance misuse and lack of engagement with antenatal care and made a referral to the Specialist Midwife.  3.5 The Specialist Midwife responded promptly to this referral and when she could not make contact with Mother or Father, she made a referral to Children’s Social Care and liaised well when Mother or Father could not be located. There was evidence here of good information sharing between the two agencies.  3.6 The midwifery and health visiting services both recognised the family’s vulnerability and this resulted in Baby Q and the parents being seen more regularly.   3.7 An Initial Assessment was carried out in a timely manner. The referrer was kept informed.   3.8 Doctor 5 took appropriate action regarding an unexplained injury in a non-mobile baby, consistent with national and local practice.  18  3.9 Police Officer 1 undertook appropriate enquiries regarding Baby Q’s circumstances. It was good practice that the change in diagnosis was followed up directly with Doctor 8; there was appropriate challenge regarding the reasons for the change in diagnosis, and Doctor 8 was asked to provide written records to confirm the medical diagnosis.   Lessons Learned  The Importance of formal and Planned Joint Health working within the Early Help Response  3.10 Pregnancy and the first years of life are where the foundations of the future health and wellbeing of children are laid down. There is good evidence24 that the outcomes for both children and adults are strongly influenced by the factors that operate during pregnancy and the first years of life. The Midwives and Health Visitor did recognise these parents’ vulnerability, and provided an appropriate enhanced level of provision. They did not have a handover because of the lack of early antenatal care and although they shared similar concerns, they did not formulate a joint plan of action to address the early vulnerabilities.    Recommendation One: Where parents are assessed as requiring enhanced midwifery services and health visiting services, health professionals should ensure that interventions and approaches are effectively coordinated and formally planned.   Recognition of the Risks Posed by Lack of Early Antenatal care  3.11 There is general recognition that poor engagement with antenatal care is a potential risk factor for the health and wellbeing of mothers and babies25. This was recognised by the Midwives who saw Mother, but meant that there was a missed opportunity for there to be a handover between the Community Midwife and Health Visitor because this usually occurred at 28 weeks gestation. New arrangements are now in place and there is now an automatic process for notifying the health visiting services of antenatal booking as soon as it happens, regardless of the stage of pregnancy.    Recommendation Two The Midwifery service should provide an update to the Blackpool Safeguarding Children Board of progress of the new process for notifying Health Visitors of all pregnancies in the context of late booking and/or poor engagement with antenatal care.                                                          24  Cuthbert, et al (2011) ‘All babies count: prevention and protection for vulnerable babies: a review of the evidence’ NSPCC  http://www.nspcc.org.uk/Inform/resourcesforprofessionals/underones/all_babies_count_pdf_wdf85569.pdf 25  Cuthbert, et al (2011) ‘All babies count: prevention and protection for vulnerable babies: a review of the evidence’ NSPCC http://www.nspcc.org.uk/Inform/resourcesforprofessionals/underones/all_babies_count_pdf_wdf85569.pdf 19  Addressing early risk Factors in the Antenatal and Postnatal Period 3.12 The Healthy Child programme26 highlights the importance of recognising maternal and paternal risk factors in the antenatal and immediate postnatal period. Information about the impact of stress and depression as well as domestic abuse in pregnancy makes early intervention and prevention important. It is critical that mothers and fathers are asked through pregnancy and the early years about mental health, substance misuse and domestic abuse and guidance27 provides a structured framework for this at key stages.  Domestic Abuse 3.13 Research28 suggests that the risk of women being subject to domestic abuse is heightened when they become pregnant or immediately after childbirth and the potential impact on the baby and mother is significant. It is essential that all professionals in contact with pregnant women and new born babies should routinely ask about domestic abuse and be prepared to offer support and guidance, alongside recognition of the risks posed.   3.14 Mother spoke to her General Practitioner (GP) before pregnancy about domestic abuse, but this information was not included in the antenatal referral and no other professionals were aware of this as a potential concern.   3.15 This Review has highlighted the need to review the use of routine enquiry. The Department of Health announced the introduction of Routine Enquiry regarding domestic violence in all health settings within an agreed framework in 200529 suggesting all services should now be working towards this goal.  3.16 Midwife 1 asked Mother about domestic abuse and she reported that this was not an issue. Mother has said during this Review process that she does not recall being asked.  It is important to continue to ask women who may be wary of telling professionals, for fear of the repercussions for themselves and any children. They may be under scrutiny from a controlling and volatile partner which causes such stress that women are not clear they have been asked30. In this case there is no evidence that Mother was ever asked again. There is some evidence that the Community Midwives and the Health Visitor may have been hampered by the presence of Father in the home, but this should have been recorded and a plan of action for when Mother could be seen alone.                                                        26  Department of Health (2009) ‘Healthy Child Programme; Pregnancy and the first five years of life’  https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/167998/Health_Child_Programme.pdf 27  NICE Clinical Guideline (2007) ‘Antenatal and postnatal mental health: clinical management and service guidance’ http://www.nice.org.uk/guidance/cg45  28  Lewis, Gwynneth, Drife, James, et al. (2001) ‘Why mothers die: Report from the confidential enquiries into maternal deaths in the UK 1997-9’, commissioned by Department of Health from RCOG and NICE (London: RCOG Press) 29 DOH (2005) ‘Responding to domestic abuse: a handbook for health professionals’, Department of Health 30 Cuthbert, et al (2011) ‘All babies count: prevention and protection for vulnerable babies: a review of the evidence’ NSPCC http://www.nspcc.org.uk/Inform/resourcesforprofessionals/underones/all_babies_count_pdf_wdf85569.pdf   20   3.17 Mother reported in the interview as part of the Review process that she was only asked by Social Worker 1 in the Initial Assessment process about domestic abuse, and this was when Father was present. This was not safe practice. She does not recall being asked by the midwife.  Mother said that even if she had been asked she probably would not have disclosed and said that the involvement of so many professionals might have been a potential barrier, and did not have time to form a relationship of trust with them. However, Mother stated she was aware that help and support was available to her if she was able/willing to accept it.   Parental Mental Health  3.18 Mother sought help from her General Practitioner (GP) for depression in the months before she was pregnant. She was prescribed anti-depressants and offered counselling, which she refused. The information about depression was included in the antenatal referral but not shared with Blackpool midwives. This meant the information was not available to professionals in the antenatal or postnatal period. Mother was asked by some of the Midwives she saw about her current and past mental health but this was not consistently carried out as would be expected by Healthy Child Programme and the opportunities were limited by Mothers lack of antenatal care.  3.19 Neither Mother nor Father was asked about their mental health during the Initial assessment.   Substance Misuse 3.20 Mother told the Community Midwife who she saw when she was booked for her pregnancy that she used cannabis, and a referral was made to the Specialist Midwife. The information about cannabis use was shared in the referral to Children’s Social Care, but this information was not available to the assessing Social Worker because of an administrative error. Regardless of this, it would be expected that this would have been covered in the Initial Assessment.  There is no evidence that any of the Midwives who saw Mother or Father asked about substance misuse.   Recommendation Three  All professionals need to ensure that parents are routinely asked about domestic abuse, parental mental health and substance misuse when undertaking assessments, planning interventions and delivering services in the antenatal, postnatal period and beyond.  Recommendation Four All professionals need to be reminded about the importance of ensuring that it is safe and appropriate to ask about domestic abuse, and to ensure that where it is not safe to do so this is recorded, and follow up enquiries are planned and conducted where appropriate.    21  Addressing Parental Self report 3.21 In this case, the parents’ own version of events was often accepted by professionals without triangulating with other sources such as professional information or records. Mother was able to tell maternity services that she had accessed care and had been denied a booking in process because the Midwife did not turn up, an inconsistency that was not challenged. During the initial assessment Mother and Father’s view about why they had not accessed midwifery care were reported without challenge, despite there being discrepant evidence regarding this.   Recommendation Five  Professionals working with families need to ensure they do not become over reliant on parental self-reporting. Agencies need to ensure that the current mechanisms in place to support effective professional practice such as supervision, management oversight, training and audit recognise the issue of parental self-report and the risks associated with professionals being over-reliant on it.    Differential Diagnosis of Deliberate Harm  3.22 When Baby Q was seen in hospital on the second occasion it was appropriate that there was an initial diagnosis of an unexplained injury in a non-mobile baby. Action was taken in line with national and local guidance.  Although a clear plan was outlined in the notes, the safeguarding action required from Doctor 8 who took over Baby Q’s care the next day was unclear and unrecorded, and was further hampered by the lack of a face-to-face discussion between the Doctors. There was also no discussion with a Designated Safeguarding professional or any other agencies before the decision to discharge was made. These are all requirements of the Lord Laming Recommendations and the NICE Guidelines regarding identification of deliberate harm.  Recommendation Six Hospitals must ensure that where there are concerns regarding non-accidental injury that there is a clear handover process, and that all Doctors fully record the rationale for decisions and actions and that these are communicated effectively.   Professional awareness of the need for robust analysis of a move from a diagnosis of safeguarding to a purely medical cause 3.23 In this case it is not clear whether all professionals were aware of the responsibility of all professionals to follow the requirement of the Lord Laming Recommendations/NICE guidance when there is a difference in diagnosis from the suspicion of non-accidental injury to a medical cause. In this case the decision to halt the strategy discussion was made without ensuring that the Laming Recommendations had been followed.  Recommendation Seven All agencies must ensure the implementation of the requirement outlined in the Lord Laming recommendations/NICE guidelines regarding the process to be followed in the event of a change of diagnosis from one of a suspected non-accidental injury to a medical cause. The expectation that all staff should consult with each other and triangulate their information should enable robust professional challenge. Where a direct handover is not possible between hospital doctors, full consultation with other 22  agencies is expected prior to any change in diagnosis. Likewise, child protection processes/ strategy discussions should not be ended until compliance with Laming has been assured.  Information sharing in the antenatal period  3.24 The General Practitioner (GP) in the Wirral was aware that Mother had experienced both physical and emotional abuse, as well as experiencing low mood. The issue of low mood was included in the antenatal referral; the domestic abuse was not, meaning this risk factor was lost.  Recommendation Eight General Practitioners in the Wirral need to ensure that all vulnerability factors are fully reported on antenatal referral forms. The Blackpool Safeguarding Children Board needs to be assured that practice in Blackpool in this area is effective also.  The transfer of Midwifery care 3.25 The midwifery service in the Wirral were told by Mother that she was moving to Blackpool, but there is no evidence that contact was made with the Blackpool midwifery service or that the Wirral checked that Mother was receiving care in the new locality. The Community Midwife in Blackpool did make contact with the Wirral when Mother was eventually seen, but was not informed about the reference to Mother’s low mood.      Recommendation Nine The midwifery transfer arrangements in the Wirral should be reviewed to ensure that all information is shared with the receiving service and is robust. The Blackpool Safeguarding Children Board needs to be assured that practice in Blackpool in this area is effective.  Checks about whether families have been previously been known to Children’s Social Care 3.26 Baby Q was known sometimes by Father’s surname and at other times by Mother’s surname prior to and after birth. When a search of Children’s Social Care records was carried out at the time of the Strategy Discussion those involved in decision-making at this time were unaware of the previous involvement or that an Initial Assessment had previously been completed.  Recommendation Ten Agencies must consider what mechanisms could be put in place to reduce the risk of confusion arising as a result of the recording of multiple surnames occurring in the future.   Access to General Practitioner care during pregnancy when Parents do not live in permanent accommodation  3.27 Mother reported when interviewed as part of this Review that she was unable to register with a General Practitioner (GP) because she lived in temporary/holiday accommodation. It has not been possible to establish if this was the case, but the 23  Blackpool Safeguarding Children Board needs to be assured that living in temporary/holiday accommodation does not preclude parents and/or children from registering with a GP.   Recommendation Eleven  Blackpool Safeguarding Children Board should seek assurance that parents and/ or children who reside in temporary accommodation are able to register with a GP.     24  Appendix  Serious Case Review Process and Methodology  Blackpool Safeguarding Children Board (BSCB) discussed this case at a Case Review Sub Group in 2013 and agreed that it met the criteria for a serious case review.  Regulation 5 of the Local Safeguarding Children Boards Regulations 2006 sets out the requirement for Local Safeguarding Children Boards to undertake reviews of serious cases where:  (a) Abuse or neglect of a child is known or suspected; and  (b) Either (i) the child has died; or (ii) the child has been seriously harmed and there is cause for concern as to the way in which the authority, their Board partners or other relevant persons have worked together to safeguard the child.   It was initially planned that this review would be undertaken using the Learning Together Framework designed and implemented by the Social Care Institute for Excellence31.  However, this was not possible because of the on-going criminal proceeding, which meant Baby Q’s parents, and professionals could not be interviewed until the trial had finished. It was agreed that the review would be carried out in two stages.    Stage One:  During the first stages of the review there was a full analysis of the case records held by each agency including a critical incident report undertaken by Hospital 2.  There were delays in accessing some records, however, all necessary records were provided by agencies covering the review period.  Stage 2 When the criminal trial was concluded interviews (face to face or telephone) were undertaken with Baby Q’s Mother and professionals who had had significant involvement. These included:  Consultant Paediatricians   Police Officers 1 & 2  Social worker 1 & 2  Specialist Midwife  GP  Midwifery services area 1  It was not possible to interview the Health Visitor or the Paediatric Registrar as both had left their posts.  Although the review has not been determined by any particular theoretical model it has been carried out using the principles outlined in Statutory Guidance (Working Together  201332). Therefore in both stages the review has sought to:                                                       31 Fish, S. Munro, E. Bairstow, S. (2008) ‘Learning Together to Safeguard Children: developing a multi-agency systems approach for case reviews’. Social Care Institute for Excellence (SCIE) London 32 Department for Education (2013) ‘Working Together to Safeguard Children – a guide to interagency working to safeguard and promote the welfare of children.’ https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/281368/Working_together_to_safeguard_children.pdf 25   Recognises the complex circumstances in which professionals work together to safeguard children;   Understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did;   Understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight.  Time Period  The time period under review is from when this Mother’s pregnancy was confirmed by her General Practitioner to the day of the critical incident.  All dates have been removed in order to anonymise the report.   Membership of the Serious Case Review Panel: The Panel was made up of senior multi agency representatives from across Blackpool who had no direct involvement with Baby Q or the family. They worked with the Independent lead reviewer to analyse the case material, collect and contribute to information about organisational context, strategy, resources and local policy and were central to the writing of the report, its conclusions and findings.  The Review Team met throughout the process, and they made comment on all draft versions of the report.  At the final stage of phase 1 of the review process, the panel recognised that input from Hospital 2 was required and a representative joined the panel.  At this stage the Principal Social Worker was appointed as Chair of the panel.  Role Agency Principal Social Worker Children’s Services Designated Doctor Fylde and Wyre Clinical Commissioning Group Designated Nurse Blackpool Clinical Commissioning Group Service Manager  Safeguarding, Quality and Review Children’s Services Business Development Manager BSCB Review Officer Lancashire Constabulary Head of Safeguarding Blackpool Teaching Hospitals NHS Foundation Trust  About the report author  Jane Wiffin, independent lead reviewer is a qualified Social Worker who has extensive experience of working in safeguarding; she is an experienced SCR author and chair. Jane Wiffin is an accredited as a SCIE Learning Together Reviewer and has undertaken a number of reviews using this methodology and is independent from all the agencies involved in this review. 