Death of a less than 1-year-old girl from a serious head injury. Child A was in the care of her paternal aunt when the incident took place. Aunt was found guilty of manslaughter and given a custodial sentence. Prior to the birth of Child A, the paternal aunt had left her own children, Child B aged 9-months and a 2-year-old, unsupervised leading to an unwitnessed fall and head injury to Child B. Child B was admitted to the children's ward; the injuries were minor and no treatment was required. Children's Social Care was notified but the case was closed. Ethnicity or nationality is not stated. Learning: in cases of injury to a child, where the care givers do not speak English, an interpreter must be used once the immediate medical needs of the child have been attended to; if Children's Social Care are notified of an incident for information only, the rationale for this and any expected response needs to be explicitly recorded; cases should not close to Children's Social Care when there is agency feedback outstanding. Recommendations: to consider a revision to procedures regarding injuries to mobile and non-mobile babies; to undertake work regarding accessibility of child health information in other languages; for agencies to be clear regarding recording of discussions held between agencies so professionals agree what is to be recorded, what action is to be completed, by whom and in what time frame; to raise awareness with parents and carers of how to seek emergency services.
      
 Title:  Serious case review overview report: subject: Child ‘A’ 2015. LSCB: Leicestershire and Rutland Safeguarding Children Board Author: Hayley Frame Date of publication: 2018  This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC.  This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above.                           Published 5.6.18 1                 Serious Case Review    Overview Report  Subject: CHILD ‘A’ 2015                                Published 5.6.18 2  1. Decision to hold a Serious Case Review   1.1. Regulation 5 of the Local Safeguarding Children Boards Regulations 2006 sets out the functions of LSCBs. This includes the requirement for LSCBs to undertake reviews of serious cases in specified circumstances. A serious case is one 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.    1.2.  This review has been initiated following a referral to the Leicestershire and Rutland Safeguarding Children Board Serious Case Review Subgroup on 31st March 2015 following the death of CHILD ‘A’ earlier in 2015.  1.3. In  2015, the Subgroup recommended that a Serious Case Review be completed in respect of CHILD ‘A’ and the decision to complete a Serious Case Review was made by the Independent Chair of the Leicestershire and Rutland Safeguarding Children Board. 2. Parallel Processes 2.1. The paternal aunt of CHILD ‘A’ was found guilty of her manslaughter and sentenced to a number of years imprisonment.  2.2. Public law proceedings were issued in respect of the children of the paternal aunt and supervision orders were made. These orders have now expired and the children remain in the care of their father.  3. Scoping period  3.1. The chronology of events is from the date of CHILD ‘A’s birth in 2014 until the date of the incident in 2015.    3.2. The SCR will also include the circumstances and resulting investigations in respect of a specific incident that occurred in 2013 involving the same paternal aunt, and her nephew, who for the purpose of this review is known as CHILD ‘B’.CHILD ‘B ’received a head injury during this incident.  4. Lead Reviewer   4.1. Hayley Frame, Independent Safeguarding Consultant, has been commissioned as the lead reviewer in this case.   5. Organisations involved in the review  5.1. Chronologies were commissioned from:  Leicestershire County Council Children & Family Services Leicestershire Partnership NHS Trust University Hospitals of Leicester NHS Trust General Practice Leicestershire Police  Published 5.6.18 3 6. Methodology  6.1. Agencies with knowledge of the family were asked to complete a chronology and appraisal document which was then merged into a multi-agency chronology of involvement.   6.2. Practitioner perspectives, involving those practitioners with direct involvement with the family, were sought and a questionnaire sent out for completion. Practitioners were asked to consider the following points:    What was the nature of your involvement with the family?  What were your impressions of the family?  How would you describe the individuals within the family?    Were there any events of significance during your involvement?  Were there any language barriers?  Any other comments you would like to share with the SCR Panel?   6.3. This overview report was considered by a serious case review panel consisting of the lead reviewer and agency representatives and was also circulated to the practitioners for their comments.    7. Terms of Reference  The following terms of reference were agreed for the Serious Case Review:   7.1. What were the key relevant points/opportunities for involvement, assessment and decision making in this case in relation to the child and family?   7.2. Do assessments and decisions appear to have been reached in an informed and professional way?    7.3. Were practitioners aware of and sensitive to the needs of the child in their work, knowledgeable about potential indicators of abuse or neglect, what to do if they had concerns about a child’s welfare and to consider the voice of the child?  7.4. Was information recorded, shared and analysed appropriately?  7.5. Were senior managers or other organisations and professionals involved at points in the case where they should have been? Was there sufficient management accountability for decision making?  7.6. Was the work in this case consistent with each agency and the LSCB’s policy and procedures for safeguarding and promoting the welfare of children, and with wider professional standards?  7.7. Were there difficulties being experienced within or between agencies? Were these due to a lack of capacity in one or more organisations? Was there an adequate number of staff in post?  7.8. Did any resourcing issues such as vacant posts or staff on sick leave have an impact on the case? Published 5.6.18 4  7.9. What do we learn from this case?  7.10. How do we assure ourselves that information is understood when working with families where there is a language barrier?   7.11. What information is given by universal services regarding how to contact emergency services when there is a language barrier?  7.12. What is the professional view of the quality of parenting and is this recorded within the records?   8. Involvement of family members   8.1. The involvement of family members, and specifically CHILD A’s parents, was sought as part of this Serious Case Review, including correspondence being produced in their own language. They have not wished to be part of the process.   8.2. It is the view of the Police and Children’s Social Care that the family have struggled to come to terms with what happened to CHILD ‘A’. This was also reflected in the statement that CHILD ‘A’s father provided to the Judge as part of the criminal proceedings, which expressed the whole family’s love for the paternal aunt, despite her conviction. The paternal aunt’s sentence was reduced as a result.    9. Perceptions of the family   9.1. The community midwife described CHILD ‘A’s parents as a nice, friendly couple who were easy to work with. They attended all appointments and asked relevant questions. Although language was a barrier, Interpreter Services was used to communicate with them. The midwife felt that the parents had a good family support network close by.  9.2. One health visitor who had contact with the family and saw them in clinic described the parent’s relationship with CHILD ‘A’ in positive terms, in that both parents were observed to talk and communicate with CHILD ‘A’ who responded with smiles and babbles. CHILD ‘A’s father was noted to ask appropriate questions. With regard to language, the health visitor reported that CHILD ‘A’s father was able to answer her questions and translate for the mother. The health visitor was of the view that both parents were aware of how to access the health visiting service and how to book a clinic appointment if required.      9.3. The GP for the family reported that during his contact with the family, both parents seemed appropriately concerned for CHILD ‘A’s welfare and were attentive to her. He used Interpreter Services to communicate with the parents.         Published 5.6.18 5   10. Case Narrative   NB: Author comment is in bold  Although this SCR is in respect of CHILD ‘A’, events prior to her birth in relation to her cousin ’CHILD ‘B’ form the initial part of the scoping period.    10.1. In early 2013, CHILD ‘B’, aged 9 months, attended the Emergency Department after an unwitnessed fall and head injury to the back and to the front of his head. The incident had reportedly occurred at 8 pm. An interpreter was not used in the Emergency Department, but the initial story suggested that CHILD ‘B’s mother had gone to the restaurant next door and left CHILD ‘B’ and a two year old cousin alone. The child was admitted to the children’s ward the next day for further review and investigation.   10.2  The Consultant Paediatrician undertook an assessment of CHILD ‘B’ including the completion of a full body map and spoke to both parents using telephone interpreting services. The history given was that it was the paternal aunt who had care of the children. The Consultant Paediatrician then spoke to the paternal aunt on the telephone, again using telephone interpreting services, to obtain a sequence of events. The paternal aunt stated she had left CHILD ‘B’ and her own child in a room whilst she went to the toilet. CHILD ‘B’ was stated to have fallen out of a low seat onto toys on the floor. The Consultant Paediatrician deemed the reported mechanism to be consistent with the injuries seen to the head and therefore deemed the injuries to be accidental in nature. The injuries were minor and no treatment was required. CHILD ‘B’ was discharged home with parents with a plan for the health visitor to be informed of the admission.  10.3 The UHL Safeguarding Children Team notified Children’s Social Care for ‘information only’ by fax and the health visitor by electronic notification of the attendance on the next working day, 3 days following the event. The G.P. was sent a standard notification of attendance to the hospital by the Emergency Department and the Children’s Hospital, and a copy of the Consultant Paediatrician's medical report was sent to the G.P.  The records indicate that it was difficult to communicate with the family, but through the use of Interpreter Services more information was obtained. Two versions of events were provided with regard to the injury, one being elicited with the use of an interpreter.    The review has established that the hospital’s safeguarding team received a referral from the Emergency Department on the Friday evening by phone message and faxed referral form, and this was picked up by the Safeguarding team on the Monday morning, hence it being received 3 days later. In the interim period, CHILD ‘B’ had been seen by the Consultant Paediatrician who did not feel that there were any safeguarding concerns. Had she determined that this was a safeguarding matter, then a referral would have been made to the Children’s Social Care Emergency Duty Team over the weekend.   There is an error on the LSCB referral form, completed in the Emergency Department, in that the name of mother is recorded as the child’s, although Published 5.6.18 6 the mother’s date of birth and address are correct. It is difficult to establish from the referral from the actual date of the incident and the names of the adults who were indicated as having care of CHILD ‘B’ when he was injured. The referral focused on physical harm and did not record any concerns relating to possible lack of supervision.  The rationale for the notification to Children’s Social Care being for information only rather than a referral is not recorded. The review has established that the agreed process for referrals to Children’s Social Care by the hospital was not followed in this case. The process, that is well established, works on a ‘traffic light’ safeguarding system, with red for child protection concerns, yellow for lower level safeguarding, and green for ‘information only’. Once the hospital safeguarding team received the information on the Monday morning and reviewed the clinical notes, the initial concern of the Emergency Department was reduced and the case became ‘information only’ i.e. a green case.  In this scenario, as with all ‘green’ cases, the matter should have been recorded on the hospital’s safeguarding electronic notes system and the health visitor notified and no further action taken. The decision to share the information with Children’s Social Care ‘for information only’ would not be expected in such a case.  Changes in practice: The hospital safeguarding referral form has now replaced the LSCB referral form and contains prompts for more relevant information.   10.4 As a result of the notification a Duty Social Worker spoke with the Health Visitor the next day. The Health Visitor informed the Duty Social Worker that the injury consisted of red patches to CHILD ‘B’s head. It was recorded by the Duty Social Worker that CHILD ‘B’ and his parents lived in a flat above a Chinese restaurant and the aunt lived two doors down.  CHILD ‘B’ was being cared for by his aunt and she went to the toilet, leaving CHILD ‘B’ and her own two year old child unsupervised and when she came back she noticed the marks.   10.5 The Health Visitor described the family as lovely, that she saw the mother and aunt regularly in clinic but that the family were difficult to understand as they spoke very limited English. The Health Visitor reported having observed the mother of CHILD ‘B’ to be caring. The Health Visitor did not have any concerns regarding supervision but did raise the issue of cramped home conditions. It was recorded in the social care record that the Health Visitor would visit the family and notify social care if she had any concerns. This agreement is not recorded within the Health Visiting records. The Health Visitor recorded that the expectation was that the case would close to social care.   The agreement with the Health Visitor regarding a potential visit is not reflected in both agency records of the same conversation.   10.6 Given the lack of supervision and two injuries to the front and back of CHILD ‘B's head, it was decided that Children’s Social Care would progress to an assessment.  The Duty Social Worker spoke to a safeguarding nurse at the hospital who advised that the only reason for the referral to Children’s Social Care was due to a concern regarding a lack of interpreter being used in the Emergency Department and therefore miscommunication in respect of the injury. The Published 5.6.18 7 Consultant Paediatrician saw the child and was happy with the explanation. She had no concerns or suspicions.   10.7 A few days later, the Duty Team Manager questioned why the incident had been sent through for referral and decided that given that the agency checks had not presented any concerns and the child had been reviewed by a doctor; there did not appear to be any child protection concerns regarding the injury and the case would therefore close.    The case was closed without knowing the outcome of any subsequent Health Visitor contact with the family and the decision to close was not fed back to the Health Visitor.   10.8   In early 2014, the mother of CHILD ‘A’ presented at her antenatal booking appointment.  Interpreter Services was used to take the booking history. Antenatal care progressed appropriately, and Interpreter Services was used during appointments.   10.9 In mid-2014, the paternal aunt gave birth to a male child. About a month later, CHILD ‘A’ was born.   10.10 The next day a post-natal check was undertaken by a midwife to CHILD ‘A’ and her mother, whilst still in hospital. It was recorded that there were some difficulties regarding the language barrier as the mother did not speak English. It was also recorded that the father spoke a small amount of English and was able to translate. Physical checks were all normal and CHILD ‘A’ was breast feeding regularly.   10.11 Also on the same day it was noted that the Grandmother of CHILD ‘A’ was observed feeding the baby rice from a spoon. Using Interpreter Services the midwife was able to explain to the mother that it was not safe to feed CHILD ‘A’ anything other than breast milk or formula milk. The hospital safeguarding team were informed as a matter of course. As a result of CHILD ‘A’ being fed rice, a medical review was requested and it was decided that mother and baby would remain in hospital overnight to monitor for potential signs of vomiting or aspiration. The following day they were discharged home.   10.12 A few days later, a post-natal visit was completed by a midwife. The midwife commented on difficulties with language barrier but felt that the mother understood.   It would appear that no interpreter services were used.   10.13 A few days later, the Health Visitor completed a birth visit accompanied by an interpreter. It was recorded that there was no reported history of parental drug use or domestic violence. The parents were enjoying the baby and stated that they had a supportive extended family and friends nearby. A Mongolian blue spot was observed on the sacral area and small red mark on the back of CHILD ‘A’s head was described as strawberry birth mark.  A body map was completed for the Red Book children’s health record. It was recorded that the family lived in a flat above Published 5.6.18 8 the paternal grandmother’s shop. The father worked in the kitchen of his mother’s shop and the mother was likely to start working there again after a few months.  10.14 A further visit took place later the same month. The Health Visitor documented that she observed that CHILD ‘A’ was not strapped into her bouncy chair. She advised the parents to ensure that CHILD ‘A’ was strapped into her bouncy chair when put down to rest and warned that babies give no warning of when they can roll over.  10.15 Two weeks later, the mother took CHILD ‘A’ to see the GP as she was vomiting after feeds. An interpreter was used. Probable reflux was diagnosed and Gaviscon was recommended, with a plan to review in one week. A week later the mother went back to the GP with CHILD ‘A’ and described the vomiting as having settled. Again an interpreter was used.   10.16 A month later, CHILD ‘A’ was seen by the Practice Nurse due to a mild upper respiratory tract infection. It was recorded that an interpreter was not required and a clear history was obtained.    10.17 The next month, a four month health visiting visit was completed. It was recorded that positive interaction was observed between the mother and baby. The universal assessment was completed, no concerns were raised, and therefore no further contact was planned. The mother was advised to contact the Health Visitor if any further support was needed.  10.18 CHILD ‘A’ was taken to the GP by her mother the following month. Interpreter Services was used. CHILD ‘A’ had a febrile illness. Blood tests were arranged. The following month, CHILD ‘A’ was seen again by the GP in the company of her mother. CHILD ‘A’ was described as alert, orientated, smiley and happy in her mother’s arms. Interpreter Services was used and a further febrile illness diagnosed. CHILD ‘A’ was also vomiting after food and gastro-oesophageal reflux was diagnosed. Gaviscon was again prescribed and the mother advised to return if it did not settle with treatment.   10.19 Just over a week later, CHILD ‘A’ was seen in the health visiting clinic, with both of her parents. It was recorded that all was well with the baby, and that the parents had no concerns. The parents stated that CHILD ‘A’ was just getting over a cold, but was quite well that day and did not have a temperature. CHILD ‘A’ was described as being dressed in clean and appropriate clothing, handled gently and in a caring manner by both parents.  The Health Visitor has described the father’s English as broken but that they could understand each other. She said she would have stopped the consultation if she had felt that interpreting services were required.  10.20 Three weeks later, a telephone call to phlebotomy service was made by the father who stated that CHILD ‘A’ was now well and therefore there was no need for blood tests. Published 5.6.18 9  10.21 On the day of the incident to CHILD ‘A’ in 2015 a 999 call was made by a distressed female now known to be the mother of CHILD ‘A’. Due to a language barrier the Operator was unable to understand which service was required so put call through to the police. There was a problem understanding exactly what service was required but it was established that it was an ambulance. A male, now known to be the father of CHILD ‘A’, came on to the phone who was equally distressed but then an English speaking male came onto the phone and advised that the baby was ill but had now been taken to hospital.    10.22 CHILD ‘A’ was subsequently admitted to Birmingham Paediatric Intensive Care Unit with a serious head injury.  The paternal aunt was arrested the next day. CHILD ‘A’ died three days later. She was later convicted for causing the death of CHILD ‘A’    11 Analysis  11.1 What were the key relevant points/opportunities for involvement, assessment and decision making in this case in relation to the child and family?   11.2 The review has determined that there were no relevant opportunities for involvement, assessment and decision making in relation to CHILD ‘A’. All contacts were appropriate and in line with agreed policy and procedures. There were no concerns in relation to CHILD ‘A’.   11.3 With regard to the incident involving CHILD ‘B’ in 2013, the review has considered whether the agency responses could have been more robust. It would appear that the Consultant Paediatrician was satisfied with the explanation provided by the family members once an interpreter was used. The earlier account was given in the Emergency Department and an interpreter was not used. This then led to a concern regarding two accounts for the injury. The second explanation, given that an interpreter was used, was understandably given more credibility.   11.4 Learning: In cases of injury to a child, where the care givers do not speak English, an interpreter must be used from the earliest opportunity after the immediate medical care needs of the child have been attended to.    11.5 The injury did not trigger a referral to Children’s Social Care as the Consultant Paediatrician did not identify any safeguarding concerns. The review has established that the hospital’s safeguarding team received a referral from the Emergency Department on the Friday evening by phone message and faxed referral form, and that this was picked up by the Safeguarding team on the Monday morning. In the interim period, CHILD ‘B’ had been seen by the Consultant Paediatrician who did not feel that there were any safeguarding concerns.   Published 5.6.18 10 11.6 Children’s Social Care were then notified of the incident, for information only, three days later. The purpose of this notification is unclear and not in line with the agreed referral process within the hospital. In line with the hospital safeguarding procedure, the matter was categorised as ‘green’ and therefore for information only and should have been shared only with the health visitor. Had the process been followed the circumstances of CHILD ‘B's admission would not have been passed on to children’s social care.   11.7 Learning: If Children’s Social Care are notified of an incident for information only, the rationale for this, and any expected response, needs to be explicitly recorded by the professional making the notification.   11.8 Upon receipt of the notification, Children’s Social Care decided initially that the case warranted an assessment. A telephone discussion took place with the allocated Health Visitor. The Health Visitor was already aware of the incident, having been notified directly by the hospital.  11.9 Within the agency records, there is a discrepancy between that of the Duty Social Worker and the Health Visitor recordings of that conversation. The Duty Social Worker recorded that the Health Visitor was to complete a visit and feedback if she had any concerns. This is not reflected in the Health Visiting records.   11.10 Learning: When agreeing a course of action, professionals must agree what is to be recorded, what action is to be completed, by whom and in what timeframe.   11.11 It would appear that this conversation in part influenced the decision to close the case to Children’s Social Care. An assessment was not completed, and given that the Health Visitor did not follow up the matter, there were no further investigations into the incident by any agency. That said, there is nothing within agency records to indicate that there were any subsequent concerns relating to the family, including the aunt who went on to have another child within the scoping period.   11.12 Do assessments and decisions appear to have been reached in an informed and professional way?    11.13 There are no documented assessments within the scoping period. The Consultant Paediatrician was satisfied with the explanation given in respect of CHILD ‘B’s head injury.   11.14 The Team Manager within Children’s Social Care decided to close the case without an assessment being completed. The rationale for this was recorded as being that the agency checks did not present any concerns and the child had been reviewed by a qualified doctor, therefore there did not appear to be any child protection concerns regarding the injury. Whether the Team Manager could have shown a greater degree of professional curiosity or critical challenge has been considered by the review. It is evident that the Team Manager was guided by the Published 5.6.18 11 view of the Consultant Paediatrician who had seen the child. The decision to close the case would appear to be appropriate.  11.15 The case was closed however without any feedback from the Health Visitor whom Children’s Social Care were expecting to complete a visit.   11.16 Learning: Cases should not close to Children’s Social Care when there is agency feedback outstanding and agencies must be clear of the expectations of them following discussion with Children’s Social Care.  11.17 Were practitioners aware of and sensitive to the needs of the child in their work, knowledgeable about potential indicators of abuse or neglect, what to do if they had concerns about a child’s welfare and to consider the voice of the child?  11.18 There were no concerns regarding the welfare of CHILD ‘A’. Agency contact with her was appropriate and in line with expected practice.   11.19 The agency responses in respect of CHILD ‘B’ were appropriate. A referral to children’s social care was not required, but a notification ‘for information only’ was sent. This was not in line with hospital policy but did then trigger the start of an assessment by children’s social care. The decision to end the assessment and close the case was appropriate given the absence of indicators of abuse or neglect.   11.20 Was information recorded, shared and analysed appropriately?  11.21 There is evidence of information sharing between health and Children’s Social Care in relation to CHILD ‘B’. The UHL notification record lacked detail and contained inaccuracies. The UHL notification was sent to children’s social care for information only, which is not excepted practice. The UHL notification should only have been sent to the health visitor.    11.22 There were no areas of concern in relation to recording or sharing of information in respect of CHILD ‘A’.    11.23 Were senior managers or other organisations and professionals involved at points in the case where they should have been? Was there sufficient management accountability for decision making?  11.24 CHILD ‘B’ was seen by a Consultant Paediatrician which was appropriate given the injury.   11.25 There is evidence of management accountability within Children’s Social Care in that the Team Manager recorded the rationale for the decision to close CHILD ‘B's case.   Published 5.6.18 12 11.26 Was the work in this case consistent with each agency and the LSCB’s policy and procedures for safeguarding and promoting the welfare of children, and with wider professional standards?  11.27 The agency involvement with CHILD ‘A’ was consistent with each agency’s policy and procedures and wider professional standards. On occasion interpreter services were not used when in contact with the family but this did not adversely impact upon the service provided.   11.28 With regard to CHILD ‘B’, an explanation for his injuries was provided which the Consultant Paediatrician considered to be an acceptable mechanism for the injuries presented.   11.29 Whether CHILD ‘B’ was mobile or non-mobile is not recorded within any community health records (although it was recorded in the hospital records), and is not referred to within the Children’s Social Care record.   11.30 Learning: In cases of bruises or injuries to children under the age of 1 year, it needs to be explicitly recorded whether or not the children is mobile, and to what degree.   11.31 Were there difficulties being experienced within or between agencies? Were these due to a lack of capacity in one or more organisations? Was there an adequate number of staff in post?  11.32 There are no identified contextual difficulties or issues regarding capacity.   11.33 Did any resourcing issues such as vacant posts or staff on sick leave have an impact on the case?  11.34 As above there are no identified resourcing issues that impacted upon the case.   11.35 What do we learn from this case?  11.36 Learning points have been identified throughout the analysis and will inform the conclusions of the review.   11.37 How do we assure ourselves that information is understood when working with families where there is a language barrier?   11.38 In most instances of contact with the family of CHILD ‘A’, interpreter services were utilised. When CHILD ‘B’ presented at the Emergency Department, no interpreter services were used. The medical needs of a child must always take priority however had interpreter services been engaged earlier, this might have avoided the concern that emerged regarding the two differing explanations regarding the injury to CHILD ‘B’.  Published 5.6.18 13  11.39 Learning: Given the availability of Interpreter Services, interpreter services should be used in all child contacts, in a timely manner, and a reliance should not be made upon a relative to translate.   11.40 The information given to parents by health visiting services is written in English. The NHS Booklet “A Guide for Parents and Carers of Children aged Birth – 5 years: Childhood health and well-being”, is available for all parents. This booklet is in English but advises that online copies are available in different languages. The websites referred to do not contain copies of the booklet in other languages. The Council website does have a link to copies in other languages but not in the language spoken by this family.   11.41 Learning: If a document is referred to being available in other languages, then it should be easily accessible on line. Consideration should be given to widening the languages available and ensuring that the booklet contains information relating to accessing emergency services.   11.42 What information is given by universal services regarding how to contact emergency services when there is a language barrier?  11.43 It is evident that in the case of CHILD ‘A’, her parents were unable to communicate the need for emergency services, specifically which service and what was the nature of the emergency. Although this sadly would not have altered the outcome, it did lead to a delay in CHILD ‘A’ being admitted to hospital.   11.44 The NHS Booklet “A Guide for Parents and Carers of Children aged Birth – 5 years: Childhood health and well-being”, does not advise parents whose first language is not English how to seek emergency help. The booklet provides details of health services contact details including NHS 111, Walk-in centre, 999.   11.45 Learning: Parents whose first language is not English, and where there is a clear language barrier, should be provided with the key words required to seek emergency services.   11.46 What is the professional view of the quality of parenting and is this recorded within the records?  11.47 There were no recorded concerns regarding the parenting of CHILD ‘A’. The parents were viewed as caring and attentive to CHILD ‘A’. They sought appropriate medical attention when she was unwell and engaged well with universal services.   11.48 The review has established that the paternal aunt gave birth to a child shortly prior to the birth of CHILD ‘A’. The paternal aunt and CHILD ‘A’s mother shared the care of both infants. This was not known to agencies at the time.  Published 5.6.18 14  12 Conclusion   12.1 There were no concerns regarding the care CHILD ‘A’ received from her parents. Agency intervention was in line with expected practice and there were no identified additional needs.   12.2 Any potential risk posed to CHILD ‘A’ by the paternal aunt was not known by agencies. CHILD ‘B’ was accidentally injured in 2013 whilst in the care of the paternal aunt. Even if this injury had required a safeguarding response, it is unlikely that it would have identified the paternal aunt as a risk of physical harm.   12.3 There were no concerns regarding children within the family prior to the incident involving CHILD ‘B’. There were no concerns reported after the injury to CHILD ‘B’ and prior to the death of CHILD ‘A’ and, in particular, there were no safeguarding concerns in respect of the paternal aunt’s children.   12.4 The learning arising from this review has been in respect of the consistent use of interpreter services and preparing parents to access emergency services when English is not their first language. In addition, it was felt that it would be beneficial to revise the procedures with regard to injuries to both mobile and non-mobile babies given that CHILD ‘B’s mobility was not consistently recorded in agency records. This learning has informed the recommendations of this review.  Recommendations  These recommendations were made in March 2016 prior to the conclusion of the criminal proceedings.   1. The LSCB should consider a revision to procedures with regard to injuries to both mobile and non-mobile babies. This will include definitions of what is mobile or non-mobile; revisions to the referral form to indicate whether a child is mobile or not; and the expected response of the key agencies: health, police and children’s social care.   2. The LSCB will seek assurance from Public Health in respect of work being undertaken regarding accessibility of child health information in other languages.   3. “The LSCB are to seek assurance that as part of the care package delivered by midwives and health visitors in the antenatal and post-natal periods to those families whose first language is not English, that professional interpreters are utilised to ensure that the families are provided with the information they need to effectively contact appropriate services in an emergency situation” 4. The LSCB will use this case as an example to highlight key messages to relevant agencies:  For agencies to be clear regarding the recording of discussions held between agencies, so when agreeing a course of action, professionals agree what is to be recorded, what action is to be completed, by whom and in what timeframe  The importance of raising awareness with parents and carers of how to seek emergency services.   Published 5.6.18 15 Action Taken   The LSCB procedures have been revised in light of the learning arising from this SCR, specifically in relation to injuries to mobile and non-mobile babies.   A new under-fives website, part of a suite of webpages for families of children and young people, is being developed by Leicestershire Partnership NHS Trust. In order for this to be accessible to as many communities as possible, DVD footage has been embedded regarding what to do if a child chokes and how to administer paediatric CPR. Consideration is being given to additional DVD footage regarding how to contact emergency services being commissioned.           