Death of a 13-week-old baby in March 2017 as the result of acute traumatic brain injury due to abusive head trauma. Father had called emergency services as baby BZ was unresponsive and not breathing. BZ admitted to hospital and injuries found to be consistent with abusive head trauma. BZ died two days later. Father was arrested for BZs murder and was found guilty in March 2018. Mother had longstanding mental health problems, learning difficulties and a diagnosis of schizoaffective disorder. Father had a history of domestic abuse in a previous relationship. BZ was subject of a Child Protection plan at birth for emotional harm. Sibling had been the subject of Child Protection plan for neglect and physical abuse. Mother was detained under the Mental Health Act and Father became the sole carer for BZ. Ethnicity or nationality of the family is not stated. Key areas of learning include: historical information and understanding its importance and relevance to on-going work should be recognised to safeguard unborn and new-born babies; the practice of waiting until mothers are 30 weeks pregnant before a multi-agency approach is adopted in cases that meet the threshold for child protection may leave unborn babies and new-born babies at unnecessary risk. Case review uses the Welsh concise model. Recommendations to the Local Safeguarding Children Board include: review the arrangement around parenting assessments to ensure they are robust; seek assurance from Children's Social Care (CSC) that all assessments are subject to oversight, challenge and scrutiny by managers within CSC; seek assurance from CSC and adult mental health services that analysis of the effects of parents behaviours on their children forms part of assessments and is evident within CP plans.
      
 Title:  Child BZ: serious case review: final report. LSCB: Blackpool Safeguarding Children Board Author: Nicki Walker-Hall Date of publication: 2018  This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC.  This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above.                                Child BZ  Serious Case Review  Final Report    BSCB Child BZ SCR FINAL 2 1 INTRODUCTION Initiation of Serious Case Review  The interim Head of Safeguarding and Principal Social Worker referred this case to the case review sub group the day before BZ’s death in March 2017. The chair of the case review sub group determined there was prima facie evidence that the case met the criteria for a Serious Case Review and called for all involved agencies to provide further information.   The chair of Blackpool Safeguarding Children Board supported the Case Review subgroup’s determination that the case met the criteria for a serious case review, on the basis that abuse and neglect were clearly evident in the period prior to the incident and BZ had died. The known facts in relation to this case met the statutory requirement, in accordance with Working Together to Safeguard Children 20151:  Abuse or neglect of a child is known or suspected and   Either a child has died; or the child has been seriously harmed and there is cause for concerns as to the way in which the authority, the board partners or other relevant persons have worked together to safeguard the child  The Department for Education and the National Serious Case Review Panel were informed. Family Composition 1.1.1 BZ was the only child of Mother and Father. Below are tables to demonstrate household composition and significant family members of BZ, Mother and Father. TABLE 1: Household composition    TABLE 2: Significant others referred to in the report                                                    1 Working Together to Safeguard Children, 2015 Chapter 4 Term used in report Relationships Age in March 2017 BZ Subject of the review 13 weeks Mother Mother of BZ 24 Father Father of BZ and Half sibling 35 Term used in report Relationships Age in March 2017 Sibling Half sibling 13 Ex-partner Half sibling’s mother  MGM Maternal grandmother  MGF Maternal grandfather  MU Maternal uncle  PGM Paternal grandmother  PA Paternal aunt  BSCB Child BZ SCR FINAL 3 Methodology 1.1.2 This review adopted the Welsh2 concise model. This formal process allows practitioners to reflect on case in an informed and supportive way. The review sought to understand:  precisely who did what through development of agency chronologies and review of relevant documentation  the underlying reasons that led individuals and organisations to act as they did through conversations with practitioners involved in the case. Where practitioners were no longer in post, managers of the services provided organisational and service context 1.1.3 A panel consisting of senior managers of the involved agencies, working with an experienced lead reviewer Nicki Walker-Hall from a health background and the independent chair of the panel the Head of Safeguarding for Blackpool Teaching Hospitals, managed the review.  1.1.4 The review looks in depth at the period from March 2016 until the death of BZ in March 2017. Agency involvement 1.1.5 The following is a list of the agencies involved with the family and the services they offered. Where abbreviations have been identified these will be used throughout the report to denote the organisation the author is referring to:  Blackpool Teaching Hospital NHS Foundation Trust  Blackpool Council (Children’s Social Care (CSC), Early Help, Adult Mental Health service, Children’s Centre, Safeguarding, Quality and Review Service)  Lancashire Constabulary  NSPCC Blackpool Service Centre  Lancashire Care NHS Foundation Trust  North West Ambulance Service  Wythenshawe Mother and Baby Unit, Greater Manchester Mental Health NHS Foundation Trust (GMMH) previously part of University Hospital of South Manchester NHS Foundation Trust  Blackpool Clinical Commissioning Group (CCG)  GP practice  NHS England The process 1.1.6 The process included:  Chronologies from all involved agencies.  A practitioner’s event to gather first-hand the experiences of the practitioners involved with BZ at the time and maximise the learning opportunity whilst informing the review process.                                                  2 Protecting Children in Wales, Guidance for Arrangements for Multi-Agency Child Practice Reviews, Welsh Government, 2012 BSCB Child BZ SCR FINAL 4  The lead reviewer was given access to key documents and assessment. The panel met on four occasions to discuss and progress the review. Timeframe 1.1.7 The timeframe for this review has not met with statutory timescales. The parallel process, please see section below, lead to considerable delay. Parallel Processes 1.1.8 There were two parallel processes. This case has been subject to Coroner’s Inquest and criminal proceedings. BZ’s Father was arrested for BZ’s murder. Many of the professionals crucial to complete the review gave evidence in the trial. A decision was made in September 2017 to halt the process pending the outcome of Father’s trial. Father was tried and found guilty of murder in March 2018. Family participation 1.1.9 Mother was contacted via her Adult Social Worker and Father was contacted via his probation officer, firstly to inform them of the review and then to invite them to be part of the review process. Both agreed to be interviewed however, Mother was initially too unwell and Father, having agreed, later declined to meet the lead reviewer and chair. The lead reviewer and chair of the SCR made further efforts to engage the parents in the process, through their respective workers and via MGM, prior to completion of the final report, but without success. Limitations 1.1.12 This review has been affected by the lack of discussion with mother and father. The lead reviewer would have welcomed an opportunity to explore Mother and Fathers perspectives on the support and services offered and how practitioners and agencies worked together to support the family. Key focus points 1.1.10 The Serious Case Review panel decided upon the key focus points for the review and highlighted the lines of enquiry for consideration. These can be found at Appendix 1.    BSCB Child BZ SCR FINAL 5 2 CONTEXT  Parental background  2.1.1 Mother had longstanding fluctuating mental health problems and a diagnosis of schizoaffective disorder3. Mother had been under a consultant psychiatrist for a number of years having regular reviews of her care and management. Mother had at times needed acute in-patient treatment. Staff reported Mother could be very aggressive when unwell. Mother also had learning difficulties. 2.1.2 Father had a history of perpetrating domestic abuse in a previous relationship. In 2004, there had been child protection concerns regarding sibling; Father had been the only adult present when sibling sustained injuries at a young age.  The Child 2.1.3 BZ was born three weeks earlier than the due date. BZ required some initial assistance at birth requiring oxygen and had a brief stay on the special care baby unit (SCBU) for intra-venous antibiotics due to maternal infection. BZ had a relatively disrupted life; BZ spent the first weeks of life living in a Mother and Baby Unit. Mother was acutely emotionally unwell at times so much of BZ’s care was delivered by hospital staff or by Father when he was visiting. In the weeks before his death, BZ moved into the full time care of Father. Father’s Mother (PGM) and Paternal Aunt (PA) offered their support, caring for BZ whilst Father tended to his affairs. BZ was meeting expected developmental milestones. Family Dynamics 2.1.4 Mother lived with MGM, MGF and MU. MGM was a carer for MGF and Mother, both of whom had serious mental health difficulties and for MU who had learning disabilities. MGM was under her GP for low-level anxiety. This was a family who, to professionals, seemed to “muddle along”. There was a history of MGM declining support. Whilst MGM took the lead for Mother, she could be inconsistent herself. Where Mother was living became less clear nearer to the birth of BZ. Health workers believed MGM’s address was Mother’s main address, CSC viewed Father’s address as the main address. Professionals reported it was not unusual for service users to move between addresses however, this was more problematic in this case, as Mother did not have her own telephone so there was greater reliance on MGM and Father to pass on messages. 2.1.5 Father’s family dynamics were complex. Father was brought up in his younger years by extended family members and due to bereavement facts about his parentage came to light which impacted on his relationship with his biological parents and caused him some distress. Father was known to be receiving medication for depression from his GP. In February 2015, father was indicating a number of longstanding family issues, including difficulties in his relationship with MGM, which detracted from his mental wellness and that he had recently been using alcohol to                                                  3 Schizoaffective disorder is a mental disorder in which a person experiences a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania  BSCB Child BZ SCR FINAL 6 try and help with his symptoms and sleep (four – five cans a night). Father, according to family, had been a recluse for a number of years having difficulty leaving his home; this was not evident to professionals. Father had a nocturnal lifestyle playing computer games for many hours.  Background prior to period under review 2003 2.1.6 During 2003, at the age of two months, Father’s first child (sibling) was taken to A&E. Father was hostile and aggressive to his partner and nurses screaming in partners face. Sibling was oblivious and slept through causing staff to wonder if Father was exhibiting his normal behaviour. Father ran off before the Police arrived. The incident was referred to children’s social care (CSC). The couple separated. 2.1.7 The following month partner alleged Father became aggressive refusing to leave contact. Partner locked herself and sibling in the bathroom. Father was kicking the bathroom door in when Police arrived. Father was removed and the case referred once more to CSC. 2.1.8 Within weeks, there was a further domestic abuse (DA) incident at a bus stop. Father was drunk and partner was arguing with him whilst sibling was present. The incident was referred to CSC. 2004 2.1.9 At the beginning of 2004, there was a DA incident where a female lunged at Father who was holding sibling. This was once again referred to CSC. 2.1.10 The following month Father was physically and verbally aggressive during an argument over sibling and slapped and kicked partner. A further referral was made to CSC. CSC carried out an assessment; partner and her family reported Father kept partner and sibling hostage for three days, Father was reported to be verbally and physically abusive. Father was thought to be more believable.  2.1.12 In April, sibling sustained a physical injury whilst in Father’s care. The injury was not consistent with the history. The case went to initial child protection conference (ICPC). Father stated sibling fell down three steps trying to follow him, sibling had bruising to eye and cheeks. The injuries were not consistent with the explanation however, the CPS concluded there was insufficient evidence to charge based on the Paediatrician’s report.  2.1.13 In July sibling was made the subject of a Child Protection (CP) plan under the categories of neglect and physical abuse; a core assessment commenced. 2.1.14 By the end of the year partner and Father were no longer together. The CP plan ended, it was a unanimous decision. 2005-2016 2.1.15 Between February 2006 and December 2013 Father had five attendances to A&E with alcohol related issues. Whilst this would not be seen as overly significant, it may indicate an underlying alcohol problem. BSCB Child BZ SCR FINAL 7 2.1.16 In August 2013, Mother had an argument with her then boyfriend who punched her in the face; he was jealous mother had been in contact with MGM. The attending police officer was aware Mother had a mental health diagnosis; it is incorrectly recorded that mother had schizophrenia.  BSCB Child BZ SCR FINAL 8 3. NARRATIVE, APPRAISAL OF PRACTICE AND ANALYSIS OF THE KEY LINES OF ENQUIRY 3.1 Introduction 3.1.1 This section will provide the narrative, appraisal of practice, analysis of the key lines of enquiry and the findings of this serious case review, with associated recommendations for BSCB and its partners. The findings relate to what has been learnt about the strengths and weaknesses in the multi-agency systems. 3.2 Events and activities prior to mother becoming pregnant 3.2.1 In the six months prior to Mother’s pregnancy being confirmed Mother had a prolonged admission (over two months) in hospital, having been detained under the Mental Health Act (MHA). Mother had not been taking her prescribed medication and this was thought to be the reason for her relapse.  3.2.2 On discharge there were difficulties getting the dosage of Mother’s medication to a point where her symptoms were reduced without her being overly medicated. Mother and Father were already a couple having met five months earlier, however Mother continued living with her family with MGM as her Carer. Mother once again became low in mood with reduced self-caring. MGM was advised to seek advice earlier. This decline in Mother’s mental health was followed up with a call by the Mental Health Social Worker (MHSW), however whilst the call was to Mother the MHSW spoke to Father, who reported Mother feeling better, eating ok and no unusual thoughts.  Comment: This is the start of a re-occurring theme of professionals making attempts at telephone contact with Mother and not speaking directly to her. Insufficient consideration was given to the role of partners. Father’s suitability as a Carer was, at this point, unassessed and Mother was choosing not to live with him. 3.2.3 Mother was subsequently offered a support worker to try to provide some structure to her days, as she had no meaningful activities; this was declined. There remained non-compliance with taking medication and Mother’s mental health was a concern. Father was offered a support worker and declined. An outpatient appointment (OPA) was cancelled by Mother, this was followed up, rearranged and attended; Mother was once again offered, but declined a support worker. Comment: Health professionals were clearly identifying Mother needed and likely, would benefit from support worker involvement. Mother and Father’s declining of additional support was their right. 3.2.4 Mother was involved in an incident in a pub where she was asked to leave because of her behaviours; she had spat in the pub managers’ face. Alcohol was believed to have exacerbated the situation. Mother received a community resolution for common assault. The police officer dealing with the incident was unaware of Mother’s mental health disorder; she was seen as violent and aggressive. Comment: There is a reliance on frontline police officers having the skills to assess whether violent and aggressive behaviour has a mental health component. Officers can now ring to check if a person has a mental health disorder, but it is down to BSCB Child BZ SCR FINAL 9 the judgement of the attending officer as to whether behaviour relates to alcohol or mental illness. 3.3 Actions and activities during Mother’ pregnancy  3.3.1 Mother was very open with the health professional’s involved in her care at the point she found out she was pregnant. MGM was proactive in requesting information from the GP as to whether Mother’s medications may be harmful or potentially dangerous to BZ. An outpatient appointment (OPA) and Pharmacist review were booked. MGM, Mother and Father attended the pharmacist meeting. Mother was on the correct medications for her condition in pregnancy. Mother failed to attend (FTA) her OPA the following week. Comment: The pharmacist’s review was good practice. Mother was reliant on MGM or father to remind her of appointments. 3.3.2 In referring to midwifery the GP wrote and shared Mother’s past history including her mental health and her medication. All professionals involved during the pregnancy were therefore aware of Mother’s mental health condition. Two weeks post referral Mother and Father attended a booking in appointment. The community midwife (MW) was concerned by Father’s controlling behaviour; Mother was asked about domestic abuse, but denied any abuse. Mother’s PHQ94 showed moderate depression; Mother was referred for consultant care and to the specialist MW for complex social needs and to Baby Steps 5. Father disclosed previous CSC involvement with his now 13-year-old child and seemed very keen for Mother to move in with him.  Comment: There is much to explore at a booking in appointment, so whilst Father’s disclosures and behaviours could have been explored further, it becomes understandable that they were not. A follow-up appointment should have been arranged the following week to discuss these further. Father’s disclosures and behaviours should have formed part of the onward referral. 3.3.3 The community MW with additional input from the mental health specialist midwife (MHSM) provided Mother’s care. The MHSM believed mother to be 16 weeks pregnant. Mother disclosed the injury to Father’s previous child to the specialist MW, Father did not. Father gave varying accounts of his level of contact with sibling, which ranged from seeing sibling at weekends to none; this discrepancy was not highlighted in discussions between professionals. 3.3.4 Other professionals learned of the incident where sibling sustained an injury in Father’s care, largely through Father’s self-report. This self-report made Father appear open and truthful to professionals. The incident was not known to any of the health professionals currently involved, nor had the paediatrician’s child protection medical report been seen. The difficulty for health professionals is often how the transfer of relevant information flows when parents have children with multiple                                                  4 PHQ9 – A patient health questionnaire, used by health professionals to assess mood. 5 Baby Steps is an educational programme designed to support Mums and Dads to be able to manage the emotional and physical transition into parenthood.  BSCB Child BZ SCR FINAL 10 partners. The information about a child remains with the child and therefore with the household in which the child is living, in this case Father’s ex-partner and is not readily available. This means that health professionals have to actively seek that information and, unless it was known that there was a safeguarding issue would have to request permissions in order to do so. The same is not the case for the police and CSC who can access the required information readily from their systems. There was recording of the incident on police and CSC IT systems and CSC records.  3.3.5 Father disclosed his own mental health issues to the MHSM and indicated he was taking anti-depressant medication. The MHSM sought further information regarding Father via the Adult MASH. 3.3.6 Mother was managed through a joint clinic and joint work between the MHSM and Mother’s mental health Adult Social Worker. The midwives and psychiatrists met every Wednesday to discuss pregnant women with mental health conditions and Mother was part of those discussions. Mother had an antenatal scan and all seemed well; Mother was deemed to be 21/40 weeks pregnant by obstetrics (later believed 17). Comment: This was good practice. It was felt by those attending these meetings that the discussions could have been enhanced further by the attendance of the obstetrician. 3.3.7 A mental health management plan was developed and the fact that Mother did not recognise when her illness was in decline was included in the plan.  3.3.8 At a Multi-Disciplinary Team (MDT) meeting, there was discussion that Mother was at high risk of relapse; thus, a referral should be made to CSC. Blackpool SCB policies and procedures indicates referrals should be made 16 weeks into the pregnancy, Mother was either 17 or 21 weeks into her pregnancy, as she was thought to be further along in the pregnancy, when a Getting It Right referral (Level Three) was submitted. The referral noted that MGM, Mother’s carer, was also caring for her son with learning disabilities and husband with mental health issues.  3.3.9 The referral contains all pertinent information and the CSC SW was advised to progress the referral and arrange a visit prior to going on leave; this did not happen. A week later the MHSM contacted CSC raising concerns in respect of Mother’s mental health, indicating the need to approach the assessment with care as Mother was at high risk of relapse, and suggested a joint visit. The MHSM was advised that the CSC SW was on leave and a visit was arranged for three weeks’ time. The MHSM suggested the case should be reallocated given concerns around Mother’s mental health and the need for her to build a relationship with the CSC SW; this was good practice however, it did not happen. Indeed, the planned visit was delayed by a further two weeks. The lead reviewer learned that pan Lancashire procedures indicate 30 weeks is the latest time for a conference to be held. Practitioners reported that, because of the pressures of work, there is a practice of waiting until 30 weeks to start preparations for conference, however, there is nothing to prevent multi-agency meetings taking place. Some CSC SW’s start preparation for conference prior to 30 weeks, but that is up to individual CSC SW’s and results in an inconsistent approach. Perinatal team meetings were happening although they were multi-disciplinary in nature they were single agency with health staff only in attendance.  BSCB Child BZ SCR FINAL 11 Finding: The practice of delaying holding multi-agency meetings, in cases where safeguarding concerns have been identified, until the pre-birth conference is not making the best use of a pregnancy when mothers are most receptive to change6.  Recommendation 1: BSCB and its partners to review the current policies, processes and practices around unborn babies to ensure professionals are clear about the need to proactively progress referrals, build relationships between social workers and parents, and request information to complete assessments wherever possible prior to the birth of the child. Compliance must be subject to monitoring and audit. 3.3.10 At 20 weeks’ gestation, the care co-ordinator and specialist midwife start joint visiting. Mother’s mood was flat; she reported her family were accusing Father of taking Mother’s money. At the visit Father was speaking for Mother; practitioners in recognition of this told Father to leave, but he kept returning. Mother indicated she did not feel ready to move in with Father, was having difficulty coming to terms with pregnancy, struggling with going out and managing finances. Father was buying baby items without Mother. Comment: It is clear that there were a number of issues at this point and it would have been useful to have a multi-agency approach however, the first CSC assessment session was planned for a month hence; the timing being somewhat impacted by SW annual leave; the specialist midwife challenged this delay suggesting the case be reallocated given mother’s mental health and the need for her to build a relationship with the social worker – no change of plan was made within CSC. 3.3.11 During this period, health disciplines continued to work well together with a shared care approach. When Mother cancelled a psychiatrist appointment, this was discussed at Perinatal MDT and a further appointment made for psychiatric review. On attendance, Mother was reported worried, not talkative and it was difficult to access her thoughts. Medication was discussed with liaison with Mother’s GP for review of medication a few weeks later. 3.3.12 Joint visiting continued with the care co-ordinator and specialist midwife visiting MGM’s when Mother was 24 weeks pregnant. Father was once again speaking for Mother and asked to leave. The Adult Social Worker was going on maternity leave so a new MHSW was to be introduced. There was no DA enquiry. 3.3.13 At the GP review, Mother requested a change of medication. The GP agreed to discuss this with the CMHT. Mother was seen by the consultant psychiatrist and reported erratic use of one of her medications. Mother was reluctant to take it so it was discontinued and her other medication increased. Mother indicated she was not keen to go to the mother and baby unit, post birth, as it was out of area. Practitioners report Father appeared to be influencing Mother, as he did not want his relationship with baby to stall. Perinatal mental health problems are very common, affecting up to 20% of women during pregnancy or the first year after childbirth. Since this case, there has been a proposed change to services to women in Cumbria and Lancashire experiencing perinatal mental health problems. A new                                                  6 Olander, E., Smith, D. & Darwin, Z. (2018) Health behaviour and pregnancy: a time for change. Journal of Reproductive and Infant Psychology. 36:1, 1-3, DOI:10.1080/02646838.2018.1408965 BSCB Child BZ SCR FINAL 12 local specialist Perinatal Mental Health Unit is due to open in 2018; it is hoped this will lead to women receiving care locally alongside their babies.   3.3.14 Professionals report having seen MGM and Father together and there being no evidence of hostility between them. MGM tended to let Father do the talking, but affirmed the information he was sharing. MGM had indicated to professionals that she hoped Mother and Baby would come home to her. MGM was described as a quiet, timid woman. Father had expressed that he did not want baby to go to MGM’s because it was smoky. As time went on the relationship seemed fractured. 3.3.15 During this time, MGM had taken an overdose and was in hospital; not all the professionals involved knew this information. 3.3.16 A family engagement worker from the NSPCC received the referral for the Baby Steps programme and contacted Father to speak to Mother. Mother was overheard to say she did not want to speak to the FSW directly and they were not sure they wanted to participate. However, the couple indicated they would attend. The referral contained limited information regarding the incident with sibling and the mental health issues. A decision was made for no lone working until further information regarding risks had been received. The case was discussed with the manager and Framework i (IT case management system) was checked and further information on the system regarding the previous child and planned pre-birth assessment was gleaned. There was an issue regarding date recording on the NSPCC system at that time, which makes it appear that case was closed before a visit took place, this has since been resolved. Finding: Referrers are not recognising the importance of providing full information on referral forms. A poorly completed referral can lead to, poor decisions on the acceptance and advancement of referrals for appropriate services, delay and can place workers in risky situations. Recommendation 2: Partner agencies of the BSCB to review all its referral forms to ensure they include a prompt to the referrer to provide full and accurate information and an assessment of risk when referring to another service or agency. Where referrals are of a particularly complex nature this should be indicated with a request for contact. 3.3.17 When Mother was 25 weeks pregnant a home visit was conducted by the family engagement worker at Father’s address.  Mother indicated she was not living with Father; they had only been in a relationship a year and she was not ready. Mother was quiet and needed assistance to complete the forms. Father raised a concern regarding Mother possibly not bonding with the unborn. From the information gleaned, the worker concluded the couple had good supportive families, but with little evidence other than self-report. The ‘Baby Steps’ programme was to be delivered at a children’s centre location which Father identified was too near his ex-partner’s house so this was changed. The family engagement worker attempted contact with the MW and CSC SW for further information and got no reply from one and the other was off sick. Because Mother and Father wanted to access the programme at an alternate venue, they would come under a different family engagement worker so plans were made to transfer the case therefore no further BSCB Child BZ SCR FINAL 13 entries were made on the file and the case was closed in that group and for that worker. 3.3.18 Before the case had been reallocated to another Baby Steps worker and group, Mother contacted the service advising she and Father did not want to take part in the Baby Steps programme. Mother was reported not well enough. The midwife was informed who indicated Mother was very poorly at present and should not be pushed. The family engagement worker’s team manager signed off the episode concluding it was a shame Mother had chosen not to participate.  Comment: The Baby Steps programme is somewhat isolated from other services. The practitioners indicated they are almost fully reliant on the quality of information in the referral; inclusion in multi-agency meetings would have helped. Adult mental health workers were unaware that the service had been involved. The negative effect on the unborn was not given sufficient consideration and whilst mother might have been too poorly to attend groups, further exploration of how the programme might have been delivered did not happen. 3.3.19 Over the next few weeks, there was a flurry of activity by professionals as Mother’s mood fluctuated, however agencies were initially working in silos; there remained no meetings where all professionals were present. 3.3.20 Commencing at 27 weeks’ gestation Mother and Father engaged in a pre-birth assessment carried out by a CSC SW over three sessions. Although there is little recorded, it is clear relevant information had been gleaned as when the case was discussed in CSC SW supervision, the incident with sibling featured and, the CSC SW requested Mother be put on the list for a Parenting Assessment Manuel (PAMS) assessment. The CSC SW also discussed that Father took medication for anxiety, depression and agitation and sometimes had difficulties leaving the house. What is less clear is analysis of the information.  3.3.21 Following the third assessment session a request is made for sibling’s case file; it is not clear why this occurred so late in the assessment. The plan at this point was for:   a PAMs assessment in respect of Mother,   to clarify Father’s MH issues with his GP,   for Mother to continue to engage with MH services,   a Carer’s assessment to be completed of Father,   further information required re sibling and   for legal advice to be sought.  3.3.22 What is missing from the documented assessment is MGM and the wider family, and an assessment of the risks to and the impact on, the unborn of parental mental health. It is clear the assessment was discussed in CSC SW supervision on one occasion, but there appears to have been a lack of managerial oversight and lack of challenge as to why actions required had not been completed. 3.3.23 One explanation could be that the time for booking an initial conference was close, the assessment would have gone out of timescale if this information was needed, and the assessment started very late. Later the SW confirmed that multi-agency BSCB Child BZ SCR FINAL 14 plans were completed, but were not specific in the assessment and that agencies were consulted as part of the assessment. MGM was spoken to as part of the assessment, but this again was not specifically recorded in the assessment. It was reported that MGM also had mental health difficulties, which would have resulted in her being in a poor position to support Father and Mother with the baby. Wider consideration of how MGM was fulfilling her Carer role and what this meant was not evidenced. The risks identified in the assessment process were primarily around the impact on baby due to Mother's poor mental health and the concern that this would become more difficult when she gave birth. The planning was around this. Mother had had angry outbursts and this was of concern. Mother could manage day to day, but concern was her health would deteriorate and Father would become sole or main carer for baby. At this time, the thinking was no significant concerns had been raised about Father's ability to parent other than requiring support as any new parent may require. The risks identified in respect of Father's flat, that is was not suitable for a new-born baby as the flat was deemed for single tenancy only, prompted a plan be put in place to address this. The CSC SW recognised that Mother might disengage and Father might not be compliant with his medication. There was suggestion that if Father did not comply, questions would be asked and, an assessment made. All this was considered, but not fully incorporated in the assessment; this was not scrutinised nor challenged by managers.  Finding: This case highlights the importance of accurately interpreting historical child protection information so it can be used to plan actions to safeguard unborn and new-born babies. Insufficient credence is currently being paid to historic information to complete informed risk assessments. The focus of the Pre-birth assessment was on the here and now rather than a full assessment including the historical information. The danger of considering an assessment as complete before all relevant information has been gleaned is that, as in this case, any risk assessment can easily become skewed. Assessments are not a single event rather a continuum; they should be revisited as new information is received and reassessment of risk and adjustments made to the plan. In an NSPCC review7 it concluded that professional optimism could lead to risks being underestimated and there being a tendency to see the birth of a new baby as an opportunity for a fresh start. This sometimes hindered professionals from recognising pre-existing patterns in parents’ behaviour, which posed a risk to the baby.  Recommendation 3: The BSCB to seek assurance from CSC that all assessments and plans of children subject to CIN, CP and Pre-birth, show evidence of the gathering and appropriate use of historical information. Finding: There is no evidence that the assessment was driving the planned actions to improve outcomes for BZ. Recommendation 4: BSCB to seek assurance from CSC that all assessments and plans are subject to managerial oversight, that there is evidence of thorough scrutiny and challenge by managers.                                                   7 NSPCC (2017) Infants: Learning from case reviews BSCB Child BZ SCR FINAL 15 3.3.24 Health held a series of MDT meetings with the MW, psychiatrist, perinatal MH nurse and specialist HV perinatal and infant mental health. Best practice would have been for either the CSC SW to have been present too or the health plan to have fed into the CSC SW assessment. 3.3.25 Mother was alternately being reported to be more engaged with the pregnancy, but worried regarding coping; or low in mood. On occasion Mother ran out of medication. 3.3.26 During this period, Mother attended a GP antenatal clinic, she was 29 weeks pregnant and all was said to be well with the pregnancy.  Learning point: There was a general lack of routine enquiry regarding domestic abuse by health professionals throughout the pregnancy. Whilst a meta-analysis8 did not detect improved outcomes for women screened for intimate partner violence, there was insufficient evidence within the meta-analysis for screening in healthcare settings and current NICE guidance advocates routine enquiry around domestic violence and abuse.9 3.3.27 In early December, a strategy discussion took place between the SW and the police; there was no health input, which appears an oversight however, the lead reviewer learned, strategy discussions in cases that clearly need to go to pre-birth ICPC had become a formality and thus no in depth discussion took place. This was outside of expected practice. Coincidentally a scheduled audit identified the same issue and as a result a clear message was sent to the CSC SW’s that this was not acceptable. Current process means there has to be a strategy discussion for a case to advance to conference. A PVP was created at a medium risk with recommendation of progression to ICPC. The PVP identifies partial information; Mother and Father plan to reside in the same block of flats, Mother is untested on her own, Father was not involved in his first child’s upbringing, both have parental support. Much of the factual information of the case is missing. Finding: Adopting a stance where strategy discussions are treated as a formality is unacceptable. This approach is fuelling a lax attitude where cases that should lead to strategy meetings are remaining as discussions between police and CSC. Health should have been part of any strategy, be it discussion or meeting. The danger of discussing such a complex case in a discussion rather than a meeting is the risks to the unborn are not sufficiently recognised and the information advanced to ICPC from this forum is scant. This was a missed opportunity to assess risk and for a multi-agency approach to begin. Recommendation 5: BSCB and its partners to audit the practice around strategy meetings for unborn babies, to ensure that meetings are being held in accordance with procedures. The audit should seek evidence that discussions within the meeting form part of the analysis of risk from the start of the child protection process.                                                  8 BMJ 2014;348:g2913Screening women for intimate partner violence in healthcare settings: abridged Cochrane systematic review and meta-analysis  9 NICE (2014) Public Health guideline (PH50) Domestic violence and abuse: multi-agency working  BSCB Child BZ SCR FINAL 16 3.3.28 The ICPC was not scheduled to take place for a further nineteen days, which at this stage in the pregnancy 33 weeks was significant. In between times:  Mother missed a psychiatry appointment   Father declined a referral to Single Point of Access (SPA).   The CSC SW sought legal advice and was advised further work was required; the decision was not to issue care proceedings.   The family engagement worker declined an invite to conference, but agreed telephone contact.   The MW was increasingly concerned regarding both Mother and Father’s MH and non-engagement.   The SW visited, but Father denied any MH issues, but his sister was present.  There was a failed visit by the HV to complete an antenatal 26-28/40 visit.  The case was allocated for Family Group Conference (FGC).   Mother attended the Delivery Suite having Phoned 111 with abdominal pain. The ambulance staff noted no safeguarding concerns at home on their records, however documented that ‘the family arguing and tensions high. Strong smell of cannabis and Father refused request to stop smoking whilst paramedics there. Mother not prepared, no bag packed unsure of dates and no credit on her phone’. There was no referral form or information sharing from the crew, but the information was passed to the allocated SW via the hospital. No evidence the SW takes any immediate action.  A Carer’s assessment in respect of Father was carried out.  Father was advised by LCFT to engage with carer service, but was unwilling to do so. 3.3.29 It is not clear whether the family engagement worker’s decision not to attend or provide any written information was discussed with and agreed by the Team Manager. However, it is evident that there was information and observations made during the initial contact with the family that would have been useful to have shared with CSC in order for them to have had a fully informed picture of risk, need and capacity. Blackpool NSPCC has subsequently addressed the matter, as this has been a reoccurring issue. Learning point: Any request for attendance at CP conference should be complied with in accordance with Policies and Procedures. If attendance is not possible a written report, including all relevant information must be provided.  3.3.30 Preparation for conference commenced. The Health Visitor (HV) was unaware of the conference. Practitioners reported that Health Visitors were not always invited to pre-birth conferences; this missed an opportunity for the HV to become involved earlier. In addition, neither Mother nor Father’s GP were made aware of or invited to the ICPC or RCPC.  Finding: Current practice of not inviting all health professionals to conferences is potentially limiting the effectiveness of safeguarding meetings. As pre-birth conferences do not occur until after 30 weeks it is likely HV’s will have conducted BSCB Child BZ SCR FINAL 17 an initial visit between 28 and 32 weeks into the pregnancy and will therefore have relevant, recent information regarding the client to share. GP’s are in receipt of all NHS health information regarding their patient. At the time of Mother’s pregnancy, the SW provided the list of who she knew needed to attend; however, where the unborn was a first child or the mother’s children were over five the SW did not always know which HV to invite. The current revised system dictates where there is only an unborn (no other siblings) the Quality Assurance (QA) team at the LA will send the invite to the safeguarding email inbox for the midwives and also send to the correct email inbox for the HV team. The SW should also be able to identify the HV as part of the pre-birth assessment by either asking the midwife or checking with the mother’s GP and linking to the correct HV team. Both parents’ GP’s must be invited to pre-birth conferences.  Recommendation 6: The BSCB to seek assurance from CSC that systems for inviting health professionals to conference are now effective. The LA Quality Assurance team to monitor attendance and provision of reports to conference and report to the BSCB. 3.3.31 The case went to conference. Absent were the HV, GP and the family engagement worker. The risks identified were Mother’s mental health and its’ manifestation when unwell, Mother’s learning difficulty in relation to how this might affect care of the baby, the injury to sibling – when CPS took no further action, and Father’s depression. What was missing was DA in Father’s previous relationship, Father’s coercive and controlling behaviours in relation to Mother witnessed by professionals, details of the family arguing and the high tensions noted by the ambulance crew, historic alcohol use and current cannabis use also noted by the ambulance crew. 3.3.32 The challenge when chairing a conference of a complex case, as in this case, is how to share all the relevant information in a relatively short period of time. Attendees’ and non-attendees’ reports need to be of a high quality and contain all relevant information; they then must be read in order the information is shared effectively. In this case, the police report contained relevant information about the incident to sibling although no conclusion as to whether the injuries were accidental or non-accidental. Police information did not include information about the incident with Mother at the pub. The MW report did not contain information from Mother’s attendance with abdominal pain, the SW report also had gaps in information, including the ambulance service information. Finding: Professionals did not include all relevant information in their reports to conference. The importance of information sharing has been an on-going issue identified within numerous national Serious Case Reviews and Inquiries for decades. Information sharing guidance has been produced for professionals.10 Recommendation 7: BSCB and its partners to assure themselves that reports for conference contain all relevant information and are compliant with best practice.                                                  10 DFE (2015) INFORMATION SHARING ADVICE FOR SAFEGUARDING PRACTITIONERS  BSCB Child BZ SCR FINAL 18 3.3.33 The SW had accessed sibling’s IT record and concluded that there was no evidence that Father caused the injuries despite the inconsistent account. This becomes understandable when you explore what was recorded on the IT system, which differed from what was recorded in the paediatrician’s report. What was absent was the impression recorded by the paediatrician that the injuries were not consistent with the history and it was difficult to explain the injuries secondary to a fall from the stairs. 3.3.34 Professionals agreed this incident made them feel uneasy and cautious as there was, they believed, at the very least, misreporting. Professionals indicated they were also conscious not to stigmatise Father and to take a balanced and proportionate approach. Professionals were informed Father was allowed contact with sibling from a CSC perspective, which served to reassure them, however, there was a lack of clarity surrounding the real situation around contact. Professionals were made aware that there was information around ten DA incidents between Father and a previous partner, one incident were Mother was the subject of domestic abuse in a previous relationship, an alcohol related incident for Mother and cannabis for Father but had failed to recognise that this was a case where the indicators for ‘toxic trio’11 were present. Finding: The incomplete representation of the contents of the historic medical report coupled with the CPS decision not to prosecute, the lack of focus on Father in terms of behaviours appears to have reduced professionals’ thinking around the risk Father might pose to BZ. No one with a health background reviewed the child protection medical report as part of the ICPC to give a health perspective on the findings of the paediatrician at that time. Recommendation 8: A system should be developed to ensure that in cases where there have been historic concerns, including previous child protection medicals regarding siblings of the subject of a Child Protection/Child in Need Conference/meeting, all agencies should review the source record and the most appropriate health person should review the information included in the child protection medical report and provide their view to the Child Protection conference. 3.3.35 The detail of the mental health management plan was shared so all professionals had an opportunity to know this. However, practitioners reported that at conference, there was a lot of information to go through and this would have been easy for them to miss. This was disputed by the panel who suggested that perhaps the practitioners were limited by their lack of mental health knowledge. 3.3.36 Parenting assessments were considered within the conference. The suggestion being that mother would be put forward for a PAMs assessment. This specialist assessment, done by social workers who are trained assessors and with approval by a CSC manager, was meant to be progressed onto the PAMs assessment list following supervision between the SW and manager when the case was first referred, but was not . A PAMs assessment is a 12-week assessment for parents with                                                  11 Toxic Trio – has been used to describe the issues of domestic abuse, substance abuse and mental ill-health issues which have been identified as common features of familieswhere harm to children has occurred. They are viewed as indicators of increased risk of harm to children and young people. BSCB Child BZ SCR FINAL 19 learning difficulties. The lead reviewer learned that prior to a PAMs assessment a cognitive assessment of ability has to be completed; this can lead to delay. The system is not easy to navigate with the potential for much delay. For Mother there should have been no need for a cognitive assessment as she had numerous assessments as a child resulting in education within a special school that demonstrated impaired cognitive ability. Although Father was quite open with professionals that he was suffering from and being treated for depression by his GP; this was not openly discussed within the conference. Father was also believed to have some level of learning disability however, there was no suggestion he might also have been eligible for a PAMs assessment. Assessment of Father’s parenting ability did not commence until after BZ was born. The lead reviewer learned there is currently a shortage of trained assessors and a backlog of assessments meaning assessments are often not started and are rarely complete before a parent has full care responsibilities for their child. Finding: If a decision and/or taking action on a decision, that a parenting assessment is required, is left until conference at 30+ weeks into a pregnancy, this must be considered in terms of what this means for care and safety of a child post-delivery and pre completion of the parenting assessment. This issue has the potential to leave the most vulnerable children in Blackpool in the care of parents who lack ability to care for them. Recommendation 9: BSCB and its partners to review the arrangement around parenting assessments, both routine and specialist, to ensure they are robust.  3.3.37 There was consideration of further referral to Baby Steps for parenting, but this was not pursued on the advice of the midwife due to Mother’s mental health and an understanding that Mother would not manage in a group setting. Baby Steps practitioners indicated that some elements of the programme could be delivered on a 1:1 basis by HV’s or Baby Steps workers; however, there is no evidence this was explored further. It was recognised that the service would not have had the capacity to do this at that time. Baby Steps do not have access to health records and are reliant on a comprehensive referral. Baby Steps were not present at the Child Protection conference; it was thought multi-agency meetings pre-birth would be useful. 3.3.38 A decision was made that BZ would be placed on a CP plan under emotional harm at birth. A pre-birth plan was developed and known to attending professionals. The plan included contingencies for if Mother’s mental health deteriorated. The mental health plan sat alongside the CP plan. The midwifery plan was for Mother and baby to remain on the ward and Father to stay too; this was outside of normal practice, but believed to be in the best interests of Mother and BZ. There had been discussion with legal services as to whether the case met the threshold for care proceedings whereby the child could be taken into care; it was deemed it did not, but suggested further work was needed and to return to a legal planning meeting if there were further concerns about the arrangements for and care of the baby when born. The first core group took place immediately post conference. BSCB Child BZ SCR FINAL 20 3.3.39 Three weeks later the HV contacted the CSC SW to share information from a multi-disciplinary team meeting and request information on the plan and the date for core group. 3.3.40 The midwife informed the CSC SW in an email of MGM’s concerns that Father would not call anyone if Mother’s mood were to relapse, due to actions that could be taken by CSC e.g. taking the child into care. A CSC Social Work Assistant (SWA) was allocated to assess Father’s parenting and an initial meeting took place.  3.3.41 An adult MH worker visited. Issues on this visit related to the flat being cold; it transpired the gas had been disconnected. The CSC SW believed Mother was staying at MGM’s because of the cold, but the adult MH worker records tensions between Mother and Father as the reason Mother went to stay with her parents for support. Comment: Parental tensions were not shared appropriately with the core group. A professionals’ meeting could have been held; the quality of information sharing was identified internally and measures put in place to address this. 3.4  Events and activities after the birth of BZ 3.4.1 BZ was born at 37 weeks into the pregnancy, five weeks after being placed on a CP plan. BZ required some initial assistance at birth including oxygen. There was an added complication as Mother had a Strep B infection and needed antibiotic treatment and BZ needed a blood test and monitoring to establish whether BZ also had Strep B; results proved negative. There was some confusion as to whether BZ may need scoring for drug withdrawal from Mother’s prescribed medication; although it was agreed that this was not necessary. 3.4.2 The mental health plan had been for the Crisis Home Treatment Team (CHTT) to assess Mother’s mental health on a daily basis, however the rapid deterioration in Mother’s mental health coupled with her now expressing a wish to go to the Mother and Baby Unit (MBU) meant this never happened. The plan developed at pre-birth conference to obtain missing information, complete a PAMs parenting assessment on Mother, look at parenting support and consider accommodating BZ had not been advanced. The second core group meeting took place on the day BZ had been born. The CSC SW, MH SW, Children’s Centre, MW and adult MH worker attended the core group; although there is record of the meeting taking place on Mosaic (CSC IT system), there is no associated recording of the meeting. Additional information that Mother had a history of being in relationships that had been abusive came to light. Staff documented concerns that Father was controlling of Mother and questioned Mother’s ability to care for BZ.  3.4.3 Within 14 hours of the birth of BZ’s Mother was agitated and hearing voices. Mother indicated she would not be able to cope and regretted passing up on the out of area Mother and Baby unit placement, there was an urgent review of her care, this did not include discussing the possibility of BZ going into care. Father’s family were concerned as Father was indicating he would kill himself if he had to choose between Mother and the baby. Mother’s medication dose was increased and Mother and BZ were referred to a mother and baby unit. BSCB Child BZ SCR FINAL 21 3.4.4 There is evidence of good information sharing from the MW to the HV and CSC SW with preparation made for a discharge planning meeting.  3.4.5 The CSC SW carried out a CP visit to Mother and BZ the following day. Mother and BZ were fit for discharge. Father was upset and was supported to get BZ and Mother’s belongings. Father was struggling to feed BZ; staff offered support. The CSC SW was concerned about Mother’s interactions with BZ and Father’s irritation when he was challenged, however, made positive observations of Father’s interaction with BZ. There were concerns that Father would be separated from BZ however, stringent efforts were made to keep Mother and baby together demonstrating good practice. 3.4.6 The discharge planning meeting took place swiftly and Mother and BZ were transferred on Day two to the Mother and Baby Unit, Mother was placed on constant observation. Community midwifery from the Mother and Baby Unit visited Mother the following day completing physical health checks on Mother and BZ. 3.4.7 Mother’s MH nurse maintained contact with Father and steered him towards additional help from the Carers Centre. The adult mental health worker had a no access visit to Father; he was staying with MGM for support.  3.4.8 Over the first week Mother’s MH deteriorated and she was detained under the MHA. 3.4.9 Mother continued to be monitored by the community MW who requested maternal blood pressure monitoring as this was high. BZ had a small blister like mark on a knuckle, BZ’s weight was increasing. 3.4.10 Adult Mental Health and CCTT services were trying to contact Father in the first two weeks with no response; this was not shared with CSC. 3.4.11 By Day 14, staff reported Mother was doing little to care for BZ. It was felt Mother needed acute ward care. 3.4.12 Assessment of Father’s parenting ability took place within the out of area Mother and Baby Unit, the assessment found that BZ’s basic needs were being fully met. However, the assessment concluded ‘it is unclear if this can be sustainable when BZ returns home’. Father showed that he welcomed guidance and advice and was starting to be able to recognise and pre-empt BZ’s needs.  3.4.13 Throughout the assessment, Father reflected on his own parenting practice concerning sibling and agreed that he needed the support of professionals and family as his knowledge and experience were poor. The assessor noted ‘Father displays a willingness to learn and confidence in handling BZ that comes from the natural bond between them.’ ‘Father appears to be able to put BZ’s needs before his own and to those of Mother. Putting this into practice on a daily basis will be hard work, but achievable. I think Father embraces the commitment necessary to succeed.’ ‘I do not doubt that Father truly loves BZ and is prepared to do whatever it takes. I have to question whether the long-term commitment needed to manage BZ as BZ grows and develops is a realistic option for Father alone. Father’s family provides the confidence and experience Father needs; I am unsure Father could manage this without support.’ BSCB Child BZ SCR FINAL 22 3.4.14 Within the Child and Family Assessment there is a section entitled parental/child factors at assessment indicating the assessor should tick any child and parent risk factors, the only factor ticked was learning disability. The author believes an opportunity to reflect on all the risks present in this case was missed. Finding: The tools within the assessment designed to hone a practitioner to consider risk had not been completed in this case. There was no evidence that this had been recognised or challenged by managers. Recommendation 10: BSCB to seek assurance from CSC that all assessments are subject to oversight, challenge and scrutiny by managers within CSC. 3.4.15 The HV at the mother and baby unit shared information with the local HV, which was expected practice. 3.4.16 Mother’s condition deteriorated and she had an altercation with staff leading to a transfer of care to an acute ward. No strategy meeting was held. Following transfer LCFT completed a risk assessment and updated the care plan. The electronic safeguarding record was updated however, the information was incomplete regarding BZ’s details and potential safeguarding concerns and the information was not shared further.  Finding: This case had identified gaps in information sharing between Adult MH services and CSC with a lack of proactive response by both services. The deterioration in Mothers MH was an opportunity for a multi-agency meeting to be held. Recommendation 11: CSC and Adult Mental Health services to review their information sharing processes and ensure policies clearly state sharing of and flow of information between adult MH services and CSC must be routine in cases where children are in the safeguarding arena.  3.4.17 This transfer meant CSC had 48 hours to make a decision as to where BZ should be placed. Whilst recognising this did not afford much time for the CSC SW to make plans, the decision was made very swiftly and as a single agency, allowing BZ to go home into care of Father the following day. Father’s parenting assessment had been completed and whilst it questioned Father’s ability to care for BZ alone, regular updates obtained by the CSC SW from staff at the mother and baby unit identified no concerns.  3.4.18 It could be argued that placing BZ in the care of Father did not constitute a change to the CP plan as the plan was always for BZ to go home into the care of Mother and Father, with Father being the main carer. Promotion of keeping BZ in the care of birth family was always the thinking. However, there does not appear to have been sufficient consideration of the findings in the parenting assessment, further information that emerged regarding Father; the conference chair was not aware of the changes to the plan. CSC SW workload impeded at that time. Practitioners indicated that the concentration was on the number of cases allocated to each worker rather than the complexity of the cases; the CSC SW identified workload at that time was heavy. Practitioners report an improvement in workload and in performance monitoring and management since that time. Conference chairs now automatically review cases at the midpoint between conferences. If that had been BSCB Child BZ SCR FINAL 23 the process at that time, the chair would have been aware that BZ and Mother had entered the Mother and Baby Unit. 3.4.19 There was no consideration to holding a discharge planning meeting or a multi-agency meeting at this time; nor was the conference chair consulted. There was insufficient thought and analysis as to whether the couple’s change in circumstances warranted a multi-agency meeting or a core group to take a multi-agency decision on the best course of action to meet BZ’s needs. There was no consideration of foster care as an option. 3.4.20 If the SW had taken the full 48 hours open to her a core group, already scheduled to take place the following day, could have taken place with advice or attendance of the conference chair or a SW manager, a multi-agency decision taken and plan made. The core group was postponed to the following week. Finding: Decisions regarding unplanned changes in living arrangements for children subject to CP plans must, wherever possible, be made on a multi-agency basis, with the child as the focus. Recommendation 12: BSCB to amend its procedures to advise that any changes to the living arrangements of a child subject to a CP plan should be made with the knowledge and agreement of involved multi-agency partners. 3.4.21 In the days following BZ’s transfer of care to Father there was a flurry of activity:   the SWA conducted a home visit   the resource panel agreed Families in Need (FIN) service involvement, four weekdays and Saturday and Sunday to increase monitoring and support.  A date for the review child protection conference (RCPC) was arranged that was in line with usual timescales. There was no discussion regarding the need to bring forward the dates for this conference.  Financial and housing issues become apparent. Father attended the citizen’s advice bureau (CAB) with PGM. The CSC SW conducted a home visit the following day and noted Father was accessing appropriate support. BZ was yet to be registered with a GP. Father declined carer support, as he was staying with PGM and too busy.  CSC re-referred for family group conferencing (FGC) as an earlier referral had not been progressed; FGC open case. Mother remained unwell in hospital. Father indicated he did not think it would be beneficial for MGM to be involved as she had her own issues so invites to FGC went to PGM and PA.  Mother was noted to be verbally aggressive to Father over the phone.   Mother was found to have an infected Caesarean wound four weeks post-delivery.  The core group was cancelled leading to a five day delay. 3.4.22 During these first days, there were some positive visits to BZ and Father. PGM was supporting both Father and BZ, PGM was police checked to allow PGM to have BZ overnight. 3.4.23 The HV had a failed access visit. The core group took place, the HV was unaware of this meeting and had not been invited, the only record of the core group is by the FIN worker and CC engagement worker and no minutes exist for this meeting. BSCB Child BZ SCR FINAL 24 Practitioners recalled there was discussion within core groups regarding Father’s coercive behaviours.  3.4.24 In the ten days prior to BZ’s admission FIN visited regularly; there were no concerns regarding Father’s parenting of BZ. The Health Visitor conducted a home visit. Father was interacting well with BZ although a little nervous. BZ’s birth had not yet been registered. During the visit Father asked the HV what he should do if he was worried about something; he raised concerns about identifying bruising in babies and what to do if he was worried about something. Father shared the events of sibling. This provided the HV with an opportunity to discuss the foundation for Father’s concerns at that time; Father related this to his supervising Mother with BZ. It could be speculated that this might be Father indicating he was struggling.  3.4.25 The HV attempted, but was unable to, discuss this with the SW until the RCPC, 36 hours before the incident and Child BZ’s admittance to hospital.  3.4.26 FIN continued their visits, Father was offered and accepted a Carer assessment, MGM was also offered a Carer assessment, but declined it. The plan was that both MGM and Father would be carers for Mother on discharge.  3.4.27 Mother’s MH started to improve and she became an informal patient; there were plans to move her closer to home and register BZ’s birth. There remained some incidents of aggression. 3.4.28 LCFT completed a risk assessment, there was no suggestion that the relationship between Mother and Father was abusive/ problematic; there was no account of colleagues concerns about Father’s coercive behaviours. 3.4.29 At this time Father was trying to address the fact he had not received electric and gas payment. Father also rang EDT to ask if, PGM could look after BZ overnight, which was agreed. 3.4.30 FIN conduct a visit during which Father became hostile; as he did not wish to discuss Mother. This was the first evidence of hostility witnessed since the birth of BZ. This was not shared or challenged at RCPC.  3.4.31 The CP conference chair and SW discussed progression of the plan however risk was discussed in terms of Mother, but not Father. 3.4.32 Father appears to be starting to disengage with a no access visit for FIN, the Carer assessment worker and the Complex Care and Treatment Team (CCTT) support worker. It should be noted that there is no evidence of joint visiting as there had been pre-birth, this might have assisted Father. 3.4.33 Escorted leave visit for Mother was facilitated in order to register the birth of BZ; Mother fed and changed BZ. 3.4.34 Mother was transferred nearer to home; Father and BZ visit until 2300 hours. This was discussed with EDT. 3.4.35 All professionals except the GP, who was not invited, attended the RCPC. Father was challenged about his conversation with the HV; he gave the same explanation. There was no mention of Father’s hostility to the FIN worker, or the late night visiting, and the focus of the meeting moved to Mother and the safety of Mother going home. BSCB Child BZ SCR FINAL 25 The IRO indicated she would have been concerned if legal advice and senior management advice had not been sought prior to the ICPC. 3.4.36 Discussion at RCPC included whether Father was able to care for both Mother and BZ and it was felt that it was less onerous whilst Mother remained in hospital. What was never explored was the impact on Father of the couple’s exchanges during visits and in between visits over the telephone. Mother had been noted to be verbally aggressive towards Father and make multiple telephone contacts to Father.  Finding: Assessing the likely positive and negative impact of the relationship of parents on children needs to be constantly updated in cases where one or both parents are experiencing fluctuating mental health problems and changes in their levels of aggression. Recommendation 13: The BSCB to seek assurance from CSC and adult mental health services that analysis of the effects of parents’ behaviours on their children, forms part of assessments and is evident within CP plans. 3.4.37 There was recognition Father needed to make some lifestyle changes in order to meet BZ’s needs, as Father was nocturnal in his habits and reliant on energy drinks. What was not fully considered was whether Father was willing or able to make those changes nor how his lifestyle might be adversely affecting BZ. 3.4.38 All practitioners agreed that at the end of the conference they knew what was happening and who had responsibility for each part of the plan. 3.4.39 Physical abuse was added to categories of harm in view of Mother’s aggression. The plan was for FIN input to decrease; the rationale being there had been no concerns regarding Father’s care and he was supported by his extended family. What was also not fully explored was whether Father was finding it easier or harder to care for BZ as time was progressing, nor the extent of the support Father was receiving from his family in order to be able to care effectively for BZ. Witness statements indicate Father was receiving extensive support from his extended family to an extent that he was only partially caring for BZ. The lead reviewer believes that had this been fully explored the decision to reduce FIN input would not have been made. Not all invitees received minutes. 3.4.40 As a consequence of a deterioration in Mother’s mental health, her behaviour deteriorated post transfer. She became hostile to staff and was on the phone to Father much of the time. Family requested a planned visit, the evening before BZ was admitted, went ahead. The visit took place in two parts as Mother left part way through. 3.4.41 Unbeknown to the professionals PGM was going to care for BZ that night, however as PGM was unwell, BZ remained in Father’s care. High levels of support by Father’s family potentially masked that Father was struggling to care for BZ.  3.4.42 The next day in the early hours of the morning there was a 999 call as BZ was unresponsive and not breathing. Father had called his sister to go around prior to making the call. Father was noted to have an injury to his hand – he indicated he had punched a wall. Police launched an investigation and Father was arrested on suspicion of Assault and Child Neglect. Father stated BZ had been unwell for two BSCB Child BZ SCR FINAL 26 days; there was no mention of this to any professionals who had contact in that time. BZ was admitted to hospital at 04.16 BZ’s injuries were found to be consistent with abusive head trauma. A strategy meeting was held same day, which considered the impact on Mother. BZ was ventilated and tests commenced to ascertain if BZ’s injuries were incompatible with life.  3.4.43 BZ’s ventilator support was removed two days later and within twenty minutes BZ passed away; both parents were present. The cause of death was Acute Traumatic Brain Injury due to abusive head trauma. Father was charged with murder. BSCB Child BZ SCR FINAL 27 4 CONCLUSION 4.1.1 The death of any child is a tragedy, but the death of a child, well-known to professionals brings with it questions that warrant scrutiny so lessons that can be learned. In this case, there is evidence of some extremely good practice; of particular note is the effective joint working between midwifery and mental health services during mother’s pregnancy. There are five key areas of learning for the BSCB and its partners.  4.1.2 The first pertains to historical information and understanding its importance and relevance to on-going work. This case highlights the importance of accurately interpreting historical child protection information so it can be used to plan actions to safeguard unborn and new-born babies. Insufficient credence is currently being paid to historic information to complete informed risk assessments.  4.1.3 The second and of greatest importance, pertains to the practice of waiting until mothers are 30 weeks pregnant before a multi-agency approach is adopted in cases that meet the threshold for child protection. In complex cases, such as this, this means time that could be being used to request information, commence assessing parent’s abilities to care for a child safely and establish working relationships with families, is being lost. The lack of activity within CSC following referral of mother’s pregnancy with BZ, until a few weeks prior to the birth, meant assessments were not complete and decisions were being made on partial information. The decision to place BZ at home with Father was made before full information had been obtained on the injury to sibling. Father’s parenting assessment was overly optimistic given what was knowable about domestic abuse, the injury sustained by sibling, cannabis use and his own depression and lifestyle. The lead reviewer believes this practice is leaving unborn babies and new-born babies at unnecessary risk.  4.1.4 The third pertains to when there are significant changes to a child’s circumstances whilst they are on a CP plan. Decisions are being taken outside of the child protection arena, without core group members’ knowledge. The plan was for BZ to go home with Mother and Father, however when Mother agreed, post birth of BZ, to go to the Mother and Baby Unit much of the CP plan became null and void. The core group needed to come back together and revisit the plan.  4.1.5 The fourth element is around assessment of risk. Not all the information required to make a full and effective assessment of the risks to BZ was either recognised or available for all professionals. Significant information regarding parents’ behaviours, including domestic abuse and cannabis use were not routinely explored or shared, incidents of hostility to professionals were not seen as sufficiently concerning so as to be discussed at review conference. As a result, Father was viewed as someone who presented less of a risk to BZ than Mother; this may have been correct however, less risk is not the same as no risk. In short, indicators of the toxic trio were present in this case, but this was not recognised within conferences and plans. 4.1.6 Of significance in the later stages of the review period is the fifth element, managerial oversight and escalation. Whilst managerial oversight occurred in the early stage of assessment, at the pre-birth conference and in the third trimester of pregnancy, there was a lack of managerial oversight post birth. In addition, there is a lack of evidence that the case was discussed in supervision following BZ’s birth. BSCB Child BZ SCR FINAL 28 Appendix 1  Lines of enquiry  1. How was the historical information used?  Did the 2003 incident involving Father unduly influence decisions/ actions taken? 2.  Were practitioners aware of Mother’s mental health condition and her non-recognition of her illness when in decline? 3. Was there any pre-birth planning and was the expectations of the parents discussed? 4. What were the dynamics of the relationship between MGM and Father? 5. Was Father’s controlling and coercive behaviour explored? 6. Was there any evidence that Father suffered from mental health issues? 7. What risks to Child BZ were identified by agencies and did this change over time? 8. Were parenting assessments for both Mother and Father considered? 9. What was the non-specialist mental health practitioners’ level of understanding of Mother’s mental health and what impact did the different recording of her diagnosis have? 10. At the Strategy Discussion on 2 December 2016, who was involved, what was the purpose and what was the process? 11. How did the strategy discussion interface with the child and family assessment and initial child protection conference? 12. How was information from the incident in which Mother attended the Delivery Suite on 17 December 2016 shared? 13. Were the housing and debt issues identified in December 2016/ January 2017 new or had they previously been missed? 14. Did the core groups act as a forum for emerging issues, or were these addressed in different forums? 15. How was the decision to place Child BZ in Father’s care made and was Father living with PGM part of this? 16. What was known about the family’s financial circumstances and carers status? 17. Was the use of cannabis explored and the associated impact on the home? 18. Was safer sleep advice given and were any questions asked about where Child BZ was sleeping? 19. How were reports that Father was concerned about bruising etc. assessed and acted upon? 20. Were concerns about multi-agency working escalated appropriately? 21. How effective was management oversight (including the sign off of assessments)?  