Death of a 5-month-old boy in May 2012, as a result of serious, non-accidental injuries. Father was charged with murder and subsequently pleaded guilty to manslaughter. DD12 was born with a heart defect requiring continuing medical support. Application for an emergency protection order was made several months before DD12's death following identification of significant bruising to his penis during a hospital visit. The injury was subsequently ruled accidental and the application dismissed. Identifies themes, missed opportunities and lessons learned, including: the emotional needs of families with children with complex medical needs should be assessed and responded to; and professionals should not treat court decisions as undisputable statements of the truth. Makes various interagency and single agency recommendations, including: clear advice should be given to magistrates to help them assess emergency applications; and families of children with complex needs should, with their agreement, be subject to a Common Assessment Framework (CAF).
      
 Title:  Serious case review: overview report in respect of DD12. LSCB: Derby Safeguarding Children Board Author: Barry Raynes Date of publication: 2014  This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC.  This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above.                          1               Derby Safeguarding Children Board      Serious Case Review  Overview Report in respect of DD12   Date: 18 February 2014    Independent Overview Report Author  Barry Raynes Chief Executive Reconstruct    2  CONTENTS Introduction 3 Terms of reference  3 Summary 4 Race, religion, language and culture 4 Family tree 4 Methodology 5 Independence 5 Panel 5 Family involvement 6 Staff involvement 6 Parallel processes 7 Dissemination of learning 7 Timescales 7 Individual Management Reviews 7 Narrative of events 9  Background 10  Pregnancy 10  Hospital: Post birth 11  Period at home 11  S47 investigation 12  Court case 16  Home to second unexplained injury 18 Analysis 21 How were the specific mental health issues in respect of father and mother understood, were the right services in place and what impact did this have on the outcome? 21 How were the circumstances of the SUDI death in 2009 assessed and in consideration of this what action was taken at that time and once agencies became aware of mother's pregnancy with DD12? 22 How was the impact of Domestic Violence in existing and previous relationship understood and its impact addressed? 23 Whether specific opportunities existed prior to the birth of DD12, to improve likely outcomes evident at that time  23 Why did the local authority fail in their application for an emergency protection order and why did the magistrates make a finding of fact? 23 How did the failure to get an EPO on DD12 only weeks before his death affect the case?       31 How well was the ability of the parents to meet the complex health needs of DD12 understood and acted upon by practitioners? 32 Conclusion and lessons learned 36 Recommendations 39 Bibliography 40 Appendices  Appendix One: Terms of Reference 41 Appendix Two: Legal background information about emergency protection orders 48 Appendix Three: DSCB and Individual Agency Action Plans (06/12/13) 51   3  1 INTRODUCTION  1.1  Between May 2012 and June 2013 Derby safeguarding children board conducted a serious case review of the services provided to a child who will be referred to as “DD12”.  The review was conducted under the statutory guidance from Working Together to Safeguard Children 2010.   1.2  The purpose of a serious case review is to:  a) establish what lessons are to be learned from the case about the way in which local professionals and organisations work individually and together to safeguard and promote the welfare of children;  b) identify clearly what those lessons are both within and between agencies, how and within what timescales they will be acted on, and what is expected to change as a result; and  c) improve intra- and inter-agency working and better safeguard and promote the welfare of children.   1.3  Each agency who had been involved with DD12 produced a report of that involvement called an individual management review (IMR). These reports were discussed at panel meetings (made up of senior managers from each agency) and those reports, discussions, meetings with staff and family members make up the evidence for this report.  Terms of reference summary  1.4  Terms of reference were drawn up and are included in their entirety in appendix one of this report. Additions to the terms of reference were made late in the process because of complications arising from disclosure of evidence from family proceedings.   1.5  The terms of reference included the following key questions for the individual management reviews and this report to address: a) Whether specific opportunities existed prior to the birth of DD12 to improve likely outcomes evident at that time b) How well was the ability of the parents to meet the complex health needs of DD12 understood and acted upon by practitioners? c) How was the impact of Domestic Violence in existing and previous relationship understood and its impact addressed? d) How were the specific mental health issues in respect of father and mother understood, were the right services in place and what impact did this have on the outcome? e) How were the circumstances of the Sudden Unexplained Death of an Infant (SUDI) in 2009 assessed and in consideration of this what action was taken at that time and once agencies became aware of mother's pregnancy with DD12? f) How did the failure to get an Emergency Protection Order (EPO) on DD12 only weeks before his death affect the case? 4  Summary  1.6  DD12 was born in 2011 in Derby and was admitted to Queens Medical Centre, Nottingham shortly after because of his significant and complex health needs. He remained in hospital until he was discharged on 18/01/12 and returned home with continuing support from professionals for his health needs.   1.7  DD12 was again taken to hospital on 10/02/12 as he was vomiting and his nasogastric tube had come out. An examination identified significant bruising to his penis and a referral was made to children's social care by hospital staff. An application for an emergency protection order was subsequently made and the case was considered over a total of four days. The magistrates ruled on 24th February 2012 as a ‘Finding of Fact’ that the injury was accidental and dismissed the application for an emergency protection order.  1.8 DD12 returned home and received services as a child in need. On 08/05/12 an emergency telephone call was made by DD12’s father claiming that DD12 was having a fit. He was admitted to hospital and died the next day. He had serious injuries and these were not considered to be consistent with the explanation from his father but were indicative of a non-accidental injury. DD12’s father was initially charged with murder and subsequently pleaded guilty to manslaughter.  Race, religion, language and culture  1.9  All members of the family are English speaking White British. It is not known whether religion is a feature in their lives as this has not been noted in records.  1.10  Mother comes from a large family. She has had a stormy relationship with her mother over the years but they remain in contact and live near each other.   Family tree     Father’s Ex-Partner  Father  Mother  Mother’s Ex-Partner DD12 Deceased 2012 Child (1)  (Baby)  Child (3) 11 yrs  5  2 METHODOLOGY  Independence  2.1  An independent chair, Jane Parfrement was appointed by Derby Safeguarding Children Board to chair the serious case review panel. Soon after the commencement of the review Jane was offered a post in Derby children’s services department and therefore stood down, having set the terms of reference and held two meetings of the panel and IMR authors. She was replaced by Smruti Mehta.  2.2  Smruti was appointed as independent chair of this review by the Derbyshire Safeguarding Children Board who have a reciprocal chairing arrangement with Derby City Safeguarding Children Board. Smruti is a qualified social worker, with BA (Hons) in social sciences and an MSc in child development. Smruti has been in her current post as district manager for safeguarding and specialist services for children for Derbyshire county council, for nearly 6 years. Previous to this position she, was a local authority independent chair of child protection case conferences and looked after children’s reviews. She has experience of chairing serious case reviews and extensive experience of chairing meeting with a wide range of agencies involved in serious and complex child protection matters.  2.3  The overview author was Barry Raynes. Barry is the chief executive of Reconstruct, a company providing child care training and consultancy to managers and staff throughout the United Kingdom. Reconstruct also supplies advocacy, independent visiting and participation services to children in London and south west England.  2.4  Barry has thirty years’ experience of child protection social work. He has been involved in over 30 serious case reviews since 2007 – either overseeing the work of Reconstruct’s consultants or producing overview reports. He has written web-based child protection and child care procedures for more than 50 LSCBs and local authorities in England, Wales and Scotland.  2.5  Barry has a Masters degree in public sector management and is currently researching a PhD into common language in child protection.   2.6  Christine Cassell is the independent chair of Derby Safeguarding Children Board.  Serious Case Review Panel  2.7  The serious case review panel met on six occasions for either a half or full day between 10/07/12 and 01/05/13. The overview report was presented to an executive meeting of the safeguarding children board on 20/05/13. Following legal advice the publication of the report was delayed and a further version of the report was presented to the Derby’s Safeguarding Children Board SCR sub-committee on 18th November 2013 and ratified by the Derby Safeguarding Children Board on 11th December 2013. Final sign off of the report was agreed on 18th February 2014.   6  2.8  The panel comprised of: Director of Specialist Services Derby City Council (Children’s Social Care) Detective Superintendent Derbyshire Police Head of Patient Safety Derbyshire Healthcare NHS Foundation Trust Deputy Director of Nursing Derby Hospitals NHS Foundation Trust Chief Nurse NHS Southern Derbyshire Clinical Commissioning Group Justices’ Clerk Her Majesty’s Courts and Tribunal Service (HMCTS) Service Manager CAFCASS Head of Legal Services Derby City Council (Legal Services) Designated Nurse Safeguarding Children NHS Southern Derbyshire Clinical Commissioning Group Head of Safeguarding University Hospitals of Leicester  2.9  IMR authors were often present at the panel meetings sitting in for panel members. This had the advantage of ensuring that the panel and IMR authors were able to fully consider and debate the issues.  Family involvement  2.10  Barry met with DD12’s mother, maternal grandmother and the ex-partner of the father. Barry was unable to meet with DD12’s father until the end of the criminal proceedings. Barry met with father in December 2013.  2.11  The meetings with the family were helpful inasmuch as it offered Barry background information into DD12 and his family’s life. Mother said she often wondered whether DD12 would still be alive if the decision of the court in 2012 had been different.  2.12 DD12’s father talked about how some professionals tended to ignore his presence whereas others included him well in their discussions with DD12’s mother and him.   2.13 Staff members involved with the family saw Barry in a series of meetings on January 30th 2013. The aims of these meetings were to  a) tell staff the life story of DD12 and explain all of the professional involvement b) introduce the initial analysis of the panel c) invite them to comment upon the accuracy of the life story d) seek their views about the analysis e) allow them an opportunity to reflect upon the situation.  7  2.14 The meetings were well attended and feedback from professionals was that it was a useful way for them to contribute to the review and helpful for them to have information about the outcome before it became general knowledge.  Parallel processes  2.15 The criminal prosecution of father was also happening at the same time as this review. This meant that it was not possible to interview him until late in the process.   Dissemination of learning  2.16 The learning from this review will be disseminated throughout safeguarding children board professionals via a series of workshops.  Timescales  2.17 The serious case review took 12 months between being agreed and presented to the Board.  This is outside of the statutory guidance of 6 months. Some delay was caused by the criminal prosecution. The process was consultative involving meetings with IMR authors, staff members and family, thorough and many people were involved in critiquing this final report. The quality of the process was therefore improved.    2.18 There has been a delay in the publication of the overview report as a result of complexities arising from the criminal trial. Following the conclusion of the trial in May 2013 it was apparent that no evidence had been heard and, in particular, no reference was made to any previous alleged injury to DD12. There had been a previous Emergency Protection Order (EPO) application heard by the Family Proceedings Court in private and information relating to those proceedings was confidential. The Derby Safeguarding Children Board considered that this material was a key area for potential learning as part of the review. Following legal advice an application was made to the Family Proceedings Court for permission for the material in relation to the application for an EPO to be disclosed to the Board for the purposes of inclusion in the published overview report. His Honour Judge Plunkett, sitting as a High Court Judge on the 17th September 2013, granted permission for the material to be disclosed.   2.19 The overview report has been written to comply with legal advice from a Queen’s Counsel and the decision of the Court to ensure that it can be published in a manner that does not adversely impact on the welfare of other children, relevant family members and others.  Production of individual management reviews (IMRs)  2.20 IMRs were received from:  Derby City Council (Children’s Social Care) Derbyshire Police 8  Derby City Council (Legal Services) Her Majesty’s Courts and Tribunal Service (HMCTS) NHS Derby City (Primary Care) Derby Hospitals NHS Foundation Trust Derbyshire Healthcare NHS Foundation Trust (Child and Family Service) Derbyshire Healthcare NHS Foundation Trust (Mental Health Services) University Hospitals of Leicester  (Summary Report) Nottingham University Hospitals NHS Trust (Summary Report) CAFCASS Homestart Derby (Summary Report)  2.21 A Health Overview report was produced drawing together the issues and findings from the health IMRs. This was of a very high standard and helpfully laid out the complex medical issues that DD12 faced and dealt well with the medical evidence in court.  2.22 The serious case review sub-committee declared that the individual management reviews produced from health organisations were of an acceptable standard for the purposes of this review.  2.23 The Health Overview report was particularly helpful in describing the considerable activity of health professionals. In addition it was analytical, thorough, considerate and introduced the phrase “dominant narrative” which this report uses.      2.24 The remaining IMRs were as follows:   Derby City Council (Children’s Social Care)  Derbyshire Police  Derby City Council (Legal Services)  Her Majesty’s Courts and Tribunal Service  CAFCASS  Homestart Derby (Summary Report)   2.25 The IMRs from Derby children’s social care, Derbyshire police and Derby’s legal services were of a high standard.  2.26 The legal services IMR helpfully explained the legal implications of the case. It was constructive and reflective though the panel didn’t always agree with the conclusions.   2.27 Derby’s children’s social care IMR was thorough, reflective and identified a number of areas where practice could have been have been better at the time.  9  2.28  Derbyshire police were not heavily involved in this case but their IMR was of a high standard and considered the strategy meeting in detail and made recommendations from that event.  2.29  The panel were pleased that Her Majesty’s Courts and Tribunal Service produced an IMR. In addition the commissioner’s presence at panel meetings was helpful in explaining the legal system within which the Magistrates operated. The same commissioner also assisted the overview author with the wording of the recommendation aimed at ensuring that Magistrates receive accurate advice on the scope of their decision making in Emergency Protection Order applications and that their Legal Advisers manage such applications effectively.  2.30  The Cafcass IMR addressed the issue pertaining to the role of the children’s guardian during the court case and helpfully outlined her responsibilities. There was some discussion at panel meetings regarding the quality of this IMR as there was a view that it lacked reflection. Following considerable email exchange between the panel chair and Cafcass’ Head of Service (Corporate Services) the panel formed the view that the situation in which the children’s guardian found herself was so unusual, her options so limited by judicial rules, that the IMR had appropriately covered the issues.   2.31  The Homestart Derby IMR was understandably limited as there were only two events where Homestart Derby were involved with the family.  2.32  The reports were generally of a high standard, some exceptionally so. All were good enough in terms of providing the panel with the information that they required to conduct the review and produce this report.  3 NARRATIVE OF EVENTS  3.1  The following part of this report details the events which are significant to this review. Because of DD12’s condition and the injury that he received DD12 spent much of his short life in hospital. His story is divided into the following seven sections:  1. Background information 2. Pregnancy 3. Hospital: Post birth to 18/01/12 4. Period at home 18/01/12 – 12/02/12 5. The s47 investigation 12/02/12 – 16/02/12 6. Court case 17/02/12- 22/02/12 7. After the court case 29/02/12 until the death of DD12  3.2   Sections 1, 2, and 3 are not covered in detail, because there were fewer significant events during these periods.   3.3   This report then covers the time from DD12 going home following his birth until his death in greater depth. It is the panel’s view that this is the period of greatest significance in identifying lessons to learn.  10  Background information  3.4  A thorough analysis of the information relating to mother and father was conducted by IMR authors from the following organisations: a. Children’s Social Care b. Derbyshire Healthcare NHS Foundation Trust, (mental health services) c. Derbyshire Healthcare NHS Foundation Trust, (child and family service) d. NHS Derby City (Primary Care) e. Derbyshire Police f. Derby Hospitals NHS Foundation Trust  3.5  The findings were considered in two joint meetings between IMR authors and panel members.  The panel could identify no background information that was significant in explaining the events that led to this review. The details have therefore not been repeated in this report to protect the privacy of the individuals involved.   3.6  The GPs who saw father were not consistently aware of the link with DD12. The GP practice as a whole had information about DD12 as mother and DD12 were also registered with them. However the practice did not ensure that this information was effectively shared amongst its GPs.   Pregnancy 3.7  Mother found that she was pregnant with DD12 on 14th February 2011. Because of the death of an earlier child she was referred by the midwife to the SUDI1 health visitor who introduced mother to the CONI2 scheme and to the perinatal mental health3 services team. The CONI team “arranged for provision of a breathing alarm and symptom diary to use after the baby was born and arranged infant cardiovascular resuscitation training, all of which is standard practice”, Health Overview report”, (paragraph 4.1.1).   3.8  On 19th July 2011 Senior OT, from the perinatal mental health team, wrote to mother saying that she had tried on a number of occasions to ring her (eight times between 7th July and 4th August 2011) and she included a list of the telephone numbers that she had tried. The letter asked mother to contact Senior OT Perinatal MH Services. “…Senior OT Perinatal MH Services…contacted mother by telephone on 9th August…Mother stated that she did not currently want input, but was happy for Senior OT Perinatal MH Services to call her in September,” Derbyshire healthcare NHS foundation trust (mental health services), (paragraph 5.1).   3. 9  DD12 was born in the maternity unit of Derby hospital. He was “floppy and unresponsive at birth and required resuscitation….he had a…..narrowed gullet and an opening between his oesophagus and windpipe.  He was transferred to Queen’s Medical Centre (QMC) in Nottingham for surgery where he was operated on for this                                                            1 Sudden unexpected death in infancy. 2 Care of the next infant. 3 The Perinatal Community Mental Health Team is a specialist service which aims to provide treatment and care in order to support women who are experiencing a range of mental health difficulties associated with pregnancy and the postnatal period.   11  abnormality but where he was also found to have a complex heart defect that necessitated his transfer for specialist care to the paediatric cardiac unit (Glenfield Hospital) at Leicester.  He had surgery there to improve the functioning of his heart,” Health Overview report, (paragraph 4.2.1).  Hospital: Post birth to 18/01/12 3.10  Mother and DD12 spent the next fifteen weeks in hospital. For most of that time DD12 was cared for at Glenfield hospital where mother was able to stay in parent accommodation. DD12 was unable to feed properly and had to be fed through a nasogastric tube. “DD12’s heart defect was a significant one that until relatively recently would have been considered inoperable.  Only partial repair is possible in early infancy and further corrective surgery would have been required at a later stage.  It is unlikely, however, that even the further surgery would have resulted in DD12 having a normally functioning heart,” Health Overview report, (paragraph 4.2.1).  3.11  On 19th October 2011 father visited his GP. The notes do not indicate that he told his GP that he was now a father.   3.12  On 1st November 2011 the Senior OT Perinatal MH Services telephoned mother and was told of DD12’s condition. “During the telephone call, the Senior OT Perinatal MH Services and mother had discussed how mother's worst fears have been realised in relation to her last pregnancy”, Derbyshire healthcare NHS foundation trust (mental health services), (paragraph 5.1).   3.13  Senior OT Perinatal MH Services received no further contact from mother and so, on 21st December 2011 the Senior OT Perinatal MH Services wrote to mother and eventually discharged her from the care of the perinatal mental health team on 15th January 2012.   3.14  On 6th January 2012 DD12 was moved from Glenfield to Royal Derby Hospital.  Twelve days later then aged 3½ months, he was discharged from hospital and with his mother moved into father's home; Mother had previously been living with her mother. Mother had stayed with DD12 throughout his time in hospital, father had visited regularly. They had both been trained in, and were competent with nasogastric feeding. Referrals had been made to CONI, speech and language therapy and the KITE4 team.  3.15  DD12 had been in hospital for 105 days. According to the Children Act 1989 s85(1)(a) a referral should have been made from Derby hospital to the local authority as soon as he had been in hospital for three months; on 5th January 2012.   Period at home 18/01/12 – 12/02/12 3.16  Mother, DD12 and father lived at father's house for the remainder of DD12’s life apart from when he was in hospital. Between 18th January and 12th February 2012 all professionals case records are positive about the way in which mother and                                                            4  Kids in their environment. The KITE team is a specialist nursing service for children with long term conditions and special needs who require extra care and support so that they can be nursed at home. 12  father looked after DD12, with mother being noted to be the primary carer and father helping at night.    3.17  During this period.   professionals visited DD12 at his home on 6 occasions,   professionals spoke to mother on the phone on 19 occasions,   he was seen at the GP surgery or hospital on 5 occasions,  professionals spoke or wrote to each other about DD12 on 18 occasions.  3.18  There were 18 working days between 18th January and 12th February 2012, so on average something was taking place 2.66 times per working day, most of these were related to DD12’s health needs.   The s47 investigation 12th – 17th February 2012:  3.19  At 3 a.m. on Sunday 12th February 2012 mother telephoned the GP out of hours service to say that DD12’s nasogastric tube had fallen out and she had no money to take DD12 to hospital. She was advised to contact children’s social care for support with funds and it was suggested that she should keep an emergency amount of money available.  3.20  Later that morning mother took DD12 to the children’s emergency department at Derby hospital for the nasogastric tube to be reinserted. While she was there she mentioned to staff nurse (SN1) that “something was bugging her” because father had, the previous day, noticed a bruise on DD12’s penis. “When encouraged to speak, Mum informed me that DD12 had been in department yesterday5 and for a time was left with two nurses. This morning at home her partner had noted bruising to his penis. I then asked Mum to strip baby down to his nappy so I could take a look at these bruises. I fetched Ward Sister to witness any other comments by Mum in regards to these bruises” Derby hospitals NHS foundation trust IMR.  3.21  A Paediatric Registrar (1) was called to examine DD12 who was later examined by a second doctor, (Dr C). “Their examinations showed pinprick bruising to the …penis,” Health Overview report (paragraph 4.4.2).    3.22  Someone, (name not recorded) from the hospital contacted children’s social care to inform them of these developments at 8.40 a.m. that day.  3.23  DD12’s situation was discussed at the morning ward handover meeting and it was agreed that a full child protection medical should be carried out.  3.24  Later that morning another doctor, Paediatric Consultant (1), looked at DD12 and agreed that there was unexplained bruising to the penis. He documented his findings as a drawing in the notes.   3.25  At 5.30 pm the Locum Paediatric Consultant telephoned the children’s social care out of hours team. Following this she recorded “discussed need for full child                                                            5 It was in fact the day before yesterday 13  protection medical and investigations with duty social worker Derby Careline. She had advised NOT to do child protection medical today after discussing with police. In view of Mum’s accusation that the bruising could only have happened in CED6, police and social care services want to do a joint child protection medical tomorrow,” Derby hospitals NHS foundation trust IMR.   3.26  Derby Careline, out of hours social worker, rang Detective Sergeant (1) for a strategy discussion. According to the police record of this discussion, Derby Careline said that DD12 had a “significant bruise” on his penis.  A plan agreed was that DD12 would stay on the ward overnight; a child protection medical would be undertaken the next day and photographs would be taken by the police.  3.27  On the morning of Monday 13th February the first contact team manager in children’s social care received a referral from Careline, social care’s out of hours team, regarding Sunday’s events. It was decided the situation warranted a s47 investigation and the matter was referred to the Reception Team Manager (RTM 1).   3.28  Reception Team Manager (RTM 1) allocated the case to a social worker (SW1) and spoke to the police to arrange a joint medical. Children’s social care records “show that immediately prior to the medical, Social Worker (SW1) met with Safeguarding Lead RDHFT,(the Trust’s named nurse for safeguarding),  Detective Constable (DC1) and Detective Constable (DC2) as well as the examining doctor, Paediatric Registrar (PR1) and DD12’ complex medical history was shared. A full history was taken at the medical which included some information about the death of Child (1), Father's bi-polar diagnosis7 and mother's epilepsy,” Children’s social care IMR, (page 5).  3.29  Later that morning Paediatric Registrar (PR1) completed the child protection medical. “Present at the medical examination were the Social Worker, Detective Constable (DC1) and Detective Constable (DC2) from the police Child Abuse Unit, the Scene of Crime Officer (SOCO) photographer, and DD12's mother. The Paediatric Registrar’s (PR1) findings were noted as “Unexplained bruising and petechiae to dorsum of penis in 4 month old with no history of injury. Patient is on aspirin but has no other bruising apart from at venepuncture (blood test) sites. Therefore need to consider non-accidental injury and plan to investigate as discussed with on call consultant (Locum Consultant (LC1))”. Derby hospitals NHS foundation trust IMR.  3.30  Paediatric Registrar (PR1) wrote on a piece of paper, “initial outcome of child protection procedures (normal paperwork unavailable): I have concerns regarding unexplained bruising and petechial rash which will require further investigations as discussed with the on call consultant (Locum Consultant (LC1)). This was copied to the Social Worker” Derby hospitals NHS foundation trust IMR.  3.31  The police noted at this stage that “the doctor would not give a medical opinion as to the cause of the bruising as further tests were to be conducted and the results could affect that opinion,” police IMR (paragraph 2.1.30).                                                             6 Children’s emergency department at Derby hospital 7 This recording is inaccurate as Father had not been diagnosed with bi-polar (see paragraph 4.2) 14  3.32  Social Worker (SW2) told the mother and father that contact would need to be supervised. They gave Social Worker (SW2) a list of three family members who they thought would be suitable supervisors. Checks identified that two would not be suitable, because of a criminal history and known links with a sex offender and the third was unavailable. Children’s social care therefore set up a rota of supervisors thus ensuring that mother and father could be with DD12 for six hours per day.   3.33  Not related to this s47 investigation but, on the same day, the Dietician recorded the following concerns, “feel there are often slight inconsistencies in the information Mum provides e.g. no improvement with increased dose of ranitidine, whereas DD12 only vomit 3 times in 24 hours rather than after every feed,” (Royal Derby Hospital Dietician (Dn1) internal chronology 13/2/12).  3.34  On Tuesday 14th February 2012 clinical photographs were taken during the contact between DD12 and his parents. DD12 underwent a series of further tests which concluded that there was “no medical cause for the bruising” Health Overview report, (paragraph 4.4.5).    3.35  On Wednesday 15th February 2012 DD12 was sedated and taken for an x-ray for a skeletal survey that showed nothing untoward.  3.36  On 16th February 2012 a strategy meeting took place at the hospital attended by:  Detective Sergeant (DS2),  Reception Team Manager (RTM2) Safeguarding Lead RDHFT Named Nurse,  Locum Consultant (LC1),  Paediatric Registrar (PR1),  QMC Named Midwife,  Social Worker (SW2)   3.37  No other professionals were invited, however “On the 16th of February 2012 attempts were made…to try and obtain the time of the Strategy Meeting, so that a Health Visitor could attend….The Health Visitor had not been invited to this meeting,” Derby hospital IMR.  3.38  The strategy meeting was chaired and minuted by Detective Sergeant (DS2). The handwritten notes state that “DD12 had an unexplained bruise to the shaft of his penis and it was not safely concluded that the bruise was the result of an accidental mechanism or cause… it was decided that DD12 was to stay on Puffin ward, that Social Care and the Police were to review all background on DD12's mother and father and to consider interviewing them,” police IMR, (paragraph 2.1.33).    3.39  The CSC IMR stated; “The possibility of the bruising being caused by hospital staff in taking a urine sample was considered…. and could find no evidence that this intervention could have caused the bruising………Various other possible causes for the injury were considered and ruled out, so it was concluded that the injury must have been caused non-accidentally. Medical staff were not asked for and did not give a view of what might have happened, other than pressure had been applied to his penis,” (page 7). 15   3.40  The Derby hospitals NHS foundation trust IMR states that “A strategy meeting, held on 16th February 2012 was attended by both Paediatric Registrar (PR1) and Locum Consultant (LC1). The medical notes of these are rather brief, and discuss the “unexplained bruising” on DD12’ penis, but there is no clear opinion written regarding likelihood of non-accidental injury…..Having spoken to Paediatric Registrar (PR1) and Locum Consultant (LC1), both recall that the opinion had been clearly stated at the meeting that they felt this was likely to be non-accidental injury,” Derby hospitals NHS foundation trust IMR.  3.41  The decisions of the strategy meeting were that:  a) DD12 would remain in hospital b) Children’s social care and police would review background information on mother and father c) Legal advice would be sought, d) The child protection manager would be informed of the possible “LADO8 issues” relating to DD12’s examination by medical staff.  3.42  Reception Team Manager (RTM2), a manager in children’s social care made two telephone calls to the local authority legal services, one to one Local Authority Solicitor (SOL1) and later to a second Local Authority Solicitor (SOL2). Legal advice was that the social workers should find out whether the parents would agree to an alternative placement within the family or whether they would agree for DD12 to be accommodated voluntarily as, if neither were possible there would be grounds for an application for an emergency protection order9.  3.43  Legal services made an application to court once Reception Team Manager (RTM2) indicated that there was no suitable alternative family placement and that neither mother nor father would agree to s.2010 accommodation. “A medical report dated 14/02/12 with an addendum dated 16/02/12 (described by the children’s social care IMR author as a ‘very detailed report’) was received from Consultant Paediatrician (CP2) and emailed to the court on the morning of 17/02/12.  The report concluded, “In view of these unexplained marks on his penis, non accidental injury must be considered”, Legal services IMR, (paragraph 6.7).  “…papers were drafted and emailed to the court and mother’s solicitor.  The court fixed a hearing for 17/02/12 and a barrister (LS) was booked and briefed to attend court as there was no-one available in the team to cover the hearing,” Legal services IMR, (paragraph 6.6).  3.44  The court agreed to list the matter the following day at 10am before the Family Proceedings Court at Southern Derbyshire Magistrates’ Court. “The reasons for the application were stated to be: ‘DD12 was admitted to hospital following his                                                            8 Local authority designated officer, LADO issues is jargon relating to possible abuse of children by members of staff 9 An emergency protection order allows a local authority to have parental responsibility, shared with parents and others with parental responsibility, for up to eight days. They can therefore decide where the child shall live for that period. The situation has to be an emergency for the order to be made and there has to be reasonable cause to believe that the child is likely to suffer significant harm. The legal services IMR author produced a detailed guide to emergency protection orders and that is included as appendix two of this report.   10 Whereby parents agree to their children being looked after by the local authority 16  father noticing bruising and swelling to his penis when he was changing him. A medical examination was undertaken by Paediatric Registrar (PR1), the outcome of which was that the injuries should be considered non-accidental in nature. Parents have not been able to give any explanation for the injuries. The hospital has confirmed they will keep DD12 in overnight however, mother has refused to give her consent to s20 accommodation’”, HMCTS IMR, (paragraph 3.7).  3.45  The supervisors and hospital staff throughout this time noted that contact between DD12 and his parents was positive; Mother in particular was observed to be capable of looking after him well and both parents appropriately questioned and challenged staff about his care.  Court case 17/02/12- 22/02/12  Day one Friday 17th February 2012  3.46  The parties (local authority and parents) asked the court to adjourn the case. The parents’ representative wanted time to consider the questions that would be put to the doctors and the local authority wanted time to consider the possible explanations that the parents put forward for the bruises.  3.47  The court also made a number of directions which included appointing a Children’s Guardian from Cafcass, asking that Paediatric Registrar (PR1) be present and asking the parents to file statements regarding their explanations for the injury.  The Principal Legal Adviser to Derbyshire Magistrates’ Court sent a fax to CAFCASS advising them that DD12 was the subject of an Emergency Protection Order (EPO) application to be heard on 22nd February 2012…… The contact log shows that on 20.02.12 (the child’s guardian) Family Court Advisor appointed the CAFCASS Child's Solicitor (SolCh2) as the child’s solicitor and that they discussed the medical report as it did not fully support the injury being non-accidental insofar as it stated that “in view of these unexplained marks on his penis, non-accidental injury must be considered,” CAFCASS IMR (excerpts from paragraphs 5.1-5.5).  3.48  The Family Court Advisor discussed the case with CAFCASS Service Manager her service manager. “They discussed a possible residential placement for mother and DD12 or a “mother and baby” foster care placement. This was influenced by concern about the impact of removing a poorly baby from his main carer at a critical time health wise, as mother would be the person most alert to any changes in DD12’s health. This had to be balanced against any potential risks to the baby”, CAFCASS IMR (paragraph 5.8)”.  3.49  Prior to day two father and mother's barrister supplied the court with statements stating that, in their opinion, there were a variety of possible causes for the bruising which included the mother ‘catching’ DD12 with her rings, car straps pressing against him, a tight nappy and him being bruised when held too tightly whilst he was being dressed.    17  Day two Wednesday 22nd February 2012 (six days after the application)  3.50  At the beginning of day two and “Prior to appearing in court Paediatric Registrar (PR1) had discussed the case with Trust Named Doctor,  and was clear that the message she needed to give was that there was no feasible accidental cause for this bruising,” Derby hospitals NHS foundation trust IMR.   3.51  Paediatric Registrar (PR1) gave evidence first and notes were taken at the time by a representative of legal services. She said that the bruises were “significant findings” and were unlikely to occur in normal handling of DD12.  3.52  Paediatric Registrar (PR1) was cross examined by representatives for both parents and the children’s guardian. According to the legal IMR author she became upset by this but the local authority legal representative in court, the Local Authority Barrister, did not feel that this questioning, though full and forceful, was excessive.  3.53  Locum Consultant (LC1) then gave evidence.  During this evidence he stated, in cross-examination, that it was possible that DD12’s injury could have been caused by him jerking forward. “Family Court Advisor noted in the log that neither doctor…concluded that the injury was non-accidental but that it was unexplained,” CAFCASS IMR, (paragraph 5.10).  3.54  The hearing, which had started in the afternoon, was adjourned at 6.25pm with the parents again agreeing that DD12 could remain overnight in the hospital. “Both Paediatric Registrar (PR1) and Locum Consultant (LC1) felt after the court appearance they had clearly expressed the opinion that the most likely cause of DD12’s bruising was non-accidental injury. Both were clear that although training would be required in order for foster carers to be competent to care for DD12 this could be provided (information from interviews with Paediatric Registrar (PR1) and Locum Consultant (LC1)” Derby hospitals NHS foundation trust IMR.  Day three Thursday 23nd February 2012 (seven days after the application)  3.55  At the hearing on 23/02/12 evidence was heard from Social Worker (SW2), Safeguarding Lead RDHFT and the Children’s Guardian.   3.56  There was no representative from legal services available to take notes on this day so there is little information available regarding the evidence.  3.57  The hearing was again adjourned until the following day on the basis that father and mother agreed that DD12 could remain in the hospital.  Day four Friday 24th February 2012 (eight days after the application)  3.58  Mother's representative asked that the court make a finding of fact because of the implications that this decision would have for the parents and the future direction of social work involvement.   3.59  In the afternoon the magistrates, having considered the evidence, decided against making an order. “In making the judgement, the magistrates indicated that 18  they had ‘accepted Locum Consultant Paediatrician evidence’ thus indicating that Locum Consultant Paediatrician evidence had supported a conclusion that the injuries were accidental,” Health Overview report, (paragraph 4.5.6).  3.60  According to verbal reports from Social Worker (SW2) and Reception Team Manager (RTM 1) to the CSC IMR author, “…the Magistrates……..gave a clear statement in Court that this was an accidental injury. This was understood to be a Finding of Fact by Reception Team Manager (RTM 1), Social Worker (SW2) and subsequently in a letter from the Local Authority Solicitor (SOL 3) on 29/3/12 with copies of the orders,” Children’s social care IMR, (page 11).   3.61  A finding of fact in civil proceedings is a “fact on the balance of probabilities”. It may have been the case that professionals interpreted this logically as a “fact” – one that is incontrovertible.   3.62  A number of requests for the written up facts and reasons were made to the court by the local authority. These were eventually received on 18/10/12, (over seven months after the conclusion of the hearing), via email despite court rules stating that they should be sent within 72 hours of the hearing.   3.63  The document stated that the magistrates concluded that the injury to DD12 was accidental. They considered the only possible cause was that the injury could have been caused by holding DD12 on his front whilst he was vomiting. The magistrates noted that this possibility had not been refuted by the Locum Consultant (LC1) and concluded that DD12 was unlikely to suffer significant harm if left in his parents’ care.  3.64  Throughout this time, mother and father had only agreed to DD12 staying in hospital until the next date in the hearing.   Home to second injury 29th February 2012 – 8th May 2012  3.65  DD12 remained in hospital after this ruling for medical management of his ongoing vomiting and an infection that he had picked up whilst in hospital. A discharge planning meeting was held on 29th February 2012 attended by nursing staff, liaison health visitor, health visitor, dietician, speech and language therapist and mother. None of the doctors who had been involved in the court case were present. Children social care were not at the discharge planning meeting because of a lack of clarity and shared understanding between the key professionals about their future on going involvement.   3.66  The meeting focused upon DD12’s health needs and mother's CONI needs. “His discharge letter identified “Penile bruising – accidental injury” as the main diagnosis, although it was clarified in the text that this was a ruling of the court not a medical diagnosis,” Health Overview report, (paragraph 4.5.9). DD12 was discharged home on the 29th February 2012.  March 2012:  professionals visited DD12 at his home on 7 occasions,  19   professionals spoke to mother on the phone on 17 occasions,   he was seen at the GP surgery or hospital on 11 occasions,  professionals liaised with each other about DD12 on 23 occasions.  3.67  There were 24 working days in March so on average something was taking place 2.4 times per day, most of these were related to DD12’s health needs. Of particular significance were:  3.68  On 2nd March 2012 the Social Worker (SW2) and a student social worker (SSW1) visited mother, DD12 and father and noted good interactions between them all. The case records state, "During the visit either mother and father  held DD1211…he appeared responsive and happy with both parents, smiling a lot…Both father and mother displayed affection towards DD12, tickling his sides, speaking in soothing tones and making loving comments. Both parents appeared confident in holding DD12 and we observed mother support father by suggesting he hold DD12 facing him as the way he initially held DD12 was similar to the mechanism which they had argued in court, on reflection, may have led to DD12's unexplained injury (resting DD12 on hip, with DD12's back to father’s hip), " Children’s social care IMR, (page 12).  3.69  On 5th March 2012 Social Worker (SW2) completed a core assessment. The summary stated, "the view of the medics at the time of the child protection medical was that it was unexplained and non-accidental injury had to be considered…….the Court concluded it was an accidental injury. Parents gave an explanation…… Locum Consultant (LC1) felt this may be a reasonable explanation……No concerns have ever been raised regarding parenting capacity in this [hospital] environment…….It is felt parents would benefit from on-going targeted support around DD12’s specific needs……to enable more assessment of the family in the home," Children’s social care IMR, (page 12).  3.70  Later that day a transfer request was made by Social Worker (SW2) to Lighthouse, the children with disability, children’s social care team.   3.71  DD12’s case wasn’t allocated to a social worker in Lighthouse until 26th March 2012. The first visit to the family home by Lighthouse Social Worker (SW3) took place on 28th March 2012. "Mother began by saying that she was glad that we had visited as they needed more help than they had realised. She said that she was tired and things were 'doing her head in' as there were too many appointments - but added that she realised they were important for DD12," CSC IMR, (page 14). “Social Worker (SW3) reported her observations were that they interacted positively together and there was no sign of tension between them…though tired, neither presented as emotionally flat or low, nor as anxious or agitated,” Children’s social care IMR (page 14).   April 2012:  professionals visited DD12 at his home on 5 occasions,   professionals spoke to Mother on the phone on 10 occasions,   he was seen at the GP surgery or hospital on 9 occasions,                                                            11 Mother, Father and DD12 20   professionals liaised with each other about DD12 on 6 occasions.  3.72  There were 21 working days in April so on average something was taking place 1.4 times per day, most of these were related to DD12’s health needs. Of particular significance were:  3.73  On 11th April 2012 Social Worker (SW3) from Lighthouse made a referral to Homestart Derby for “volunteer support for DD12’s mother…as mother was anxious regarding DD12’ complex health needs,” Homestart Derby IMR, (page 7).  3.74  On 16th April 2012 Homestart Organiser visited mother and identified the needs of the family as, “emotional support and encouragement regarding DD12’s health needs, to accompany out for a walk or to attend groups with and to interact/play with DD12 if mother had jobs to do in the home,” Homestart Derby IMR, (page 7).    3.75  On 17th April 2012 CON1/Liaison Health Visitor (HV7) visited mother at home. “DD12's mother reported at this visit that she was providing most of the care for DD12 and that he cried when father tried to help.  This was not explored further,” Health Overview report, (paragraph 4.6.2).  May (up to 7th May)  professionals visited DD12 at his home on 2 occasions,   professionals spoke to mother on the phone on 2 occasions,   he was seen at the GP surgery or hospital on 1 occasions,  professionals liaised with each other about DD12 on 2 occasions.  3.76  There were 4 working days in the first week in May so on average something was taking place 1.75 times per day, most of these were related to DD12’s health needs. Of particular significance were:  3.77  On 3rd May DD12 and mother were seen by two professionals and a volunteer. These were; the Homestart Organiser and a volunteer, (both of whom visited DD12 at his home) and Family Health Visitor (HV4), who visited later in the day.    3.78  The Homestart volunteer visited with Homestart Organiser. The Homestart Organiser noticed a yellow fading bruise on DD12’s forehead which she queried. Mother said that his feeding bottle had fallen off the sofa and hit him. Mother also said that she had noticed a bit of blood in DD12’s ear which she thought may have been caused by sharp fingernails but that this had gone once she had wiped it away. The Homestart Organiser suggested that mother should mention this to the health visitor whom mother had said would be visiting later that day.      3.79  When Family Health Visitor (HV4) visited later that day she did not see a bruise and no mention of it was made by mother.  Family Health Visitor (HV4) noted that DD12 was alert and smiling, had made good weight gain and was settling well at night.  Mother mentioned the bleeding from the ear to Family Health Visitor (HV4)just before she left.  Family Health Visitor (HV4) looked at DD12’s ear but could see no 21  source for the bleeding. She suggested that mother should take DD12 to see the GP if this recurred.   8th May 2012:  3.80  When interviewed for this review mother told me that she went out in the early evening with her mum to buy some fish and chips leaving DD12 alone with father . After about fifteen minutes she received a call from father saying “DD12 is dead” and she rushed home to find paramedics at the house about to take DD12 to hospital. She went there with father. “DD12 was very ill on arrival at hospital; he was in circulatory collapse, was making no respiratory effort and required intubation and ventilation.  Four areas of bruising were noted around his head.  A scan (computerised tomography) of his head showed acute (fresh) on chronic (older – 4 to 8 weeks) subdural haematomas (bleeding and blood clots) on both sides.  No bony injuries were noted.  Once his immediate care needs had been addressed in Derby he was transferred to the specialist neurosurgical service at QMC in Nottingham.  It was not felt that the history given was consistent with the injuries found and a non-accidental cause was therefore thought to be highly likely. DD12’s injuries were very serious and, despite the intensive care provided at QMC, no signs of recovery were apparent.  He died in his mother’s arms, after removal of intensive care, at 22.26 on 09.05.12,” Health Overview report 4.7.2-4.7.3  4. ANALYSIS  How were the specific mental health issues in respect of father and mother understood, were the right services in place and what impact did this have on the outcome?  4.1  There is no evidence that mother was suffering from any diagnosed mental health problem. She had been in receipt of services from the perinatal mental health team, but this was due to her understandable anxiety about being pregnant after the death of Child (1). Therefore her emotional health needs, as far as the anxiety was concerned, were addressed.  4.2  Father received help for his mild mental health problems; he had been stable since 2005.  4.3  The recorded information relating to father was of little significance but “no information from mental health services or his GP was obtained and his mental health history was unknown to social care throughout their involvement,” Children’s Social Care IMR, (page 18).  4.4  Children’s social care did not contact father's GP during the s47 investigation. According to the children’s social care IMR author this was because the case was being handled by a manager as Social Worker (SW2) was on annual leave and the hospital had shared information about DD12’s health condition. Whilst not condoning this omission the IMR author suggests that the omission occurred because of a lack of time. The core assessment completed by Social Worker (SW2) stated that, “further enquiries were needed including into father's mental health,” CSC IMR, (page 12). 22   4.5   DD12’s GP did not appear to be aware of the child protection concerns. This lack of contact meant that a re-assessment of father's mental state was not considered either following DD12’s birth or after the court case. A re-assessment could have examined “the potential impact of the significant changes and pressures that had occurred in father’s life: a. His son had been born with life threatening medical problems and both parents must have had to prepare themselves for the possibility that DD12 might die in his early weeks b. Parental joy over his survival must have been tempered by the knowledge that DD12’s future contained further major surgery, an uncertain level of ultimate health potential and even the possibility of a shortened lifespan c. DD12's mother was resident in hospital with DD12 for over three months, much of this time in Leicester.  Although father also spent time at the hospital, he faced the practical difficulties of transport and cost and may also have experienced feelings of exclusion d. When DD12 was discharged from hospital he and his mother moved to live in father’s house.  This was the first time that DD12's mother and father had lived together and so it is likely that father will have had to make significant practical and emotional adjustments.  It is quite possible that there would have been a degree of ambivalence in his feelings about this,” Health Overview report, (paragraph 4.3.4).  4.6  In summary the information relating to father's mental health was never properly taken into account at any time during the work with the family. Had it been it is unlikely that it would have been considered particularly significant, nevertheless due consideration was not given to the impact of DD12’s situation on father's mental health. This would have been more likely to be considered had   the court not limited the options of child protection processes following their finding of fact  the court not limited the option of a prosecution following their finding of fact  children’s social care included a summary of Father's mental health  the GPs dealing directly with father known of DD12’s existence and his medical problems.   How were the circumstances of the Sudden Unexpected Death in Infancy (SUDI) in 2009 assessed and in consideration of this what action was taken at that time and once agencies became aware of mother's pregnancy with DD12?  4.7  Child (1)’s death was investigated at the time following national protocols and no suspicious circumstances were identified. Mother was offered support at the time (which she said had not met her needs). The federation for the study of infant deaths has recognised that “the particular needs of very young parents who have suffered a SIDS death who tend to want support immediately and on their own terms is difficult for traditional services to respond to,” Health Overview report, (page 23).    4.8  Mother was referred by the midwife to the SUDI health visitor in the early stages of her pregnancy and this resulted in support being offered to mother by the CONI scheme. She was also referred to the perinatal mental health team.  23  4.9  Appropriate care, advice and support about Child (1)’s death was offered to mother. There are no indications that there are any links between Child (1)’s death and DD12’s death.   How was the impact of domestic violence in existing and previous relationship understood and its impact addressed?  4.10  Domestic violence appears to have been understood and its impact correctly assessed as being negligible.  4.11  Children’s social care records were checked when the referral was made by staff at Derby hospital in February 2012. It transpired that both parents had been involved in some low level of domestic abuse in their lives.   4.12  Father had a previous relationship and there had been one incident of domestic violence with the partner that involved the police in 2009.   Whether specific opportunities existed prior to the birth of DD12 to improve his likely outcomes  4.13   Given that mother's pregnancy with DD12 was normal, there was no indication that he was going to have complex health needs before his birth and past children’s social care involvement with his parents did not indicate any serious cause for concern for his future well-being - there were no opportunities prior to his birth to improve his likely outcomes.   Why did the local authority fail in their application for an emergency protection order and why did the magistrates make a finding of fact?  4.14  The refusal of the court to make an Emergency Protection Order and the decision of the court to make a specific finding of fact, namely that the injury to DD12’s penis was accidental, influenced how professionals then approached work with the family. It is worth outlining the events, and drawing out the lessons, that led up to the decision and, in the process, address why the local authority were unable to obtain a court order which enabled them to take steps to protect the child.   4.15   From the moment that mother said that “something was bugging her” on 12th February 2012 the professionals who saw DD12 at that time and up to the end of the court case were suspicious about the cause of the injury. They followed the child protection procedures and ensured that DD12 was protected from further harm, at least until the conclusion of the court case. Taking the events chronologically there is learning from the way in which the injuries were recorded,  the strategy meeting,  the decision to apply for an emergency protection order,  the way in which evidence was presented,  the way in which the case was heard,  the way in which professionals acted after the hearing.  4.16  This analysis will draw conclusions that decisions could have been made differently and will suggest that a different conclusion at, or after, the hearing might 24  have had a different outcome for DD12. These conclusions are made with the benefit of hindsight and take into account the view that the action of the professionals would be unlikely to be different to professionals in other Authorities had these events happened elsewhere. It should also be acknowledged that it is an unusual set of circumstances that are being analysed.  The way in which the injuries were recorded  4.17  There has been some debate amongst the panel regarding the number of times DD12 was examined by doctors and for what purpose although it is unlikely that the number of medical examinations had any effect on the outcome. He was examined by three doctors on 12th February 2012 and yet the out of hours social worker “advised NOT to do child protection medical today after discussing with police” Derby hospitals NHS foundation trust IMR.  4.18  The child protection medical was completed the next day in 13th February 2012. The Health Overview author questioned this practice. “A paediatric medical examination is the same whether carried out for medical or child protection purposes…..Normal practice when a child is seen by DHFT with an injury of concern would be to record the initial examination onto the formal proforma and use that as the basis for a structured report to Children’s Social Care services and/or the police.  It is not clear why a separate examination was deemed necessary on this occasion,” Health Overview report, (page 11).  4.19  This view was not shared by the police IMR author who wrote: “The fact that DD12 was initially examined on 12 February and then re-examined in the Child Protection medical on 13 February did not cause confusion but allowed photographs to be taken of the injury,” Police IMR, (paragraph 3.3.5).  4.20  When a child comes to a hospital with an injury the practice of separating out paediatric and child protection examinations is common and is not contrary to procedures. However it is not necessarily good practice and it may be distressing for older children to be examined more than is necessary.   4.21  The photographs (the existence of which the local authority legal advisers were unaware) were not used in the emergency protection order hearing. “No conclusions can be drawn as to whether use of these photographs would have changed the outcome.  However, it is clearly important that the court has access to all relevant information and good practice would have been to ensure that the photographs were made available,” Health Overview report, (page 22).  4.22  The children’s services IMR author suggested that these medical examinations may, in any case, not have been the correct ones. “There was however no consideration between Hospital, Police or Social Care as to whether the existing examination was sufficient from a child protection medical perspective, nor whether a further medical should have been a specialist sexual abuse medical given the injury was to DD12’s genitals. Both would have been good practice,” Children’s social care IMR (page 19).  25  4.23  Paediatric Registrar (PR1), on completing the child protection medical on 13th February 2012, drew a body map on a piece of paper and made notes of the injuries. Normal practice in Derby is for doctors to use an immediate opinion form but one wasn’t available. The form includes the following section.  NAI (Non Accidental Injury)  NAI more likely than accidental injury  Accidental injury more likely than NAI  Accidental injury  Injury unclear and requires further evidence before NAI ruled out  No injury seen   No injury seen but risk of significant harm based on story   4.24  The doctor completing the form is therefore encouraged to express an opinion at an early stage of the process. The absence of the form resulted in uncertainty among professionals as to medical opinion regarding possible causes of the injury. “The unavailability of the immediate medical opinion form is unexplained; this has been identified as a concern by the Named Doctor Child Protection for DHFT and been addressed with the department concerned,” Health Overview report, (page 11).  Strategy meeting  4.25  The strategy meeting was arranged by Reception Team Manager (RTM 1) on 13th February 2012 following a strategy telephone discussion on 12th February 2012 between Derby Careline from children’s social care and Detective Sergeant of the police. The meeting on 16th February 2012 took place at the hospital which allowed the relevant doctors to be present and was also attended by professionals from police and children’s social care. Staff who knew DD12 and his family were not invited though Family Health Visitor (HV4), DD12’s health visitor had tried to find out details of the meeting; thus no staff were present who knew the family.   4.26  Derby’s strategy meeting procedures suggest that Family Health Visitor (HV4), and other staff members, could have been invited as they state that a strategy meeting, “should usually involve Children's Social Care, the Safeguarding Children Manager/Child Protection Manager, the Police, and other agencies as appropriate (for example, legal services, children's centre/school and health) and in particular any referring agency,” http://derbyshirescbs.proceduresonline.com/chapters/p_strategy_discussion.html#multi_age_invol  4.27  The minutes of the meeting were handwritten and sparse and it appears that the meeting was somewhat limited in its approach though it did address the urgency of the situation.   4.28  The Paediatric Registrar (PR1) and Locum Consultant (LC1) were present, “both recall that the opinion had been clearly stated at the meeting that they felt this was likely to be non-accidental injury” Derby hospitals NHS foundation trust IMR, a view not entirely shared by the social workers and police officers who were present: “The notes state that DD12 had an unexplained bruise to the shaft of his penis and it was not safely concluded that the bruise was the result of an accidental mechanism 26  or cause,” police IMR, (paragraph 2.1.33). “The meeting considered and ruled out….any medical cause, and the doctors had been unable to identify any possible accidental cause. This then became interpreted by the doctors and others that it was therefore a non-accidental injury, by a process of elimination,” Children’s social care IMR, (page 21).  4.29  Despite the lack of a clear medical opinion “that DD12’s injuries were most likely non-accidental it is apparent that this view was articulated sufficiently clearly at the meeting for the outcome to be that legal advice was sought and an application for an Emergency Protection Order (EPO) was made later that day,” Health Overview report, (paragraph 4.4.9).  4.30  The children’s social care IMR author makes a number of observations about missed opportunities at this meeting. She states “there could have been more challenge between agencies which would have resulted in a clearer understanding of:  the exact nature and robustness of the medical evidence  police intentions with regard to criminal investigation and prosecution  timeframes around discharge from hospital  nature of any risks to DD12 of being returned home  options available to manage those risks and social care intentions, including contingency plans  any critical information still missing, Children’s social care IMR, (page 22),  and goes on to say: “These areas were insufficiently clear and this undermined social care’s attempts to keep DD12 safe through the EPO application”, Children’s social care IMR, (page 22).  4.31  The police IMR author suggests that: “Arrest and interview of the parents were considered but were postponed until the outcome of the hearing,” police IMR, (paragraph 3.3.12), and considers: “What would have been gained however? The Police knew the explanations of both parents and so any interview would have been likely to produce the same accounts” Police IMR, (paragraph 3.3.14).  4.32  It appears therefore that, although the strategy meeting in this case fulfilled the minimum requirements, there were a number of issues that remained unclear.  The decision to apply for an emergency protection order  4.33  The strategy meeting concluded that legal advice would be sought. That advice was that an application should be made for an emergency protection order because mother and father a) would not agree to voluntary accommodation for DD12,  b) there were no suitable family members who could care for him, and  c) it was unclear whether they would be prepared to agree to DD12 staying in hospital to allow for the hearing to take place.   4.34  The children’s social care IMR author wrote “it is my view the decision to apply for an EPO on 16/2 was premature (because the parents were not demanding 27  the return of DD12 at this point) – more information by all agencies could have been gathered and considered, even the following day, which may have resulted in a different decision or would have made any application stronger,” Children’s social care IMR (page 23).  4.35  It is also the view of the children’s social care IMR author that a Gateway12 meeting at this stage would have allowed a broader consideration of the options open to the professionals and a deeper consideration of care plans.  4.36  On the other hand the decision-making was complicated by the fact that throughout the court case father and mother would only allow DD12 to stay in hospital until the next hearing; indeed they could, if they so wished, remove him from the hospital immediately. It could therefore be argued that the case always remained an emergency and that an application for an emergency protection order always remained correct.  4.37  On the other hand there was a continuing duty on all professionals involved in the case to consider whether this application remained the best course of action and an application could have been made to withdraw the application for the emergency order.  4.38  There are no records to indicate that social workers worked with mother and father during the court case to try and get the parents to agree to an alternative care arrangement, though they had attempted this before the application. Had this have been agreed to a more measured and thorough assessment would have been possible.   4.39  Court proceedings are adversarial in nature and, once they have begun it is easy for professionals’ and family members’ views to become entrenched as legal processes get in the way of negotiation and direct communication. In interview with the overview author father spoke of how, in his opinion, there was a breakdown in the relationship with the social workers during this time.  The way in which evidence was presented  4.40  Both doctors had been advised that the hearing would be short and that they would not be giving evidence for long. This was based on other, more common, applications for emergency protection orders. In the event Paediatric Registrar (PR1) gave evidence for a number of hours and became upset by the pressure being exerted by the parents’ representatives. Nevertheless “the notes of the medical evidence and discussions with the barrister do not reflect overly aggressive questioning from the other legal representatives in court,” Legal services IMR, (paragraph 7.7.5).  4.41  According to the Health Overview author both the Locum Consultant (LC1) and Paediatric Registrar (PR1) still believe that the injury to DD12’s penis was a non-accidental injury. “When they left court they felt that they had given this opinion by                                                            12 A meeting between legal services and children’s social care to consider cases involving applications to court including care planning. 28  being clear that there was no medical explanation for the bruising,” Health Overview report, (paragraph 4.5.3).  4.42   However in giving evidence Locum Consultant (LC1) was asked about the possibility of the injury being caused by one of the parents holding DD12 face down and perhaps hurting him accidentally as he fell or convulsed. Locum Consultant (LC1) said that this was a possibility but only if DD12 had not been wearing a nappy and that it would be likely that the parents would have been aware of this as DD12 would have been distressed.   4.43  The CAFCASS IMR author wrote: “The Children’s Guardian told me in interview that medical evidence consisted of the medical report and the evidence of the two hospital doctors. The medical report described the injury as unexplained rather than non-accidental,” CAFCASS IMR, (paragraph 6.5.2).   4.44  Other professionals gave evidence, including the children’s guardian who was asked about the likelihood of DD12’s welfare being properly considered if he were to be placed with foster carers. Her reply mentioned the remoteness of the accommodation, though she also said that she had come across the foster carers before and they were experienced in caring for children with complex medical needs.  4.45  The outcome of the case hinged upon the medical evidence presented by the doctors and it appears that they left enough doubt for the magistrates to refuse to make the order. “It is unusual for medical evidence to be completely diagnostic in child abuse cases…In family proceedings the level of proof is on the balance of probabilities… It is unfortunate that neither of the doctors giving evidence articulated clearly and unequivocally that on the balance of probabilities they felt the injuries to be non-accidental,” Health Overview report, (page 13).  4.46  The local authority representative “expressed his disappointment….that the Locum Consultant Paediatrician (CP2) had not referred to “gripping” in his evidence,” Legal services IMR (paragraph 7.7.5).    4.47  The accounts of the court hearing given by each agency indicate that the medical evidence was not conclusive. This is likely to be the factor that led the magistrates to conclude that the injury was accidental and for that reason not to make an order. However the court was required to address a statutory test, namely whether the applicant had proved on the balance of probabilities that there were reasonable grounds to believe that the child was likely to suffer significant harm if not removed to accommodation provided by the local authority. Whilst the uncertain medical evidence was relevant to the consideration of this test, it did not require the court to make a definite finding of fact that the injury was accidental.  The way in which the case was heard  4.48  The case was heard on four days over an eight day period. From the beginning it was clear that this was going to be an unusual court case. When the hearing was first adjourned consideration could have been given to withdrawing the application for the emergency protection order and starting proceedings for an interim care order. 29   4.49  There is disagreement between the local authority lawyers and the justices’ clerk who represents HMCTS as to whether a change in application would necessarily have been the right course of action. The local authority view is recorded in their report as follows: “Whilst this would have been legally and logistically possible, although not straightforward, it would nevertheless have resulted in 2 significant problems: 1. DD12 would have been left unprotected whilst the fresh application was lodged, served and listed for an urgent hearing. Strategically, the parents would have been less likely to agree to DD12 remaining in hospital as this would have established a status quo of DD12 being outside of their care at the start of potentially protracted proceedings; 2.  Whilst the emergency protection order proceedings took 7 days in total, (8 in fact) the protective package remained in place but the overriding urgency for a decision to be taken as to DD12’s legal status was not lost. Had the application for the emergency protection order been withdrawn, the court could have drawn an inference that the child was no longer at imminent risk and this would have been compounded if the parents had removed DD12 from hospital,” Legal services IMR, (paragraph 7.7.3.2).  4.50 The commissioner for HMCTS includes the following paragraph in his report: “At the first hearing the parents agreed not to remove the child from the hospital until the case was concluded.  This change in circumstances appears to be relevant to the assessment of whether or not the child was subject to substantial risk of harm or was in imminent danger.  Although it is not the responsibility of employees of HMCTS to give direction to parties as to the appropriate course of conduct in such circumstances, it might normally be expected that since the nature of the risk had changed, that, if the concerns of the local authority remained, they might proceed with another more suitable less draconian type of application, namely an application for a care or supervision order under Section 31 Children Act 1989.” HMCTS IMR (paragraph 4.4).  4.51  The HMCTS IMR author contended that a change of course by the local authority at this stage would have resulted in no diminution of the protection afforded to the child. On receipt of an application for a care order, the responsible legal adviser would have been required to make an immediate decision regarding allocation of the case. Since the case involved an allegation of an unexplained, possibly non-accidental, injury, the allocation guidelines would have resulted in the case being immediately transferred to the care centre to be dealt with by a Circuit Judge. The court would have had the power to shorten the period of notice given to the parties so that the application for an interim care order could have been before the judge sooner than the scheduled hearing for the EPO. The author further contends that the withdrawal of the application for an emergency protection order would have not weakened the strength of the authority’s position in any way.  4.52  The local authority did not choose to change their course of action. Because of the length of the hearing and the additional areas that the magistrates wanted to examine the court ended up exploring areas that would not normally be considered in an emergency protection order application; this included the care that DD12 would receive if placed with foster carers. “In the event, the hearing effectively assumed the 30  characteristics of a wider enquiry than an emergency protection order hearing and this did not really fit with the matters that should have been considered by the court at that hearing,” Legal services IMR, (paragraph 7.6.8).  4.53  The disadvantage of this for the local authority was that they were effectively only being allowed to give evidence about the injury and present evidence in an emergency situation. The magistrates were now of a mindset where they were requiring a higher level of proof than a focus on the injury and an emergency would allow. This approach appears to have prevailed notwithstanding the content of the written submission of counsel for the applicant which made it clear that the local authority had to, “establish that there were reasonable grounds to believe that the child would suffer significant harm if not removed to local authority accommodation, rather than reasonable cause to suspect significant harm,” Legal services IMR, (paragraph 7.7.9).  4.54  It should be noted that the same author thought that “this was immaterial due to the finding that was made that the injury was caused accidentally,” Legal services IMR, (paragraph 7.7.10).   4.55  Thus an extremely unusual set of circumstances arose. The original application stood because the local authority lawyers feared that otherwise DD12 would go home. The court considered the application over four days, during an eight day period, and allowed the parties to introduce issues which went beyond the remit of a hearing to determine the merits of an application for an emergency protection order.   4.56   The CAFCASS IMR author wrote: “The Children’s Guardian…. Wondered...with the benefit of hindsight – if this was the right application and in the right court. She expanded on this by telling me that she did not know what medical evidence was coming next and that given the emerging detailed evidence, it perhaps should have been heard by a County Court Judge, which would have meant a different application,” CAFCASS IMR, (paragraph 6.5.4).  Why did the magistrates make a finding of fact13?  4.57  The key event in this situation is the court case, and the key event within the court case is the finding of fact. The reason that this is fundamental is that it limited the avenues for future work and appeared to disempower the health, legal and social work staff who had been present throughout the court case.   4.58  It is arguable that this was not the right application and that the evidence was not presented as forcefully as it could have been. However these issues would have been largely immaterial if the magistrates had decided to just not grant an emergency protection order, and to do so without the finding of fact that DD12 was hurt accidentally.   4.59  It appears the reason the magistrates made the finding of fact, rather than just making no order, is because they were asked to do so and their Legal Adviser did                                                            13 This is common in care proceedings where the threshold of proof is higher than in an emergency hearing. 31  not give them clear advice to concentrate on the statutory grounds for making an order. The child’s guardian when interviewed by the author of this report, explained that Mother's legal representative had said to the court that the outcome of the case would have significant ramifications for the parents and that therefore she requested that they make a finding of fact. It appeared that no one pointed out the repercussions of the third option to the magistrates.    4.60  It may be the case that the magistrates themselves did not address the likely consequences of their decision. This raises questions about the advice that they received and whether there is a need for specific guidance to be issued on the correct approach to emergency applications of this type. In the light of this the justices’ clerk issued specific advice on the management of any application for an emergency protection order in January 2013.  4.61  In deciding any application of this type a court is required to make findings on the evidence put before it. In this case the court made specific findings of fact which went beyond the findings which were necessary to make a judgement on the test contained in section 44 of the 1989 Act. This would indicate that the magistrates would have benefited from stronger advice from their legal adviser on the issues that they were required to address. Whereas in this case the magistrates were provided with a Legal Adviser who was not a specialist in family proceedings, in all such applications in the future the magistrates should be advised by a member of the specialist team of family lawyers in the area.   How did the failure to get an emergency protection order on DD12 only weeks before his death affect the case?  4.62  This is the question from the terms of reference; upon reflection the question should be; “How did the finding of fact only weeks before the death of DD12 affect the case?” That is the question that this report will address. “The legal impact of making a clear and positive finding that the injury was accidental was that it was no longer legally tenable to pursue child protection procedures on the basis of the information available at the time and the legal threshold to issue an application for a care order was not crossed,” Legal services IMR, (paragraph 7.5.2).   4.63  Following the hearing some professionals still believed that the injury was non-accidental and that the judgement of the magistrates was wrong; as a result there were considerable informal discussions about the court’s decision. At the same time there appears to be no sense of urgency in regard to moving the care plan forward as a “child in need” (as agreed by the professionals, magistrates, mother and father after the court proceedings) nor was there any planning on the basis that suspicions remained. In short they could have offered child in need services and maintained a respectful scepticism with regard to the court’s decision. “Although the Finding in Court that this was an accidental injury was treated with varying degrees of scepticism, it nonetheless served to make staff question their interpretation and undermined their confidence in this respect. It also meant staff were no longer referring to a non-accidental injury – the language used is at most “unexplained injury” and there appears to be some uncertainty around what actually was the level 32  of risk for DD12. This is reflected in the transfer request and core assessment,” Children’s social care IMR (page 25).  4.64  Exploring the concerns that remained was hampered by the lack of interaction between those professionals involved in DD12’s day to day medical care and those involved with investigating the injury. They appear to have operated as two separate sets of professionals. This is highlighted by Family Health Visitor (HV4), not being at the strategy meeting and the absence of children’s social care at the hospital discharge planning meeting following the court case.  4.65 Regarding the discharge planning meeting, the children’s social care IMR author states that Social Worker (SW2), “was expecting to be notified by the hospital when they were going to discharge DD12 and hoped to have a new worker identified at that point. She was surprised to discover, on contacting mother on 1/3, that DD12 had already been discharged,” (social care IMR),  whereas the IMR author for the Derby hospitals NHS foundation trust IMR wrote that “according to our nursing records, social care were informed of DD12’s discharge,” (Derby hospitals NHS foundation trust IMR).  4.66  The discharge meeting that took place on 29th February 2012 could have formulated a plan to monitor DD12 more thoroughly as well as meet his complex health needs.  “Discharge processes for DD12 after the court ruling proceeded along routine lines and did not involve any senior medical input.  The discharge letter was prepared by a junior doctor and did not make it sufficiently clear that medical opinion remained that DD12’s injuries were most likely to be non-accidental.  Other key health professionals less directly involved in the court case were therefore not aware that medical opinion remained that DD12 had been non-accidentally injured and should be considered to be at continuing risk. The discharge planning meeting…. did not involve any other agencies and did not consider a plan for dealing with any further injuries that might occur,” Health Overview report, (paragraph 4.5.9).  4.67  The Health Overview author describes the problem of the two sets of professionals and uses the term “dominant narratives” suggesting that the professionals who had been involved in the court case had the belief “that the court had come to an incorrect conclusion and that DD12 therefore remained at risk of harm from one of his carers” whereas the professionals who had not been involved in the court case had the belief that DD12 “had been admitted with some bruising that was difficult to explain and that he had been discharged back to his parents’ care when it was concluded that this bruising was accidental,” Health Overview report, (page 22).  In fact there was a third set of professionals who became involved with the family later who were unaware that the court case had even happened. These professionals were working with the belief that DD12 was simply a child with complex medical needs.  4.68  The agreed narrative should have been that concerns remained that DD12 was a child at risk from significant harm because his injuries were still believed by children’s social care and medical professionals to be non-accidental, even though the court had deemed them, on the balance of probability, to be accidental. All professionals involved with DD12 should have been aware of this.   33  How well was the ability of the parents to meet the complex health needs of DD12 understood and acted upon by practitioners?  4.69  DD12 and his family received much professional support both before and after the court case whilst in hospital and at home. At times this support appears to be overwhelming.   4.70  The professional contact was very much geared towards DD12’s health needs and both mother's and father's ability to care for DD12’s physical needs were assessed and understood.  4.71  Organising their lives around this level of professional activity must have been a strain for mother and father and “it could reasonably be expected that a CAF could be completed in these circumstances especially at the point of discharge at the end of January,” Children’s social care IMR, (page 16).    4.72  A CAF14 would have resulted in a lead professional being appointed who may have been in a position to help mother and father make sense of what was happening around them.  “Neither a formal nor informal “Team Around the Family” approach to DD12  and his family was adopted or evolved and no “Lead Professional” was either appointed or emerged,” Health Overview report, (page 8).  4.73  The completion of a CAF (prior to the bruising of DD12’s penis) may have resulted in DD12’s case being discussed at the weekly multi-agency vulnerable children’s meeting. The family would probably then have been referred to early intervention services and there may have been a greater co-ordination of services.  4.74  There is no evidence of an assessment of the emotional impact on father and mother of caring for a baby with the complex health needs which DD12 had.  A referral to the children with disability team would have been appropriate at the point that DD12 came home from hospital in January 2012 rather than the transfer request that was made by Social Worker in March 2012.  Father told the author of this report that he felt excluded from conversations by some professionals and did not feel actively involved.  4.75  A further missed opportunity for an early social work assessment occurred in January 2012 when DD12 had been in hospital for more than three months as an assessment should have been completed under s85 of the Children Act 1989. “Had his needs been addressed in a systematic way based on the national Assessment Framework, information relevant to the compounding complexities of his parents’ needs would have been shared explicitly between professionals and could have been taken into account when planning his care,” Health Overview report, (page 8).  4.76  The points made above remain true after the court case. Though hampered by the finding of fact there are still opportunities missed to protect DD12. Immediately following the court’s decision: “It was always open to the LA15 to hold a strategy meeting to agree a way forward, but there is no indication this was                                                            14 Common assessment framework, an assessment aimed at children who have “additional” needs (additional to most children who require only education and occasional health intervention) 15 Local authority 34  considered,” Children’s social care IMR (page 25). “After the court ruling that DD12’s penile bruising was accidental, there was no evidence of a coordinated approach being taken to consider any further medical plan to protect him,” Health Overview report, (page 15).    Transfer from the reception team in children’s social care and the children with disabilities team  4.77  The decision at the end of the court case was that DD12 was considered to be a child in need and would receive services accordingly. This necessitated a transfer from the reception team to the children with disability teams, (IDCS). There were some problems associated with this and these are covered in detail by the children’s social care IMR author. Although the issues are essentially intra-agency this report is addressing them because of the ramifications for DD12.  4.78  Unfortunately the transfer was not initiated until 13 days after the court case and the transfer itself then took a further 22 days, 5 weeks in all for a process that, had it been between other teams, could have taken one week.  “There is a transfer protocol with Locality teams which stipulates that a case transferring from reception must be allocated to a worker within a week of the allocation meeting,” Children’s social care IMR (page 26).  4.79  However transfers between the reception team and Integrated Disabled Children Services (IDCS) are so rare that there isn’t a protocol to facilitate a timely and quality handover.  “The transfer process itself was characterised by different expectations of the sending and receiving teams, such that although the transfer request was sent on 6/3 an IDCS worker was not allocated until 28/3, three weeks later. In the meantime DD12’s case remained open to the Reception worker,” Children’s social care IMR (page 26).  4.80  Although social workers in the reception team remained of the opinion that the injury to DD12’s penis was more likely non-accidental and urgent monitoring was required, “this sense of urgency was not picked up by IDCS….There was attempted contact between IDCS and Reception in both ways to progress the transfer….but it appears individuals kept missing each other,” Children’s social care IMR (page 26).  4.81  The allocation of a member of the children with disabilities team would have meant that a qualified social worker would have been working with the family and co-ordinating other professionals. However the understanding of the allocated social worker from the IDCS team was that DD12 “had been identified as a child in need…and…was not considered as at risk of significant harm,” Children’s social care IMR (page 28).  4.82  The reception and IDCS teams work in very different ways. Reception work is high volume, high turnover, short term work whereas the IDCS workers work in a slower and more thorough manner knowing that they will be involved with families for the long term.  35  4.83  Father told the author of this report that he was particularly unhappy that the family did not get any social work support after the court case. He said he felt that they were” dropped by the social workers”.   4.84  Children’s social care did visit twice in the month following the court case; once on 2nd March and again on 28th March 2012.  The record of the visit on 2nd March state that it was explained to the family that DD12 was to be a child in need and that a referral would be made to Homestart Derby.  4.85  It may well be the case that the transition from the scrutiny by children’s social care during the court case to two visits in four weeks could have felt like abandonment.   Events in April and May 2012  4.86  Professionals continued to visit DD12 and his family following the court case and there are some incidents of concern in April and May which require further analysis. These incidents were:  Mother's assertion to CON1/Liaison Health Visitor ( HV7)the health visitor that DD12 cried when father tried to pick him up, (17th April 2012),  the bruise noticed by the Homestart professionals, and   the blood in his ear mentioned by mother to the Family Health Visitor (HV4) (3rd May 2012).   4.87   Before addressing these it is worth reconsidering the issue of what the staff knew about the background to the case. The two health visitors were aware that DD12 had been admitted with some bruising that was difficult to explain and that he had been discharged back to his parents’ care when it was concluded, leading them to consider DD12 a child requiring health interventions. The Homestart professionals were not aware of any of the background information and understood that DD12 was a child in need, not at risk. Had these professionals thought that DD12 was a child at risk of significant harm it is highly likely (as they have all confirmed to me in conversation) that they would have informed children’s social care of their concerns.  4.88  No action was taken following the comment that DD12 cried when father picked him up. In itself it appears to have little significance but, if it were viewed in the context of respectful uncertainty a different interpretation may have been applied.  4.89  The bruise noticed by the Homestart workers must have been fairly insignificant because it wasn’t noticed by the Family Health Visitor (HV4) who visited later that day. The Homestart workers were also unaware that there had been any court case.  However “any bruise in a non-mobile baby has to involve some sort of third party action and a non-accidental cause must be considered…The accidental explanation offered by DD12's mother was feasible but certainly warranted further investigation.  It is apparent from the Homestart IMR that they were not aware of the detail of DD12 past history at this stage and did not therefore view this as a high risk situation,” Health Overview report, (page 18).  4.90  On the same day mother mentioned bleeding in DD12’s ear to the Homestart workers and the health visitor, Family Health Visitor (HV4). “The HV was also 36  unaware of the continuing medical opinion that DD12 penile bruising was non-accidental and was therefore also unaware of the high level of risk in the situation,” Health Overview report, (page 18).      5 CONCLUSION AND LESSONS LEARNED  5.1  Mother's pregnancy with DD12 was relatively uneventful.  To the maternity services she appeared to require some additional support primarily because she had experienced a cot death of her first child.  5.2  DD12, from birth had serious and life threatening health problems.  His parents responded appropriately to these; Mother stayed over three months with her baby in hospital and father visited regularly.  Even without the requirements of s85(1)(a) of the Children Act 1989 there was a clear case for the family to have been offered a multi-agency assessment to establish whether DD12 required a co-ordinated response from agencies or should be regarded as a child in need and what additional support might be appropriate.  5.3  The reason that children’s social care were not made aware of the 105 days in hospital, according to email received by this author from RDHFT IMR author is because he was in more than one hospital and therefore the prolonged length of stay was not obvious on looking at the medical notes.   5.4  Even had this not been done the sheer number of professionals involved should have indicated that a CAF was necessary. This would have provided mother and father with a lead professional who could have helped them co-ordinate care and communicate with professionals.  5.5  For the professionals working with DD12’s family to be able to intervene and prevent the injuries that caused his death it would have been necessary for there to be a shared recognition that DD12 was in need of protection and an awareness that any injury observed may be of significance.  5.6  There was no indication that DD12 might be a child in need of protection until 12th February 2012 when bruising to his penis was first noted.   It was this incident that first brought DD12 to the attention of children’s social care.  It is unfortunate that this family’s first experience of a social worker was in the arena of child protection rather than family support, which it could have been, had an earlier assessment taken place.  5.7  Once the incident (bruising to his penis) that suggested DD12 may be at risk of significant harm was noticed the agencies involved responded appropriately.   Steps were taken to seek to protect him; a strategy meeting, followed by s47 enquiries and a court application, on notice, for an emergency protection order.   37  5.8  There were areas where these could have been better managed; the failure to contact the GP as part of the collation of multi-agency information and the narrow perspective of the strategy meeting, for example.  5.9  Taken by itself the decision by the magistrates to make no order was not unreasonable since they did not find the grounds for an EPO had been met.  What was exceptional was that they went on to make a finding of fact with regards to the injury.  The magistrates’ legal adviser ought to have made it clear to the bench that, rather than follow the contentions made by the mother’s legal representative that they should determine whether the injury was accidental or not, they should decide whether the local authority had proved on the balance of probabilities that reasonable grounds existed to believe that the child was likely to suffer significant harm if not removed to local authority accommodation.  The lawyers in the court did not assist the magistrates in addressing the issues which were relevant to determining the merits of the application.   5.10  The magistrates believed that the bruising was accidental; the relevant professionals in the case continued to believe the opposite.  Whilst it is understandable that DD12’s parents would feel rightly aggrieved that they were subject to double jeopardy, and the finding of fact limited the scope of the work available, children’s social care, as the lead agency should have ensured a suitable plan was in place to protect DD12.   5.11  It is not possible to establish to what extent the “finding of fact” prevented immediate and decisive actions being taken to establish a plan to protect DD12 but it did appear to disempower professionals.  It is almost certain that it would have made securing co-operation of the parents with such a plan, had it been made, far more difficult.  It may also have made some professionals less able to understand that DD12 was in need of protection.  5.12  There should have been a debriefing meeting of all professionals involved in his care where the legal ramifications of the finding could have been explained. Furthermore this meeting could have defined a high level and vigilant child in need plan and ensured that this was put in place. The finding of fact appeared to undermine professional scepticism.   5.13  The failure to have a shared understanding by professionals of the previous concerns about the bruising is likely to have resulted in a less than urgent response to the concerns noted in early May 2012, (DD12 crying when his father picked him up, the bruise and the blood in the ear).  It is also likely that had this been known and part of a more robust plan the monitoring of DD12 would have focussed not only on his health needs but also his safeguarding needs in the context of what was known about his history and vulnerability. This is not to say that monitoring was not taking place, indeed DD12 was regularly seen by professionals between the end of the court case and his death; rather it is to emphasise that the professionals who were visiting DD12 were not fully aware of the concerns of the doctors and social workers.  5.14  That being said the first potential suspicious injuries, following the finding of fact, were observed on Thursday 3rd May 2012; shortly thereafter DD12 was dead.  It is speculation that had the concerns observed on the 3rd of May been responded to 38  more quickly it may be that the outcome might have been different. Investigations into the bruise and bleeding from the ear could have led to protective action. However because the bleeding from the ear was not seen by professionals and the bruise so small, it is by no means certain that a further brain scan would have been carried out.   5.15  Father was observed helping with DD12’s care by professionals and was often spoken about positively by mother but he rarely appears to have been spoken to himself. Father told me in interview that he felt excluded by the way in which some staff spoke directly to mother even when he was present in the room. This lack of engagement with men is not unusual but too often has been identified in research, serious case reviews and national enquiries as a serious failing.  This issue was identified in the Health IMRs and consequently it is now a requirement that health visitors have at least one contact with the father with the view to assessing his parenting capacity. This report makes a further, more general recommendation regarding this issue.  5.17  Little is absolute in child protection work and all professionals should guard against certainty. The way this case was presented to the magistrates appears to have encouraged them to focus on the narrow issue of the cause of the injury. This led to the making of a specific finding which suggested that the cause of the injury was accidental rather than unexplained. It was not within the remit of a court, properly advised to make such a certain determination in an application of this type.  Yet this finding need not have been the end of the story. Professionals should have remained confident in their own ability and analysis and identified methods with which to counter the court’s conviction.   5.18  Serious case reviews often identify lessons that have been learnt before but this one is an exception. The practice of professionals was at least competent and in many cases good. Lessons learnt in this case are:  The co-ordination of service could have been better  There should not be such a disjoint between “protective” workers – social workers, police and hospital doctors and “caring” professionals, Homestart, KITE etc  The emotional needs of families with children with complex medical needs should be assessed and responded to  It may be unnecessary for children to have a child protection medical once they have been examined by a doctor    Strategy meetings minutes should be taken by someone who is not chairing the meeting  Magistrates’ legal advisers need to have the knowledge and confidence to manage emergency applications of this type and firmly to identify the parameters of the court’s decision.  Magistrates’ should be advised to have regard to the likely consequences for the child of making specific findings of fact  Professionals should treat court decisions for what they are; a legal finding, not a manifestation of truth  39  5.19  The review has been thorough; many avenues have been explored. Individual agencies have identified changes that have been implemented and these will be integrated into an action plan for Derby’s safeguarding children board to consider.  5.20  This report has identified a few areas in addition where practice could be improved based on some of the lessons learned and these will be listed in the next section.   5.21  Serious case reviews should address the issue of whether the injury or death of the child could have been predicted and prevented. In this case there was no evidence pointing to why professionals should believe that DD12 was at risk until they noticed the injury on his penis. Once they were aware of this it is predictable that there was an increased likelihood of a subsequent injury, though not necessarily one so severe as to cause his death. Had professionals not been so disempowered by the court’s finding of fact they would have been in a better position to prevent further injury.  5.22  Having considered this situation, on reflection, the panel and the author of this report are concerned that decisions about emergency protection orders are made in the magistrates’ court especially as “the granting of an emergency protection order is a draconian measure which removes a child from the care of his/her parents”. HMCTS IMR (paragraph 2.5)   6 RECOMMENDATIONS  6.1  The IMRs produced for this review contained many recommendations for the individual agencies and are included as appendix three. This report has identified just six further recommendations.  1. To ensure that families of children with complex needs should always, with their agreement, be subject to a CAF to ensure that the emotional needs of families with children with complex medical needs should be assessed and responded to. 2. The LSCB to commission research (either internally or externally) to determine the extent to which men are, or aren’t involved in assessments and the reasons for this. The LSCB to then identify an action plan to address the recommendations that will arise from that research. 3. The LSCB should clarify whether a child protection medical should be carried out if a child has been examined by a paediatrician. 4. The independent chair of the LSCB to discuss with the author of the HMCTS IMR ways in which the LSCB may communicate their concern about the way in which emergency protection orders are heard. 5. The LSCB should ensure that strategy meetings include representation by the appropriate professionals, are properly recorded and that there is clarity about key matters and an agreed plan. 6. Clear advice should be given to magistrates so as to enable them to determine the essential issues in emergency applications and to avoid extending the scope of their decision making unnecessarily.      40   Bibliography  Alder, C. and Polk, K, Child victims of homicide, Cambridge University Press, Cambridge (2001).  Brandon, M., Belderson, P., Warren, C., Gardner, R., Howe, D., Dodsworth, J., and Black, J., (2008) Analysing child death and serious injury through abuse and neglect: what can we learn? A biennial analysis of serious case reviews 2003‐5, Department for Children Schools and Families, Research Report   Brandon et al (2009), Understanding Serious Case Reviews and their impact (England, 2005- 2007) https://www.education.gov.uk/publications/eOrderingDownload/DCSF-RR129(R).pdf  Cavanagh, K; Emerson Dobash, R and Dobash, R; (2007) The murder of children by fathers in the context of child abuse Child Abuse and Neglect, Vol 31, Issue 7, p 731-746.  Derbyshire LSCB child protection procedures http://derbyshirescbs.proceduresonline.com/chapters/p_strategy_discussion.html#multi_age_invol  Stroud & Pritchard, (2001) Child Homicide, Psychiatric Disorder and Dangerousness: A Review and an Empirical Approach British Social Worker (SW2)urnal of Social Work   TSO (2010) Working Together to Safeguard Children  Wilczynski, (1995) Child killing by parents: A motivational model Child Abuse Review, 4 pp. 365-370      41  Appendix One  Derby Safeguarding Children Board Scope of the Serious Case Review and Terms of Reference SERIOUS CASE REVIEW – DD12  These terms of reference have been amended so that they can be included as an appendix in the overview report.   1.  Introduction  DD12 was born in 2011 in Derby and was admitted to QMC, Nottingham on 06/10/11 because of his significant and complex health needs. He remained there until he was transferred to Glenfield Hospital, Leicestershire on 25/10/11. He was discharged on 06/01/12 and returned home with ongoing support for his health needs.   On 09/05/12 an emergency telephone call was made by DD12's father claiming that DD12 was having a fit. He was admitted to hospital. DD12 died on that same day. The post mortem indicated that DD12 had died as a result of a brain haemorrhage caused by a non accidental injury. DD12's father pleaded guilty to the manslaughter of DD12 on 08/05/13.     2.  Decision to hold SCR   The Serious Case Review Panel met on 15/05/12 and agreed to recommend that a Serious Case Review be held and established an outline for the scope of the review.  The Independent Chair of Derby Safeguarding Children Board (Christine Cassell) was notified of the recommendation on her return from Annual Leave and agreed on 24/05/12 that a SCR should be held.   An independently chaired SCR Panel met on 11/06/12 to begin the process of scoping the review in detail.  The serious case review was deemed necessary for the following reasons: o DD12 died and abuse was suspected as having been a factor in his death. His father had been arrested and was charged with murder (at that time).  Ofsted were notified of the decision that the death of DD12 would be scrutinised by the SCR Panel on the 11/05/12 and were notified of the decision to hold a SCR on the 24/05/12  The scope and terms of reference were considered by the SCR Panel on: 11/06/12 and circulated for consideration.    The SCR Panel and IMR authors met with the Overview Writer on 10/07/12 to scope and agree the methodology for the SCR  The SCR IMR authors met with the Overview writer on 17/09/12 to review the narrative element of the IMRs and consider in more detail the areas that 42  required analysis. It became apparent that a separate IMR was required on behalf Derby City Council Legal Services and that the summary report by University Hospitals Leicester was required.  The SCR Panel and IMR authors met with the Overview Writer on 17/10/12 to review the analysis element of the IMRs. Notable issues emerged in respect of the involvement of Her Majesty's Court and Tribunal Service that required consideration by a High Court Judge. The need for an extension to the timescale for the completion of the review was identified. The specific timescale would be decided at the next meeting of the SCR Panel upon an informed update of the resolution of outstanding matters.  The SCR Panel met on 27/11/12, to consider the outline narrative and analysis of the Overview Report. At the meeting it was agreed that the completion date for the review will be 13th March 2013.  Further revisions of the scope and terms of reference were made on the 27/11/12 and 31/10/13 following legal advice about publication of the overview report.    3.  Completion of the Serious Case Review and publication of the Overview Report  There has been a delay to the completion of the Serious Case Review as a result of complexities arising from the Criminal Trial. Following the conclusion of the Criminal Trial in May 2013, consideration was given to the impact of publishing information on surviving children and family members and that the criminal proceedings had been concluded with no evidence being heard and, in particular, no reference being made to any previous alleged injury to DD12.    The advice of legal counsel was obtained in June 2013, for the purpose of advising the Serious Case Review. Mr Weston, QC, reviewed the draft overview report and other documents. Consideration was given to the evidence that was heard as part of the criminal proceedings and the human rights and welfare interests of the surviving children and family members and the requirements of Working Together for LSCB’s to publish as much detail as possible.  There had been a previous Emergency Protection Order (EPO) application that had been heard by the Family Proceedings Court in private. Information relating to those proceedings was confidential.  The Board considered that this material was key to the overview report. An application was made to the Family Proceedings Court for permission for the material in relation to the application for an EPO to be disclosed to the Board for the purposes of inclusion in the published overview report.  His Honour Judge Plunkett, sitting as a High Court Judge on the 17th September 2013, granted permission for the material to be disclosed.   The overview report was subsequently amended so that it could be published in a manner that does not adversely impact on the welfare of other children, relevant family members and others. 43    4.  Key Issues:    What specific issues or questions does this case raise?    Whether specific opportunities existed prior to the birth of the DD12, to improve likely outcomes evident at that time  How well was the ability of the parents to meet the complex health needs of DD12 understood and acted upon by practitioners?  How did the failure to get an Emergency Protection Order (EPO), following concern about an injury to DD12, only weeks before his death affect the case? This includes examining: o The decision making that lead to the application for an Emergency Protection Order o What lessons emerge from consideration of the court hearing including how the medical evidence was dealt with in court o The impact of the judgement on both the original concerns held by practitioners and the ongoing work undertaken by all agencies with the family   How was the impact of the SUDI death in 2009 assessed and what action was taken, once agencies became aware of mother's pregnancy with DD12?  Are there any unusual factors in this case, what are they?  An application for an Emergency Protection Order was unsuccessful and a Finding of Fact was made to the effect that a prior injury was accidental. How this was responded to and how it affected the way in which the circumstances of DD12 were considered are an unusual factor. This may identify learning at both a local and national level.  Are there any issues which relate to ethnicity, disability or faith which may have a bearing on this review?   DD12 had complex medical needs. The impact of these needs will be examined in detail as part of the review.  DD12 and his family are White British and there are no known issues that have a bearing in respect of ethnicity or faith.   Is there any known research which may assist?  The Overview Author is considering similarities with previous Serious Case Reviews and will include comment in the Overview Report.   5.  The format of the Overview Report  The Overview Report will be published in a way that upholds the human rights of surviving children and ensures that their welfare is not adversely affected by publication.  To achieve this, the Overview Report will recognise the complex circumstances in which professionals work together to safeguard children and seek to understand 44  practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight. The report will be transparent about the way data is collected and analysed whilst ensuring that the restrictions above are adhered to. Relevant research and case evidence will be used to inform the findings.  The thematic approach of the Overview Report will include analysis of the key issues set out in section 3 above. These will summarise the relevant information that was known to the agencies and professionals involved about the parents/carers, any perpetrator and the home circumstances of the children.    The overview report will analyse how and why events occurred, decisions were made and actions taken or not taken. This is the part of the report will consider with the benefit of hindsight, whether different decisions or actions may have led to an alternative course of events.   6.  Expert Opinion  Legal advice was obtained in respect of the publication of the overview report as set out in section (3) above.    7.  Time Period over which events  should be reviewed   It was agreed that the recommended time line for the review starts with the conception/identified pregnancy of DD12.  The timeline was reviewed as emerging information was considered and extended to include consideration in more detail of relevant family history.  Each IMR will include a section Background Information that should include matters considered relevant to the review that occurred prior to this.  Consideration will be given to extending the time line to take in the SUDI death dependent on emerging information.    8.  Organisations to be involved in this SCR   Individual Management Reviews will be undertaken by  Derby City Council Children's Social Care (this will include the Children's Centre)  Derby City Council Legal Services  Derbyshire Police  Derbyshire Healthcare NHS Foundation Trust (this includes Health Visiting and Mental Health Services)  Derby Hospitals NHS Trust (this includes Midwifery, Dietician, KITE Team (providing multi disciplinary support to help children with special needs at home) and Paediatric Services)  Primary Care in respect of GP Services (now under CCG)  Her Majesty's Court and Tribunal Services  CACASS   A Health Overview Report will be completed as part of the review and will 45  include consideration of the IMRs from Derby Health Providers alongside information from University Hospitals Leicester (Glenfield Hospital) and summary reports from University Hospitals Nottingham (Queens Medical Centre) and the East Midlands Ambulance Service (EMAS)   Summary reports will be undertaken by  Homestart Derby   University Hospitals Leicester   University Hospitals Nottingham   The SCR Panel will escalate any failure to cooperate with this review with the Derby Safeguarding Children Board who will take action with the respective chief officers and if necessary the appropriate regulatory body.    9.  Involvement of Family Members  The Police coordinated the notification to both mother and father that a Serious Case Review is being held.  Initial scoping identified that the mother and father of DD12 should be involved.   DD12's mother and maternal grandmother agreed to participate in the review and were interviewed by the overview author.  DD12's father’s previous partner agreed to participate in the review and was interviewed by the overview author.  Following the conclusion of the criminal trial DD12's father was offered the opportunity to participate in the review and he was interviewed by the overview author.   10.  Other Parallel reviews (e.g. PPO/ homicide or suicide reviews)  There are no additional parallel reviews being held.   11.  Involvement of  organisations in other LSCB areas  The Health Overview report will include consideration of summary reports from the University Hospitals Nottingham and the University Hospitals of Leicester.    12.  Coroner’s Inquiries/Criminal Investigations  The Coroner has been informed that a SCR has been agreed. Following the conclusion of the criminal trial a Coroner’s Inquiry will not be held.    13.  Media Coverage/Enquiries  The Police Communications Team coordinated the media coverage in partnership with SCR Panel members at the time of the trial. 46   The anonymisation of the reports will occur at the end of the process just prior to final draft version of Overview Report.  Freedom of Information requests relating to the case will be handled by Alison Moss (Derby City Council)   14.  Legal Advice   The SCR Panel is satisfied that the relevant Individual Management Review Authors obtained advice in respect of legal issues that were pertinent to the review.   15.  SCR Review Timescales  The timescale for the review has been extended as a consequence of complexities arising that required legal advice for IMR authors and set out in Sections 2 and 3 above.    16.  Commissioning of an Independent  Author  Barry Raynes has been commissioned as the Independent Author. He is the Chief Executive, Reconstruct Ltd which provides training, consultancy and direct services for the public sector. Mr Raynes has successfully reviewed 13 “inadequate” serious case reviews and written 6 serious case review overview reports in the last five years.   Mr Raynes has never been employed by any of the organisations involved in the serious case review and has no personal connection with any of the professionals involved in the case. Mr Raynes is therefore considered to be independent. Derby City Council will issue a contract to the independent author on behalf of the Derby Safeguarding Children Board (DSCB).  The author will be supported by the Derby Safeguarding Children Board Manager.  The timescales specified in the above section will be adhered to. Any variance in the timescale must be agreed by the Serious Case Review Panel   In the event that DSCB does not ratify the final overview report it will specify the rationale for this decision. DSCB will only take this position in exceptional circumstances and it is expected that only two factors would give rise to this situation: a) Failure of the overview author to meet the requirements of the terms of reference b) Failure of the overview author to provide a report of an acceptable quality   In these exceptional circumstances DSCB will either request that the overview author considers the rationale with a view to providing an addendum to the overview report addressing the issues raised, or look to commission a different author. In the event of an addendum being provided, this will be presented to DSCB for ratification. In the event that an addendum is not sought or provided the 47  Serious Case Review Panel will convene as a matter of urgency, to re-commission the overview report.   17.  Liaison with Ofsted and the DfE  The following will liaise with OFSTED and the DfE regarding the process of the review on behalf of the DSCB:  Mark Sobey                        mark.sobey@derby.gov.uk DSCB Board Manager       01332 717884    Date 11/11/13 MPS          48  Appendix Two Extract from Legal IMR setting out background information about emergency protection orders  4. Legal background 4.1 An emergency protection order (EPO) is a court order vesting parental responsibility for the child named in the order in the applicant.  Parental responsibility remains shared with the parent(s) throughout the duration of the order but how the applicant exercises its parental responsibility is subject to a number of duties and restrictions.  An emergency protection order may be made for up to a maximum of eight days and can be extended once for a period of no more than seven days.  4.2 The law governing the granting of emergency protection orders is set out both in statute (the Children Act 1989) and case law.  The grounds for making an application are set out in s.44(1) Children Act 1989 and the ground relied upon in this case is set out at s.44(1)(a):  4.3 The court may only make an order if it is satisfied that:  (a) There is reasonable cause to believe that the child is likely to suffer significant harm if (i) he is not removed to accommodation provided by or on behalf of the applicant or (ii) he does not remain in the place in which he is then being accommodated.  4.4 It is the court, not the applicant, that needs to be satisfied that there is “reasonable cause to believe” that the child is likely to suffer significant harm   i.e. there must be good reason for the belief.  The likelihood of harm is based on future harm, not harm suffered at the time of or before the application, but case law has established that previous harm may be relevant to show that harm is likely in the future.  Significant harm has the same definition as under the threshold for care proceedings, namely s.31(10) Children Act 1989:  4.5 “Where the question of whether harm suffered by a child is significant turns on the child’s health or development, his health or development shall be compared with that which could reasonably be expected of a similar child”.  4.6 An emergency protection order, summarily removing a child from his parents, is an order of extreme gravity requiring “exceptional justification” and “extraordinarily compelling reasons”.  Local authorities and courts are advised to approach every application with an “anxious awareness of the extreme gravity” of the order sought and a scrupulous regard for the human rights of both child and the parents (X Council v B (2004)).  4.7 The two primary cases relating to emergency protection orders (X Council v B (2004) and Re X (2006)) have resulted in judicial guidance on applying for and granting such orders.  The guidance states, “Save in wholly exceptional 49  cases, parents must be given adequate prior notice of the date, time and place of any application by a local authority for an EPO”.  It also states, “The requirement that Justices give detailed findings and reasons applies as much to an EPO application as it does to any other application.  In a case of urgency, the decision may be announced and the order made with the detailed reasons prepared thereafter”.  4.8 Applications for emergency protection orders must be made to the family proceedings court unless the proceedings concern a child who is the subject of pending proceedings in a County or the High Court and arise out of the same circumstances (Children (Allocation of Proceedings) Order 1991 (rule 3)). 4.9 Proceedings for an emergency protection order cannot be transferred up from the family proceedings court to another court, despite any inherent complexity in the application (Children (Allocation of Proceedings) Order 1991 (rule 7(2)).  4.10 Applications may be made either without notice to the parent(s) with parental responsibility or with prior notice of the application being served upon them.  The notice period for an application for an emergency protection order is one day although in certain circumstances the notice period can be abridged.  4.11 Leave of the Justices’ Clerk is required to make an application without notice to the parents (ex parte).  Such an application should only be made in “wholly exceptional circumstances justified by a genuine emergency or the need for extreme urgency” or “where there are compelling reasons for believing that the child’s welfare would be compromised by giving notice” (X Council v B (2004)).  Where this threshold cannot be made out, an application will proceed on notice.  4.12 Whether or not an application is made ex parte or on notice is a matter for discussion between the service manager and the Legal Services solicitor.  It will be for the solicitor to advise if he or she considers the legal grounds are made out to apply to the Justices’ Clerk for leave to proceed ex parte as per X Council v B on the basis of the information he/she receives.  4.13 If an application is to be made on notice, the application is filed with the court, the matter is listed for a hearing and the papers are served upon the relevant parties.  A Children’s Guardian must be appointed unless the court is satisfied that it is not necessary to do so in order to safeguard the child’s interests and a solicitor for the child may also be appointed.  4.14 The strict rules of evidence do not apply on an application for an emergency protection order.  The court can admit and take account of any oral evidence, or any statement contained in any report made to the court, if it considers it to be relevant to the application.  4.15 The principles laid down in s.1 Children Act 1989 apply only in part to emergency protection order applications.  The child’s welfare is the court’s paramount consideration (s.1(1)) and the court must not make the order unless doing so would be better for the child than making no order at all 50  (s.1(5)).  However, the welfare checklist (s.1(3)) is not directly applicable because an emergency protection order does not fall within the definition of “family proceedings”.  4.16 An application for an emergency protection order by a local authority may be challenged either by attendance at the hearing of the application itself or by an application to discharge it but not both (s.45(8)).  Any application for discharge of an order cannot be made until 72 hours after the making of the order.  4.17 There is no right of appeal against the making of, or refusal to make, an emergency protection order (s.45(10)).  Not only is this prohibition against any appeal enshrined in statute and therefore clearly the intention of Parliament at the time when the Children Act was drafted, it has also been tested in the High Court.  In Essex County Council v F (1993), the court dismissed an appeal by the local authority against the adjournment of an application for an emergency protection order on notice and the subsequent refusal by the magistrates to make an immediate emergency protection order ex parte.  The High Court held that it was compelled by the words of statute to decide that no appeal by the local authority against the refusal to make orders could be bought.  The court indicated its regret that it could not interfere with the court process despite it being one “which cried out for the intervention of the court”.    4.18 The case of Re P (1996) did not revolve directly around an application for an emergency protection order but it was referred to within an appeal against another aspect of the case.  The magistrates had refused to extend an emergency protection order despite firm medical evidence pointing to life threatening abuse of a child.  The judge drew attention to the fact that the Children Act lacked any effective procedure by which a local authority could challenge a refusal by the court to, in this case, extend an emergency protection order.  It recommended that consideration should be given swiftly to providing a mechanism for review which could be operated quickly.  To date, no such mechanism has been invoked.     51  Appendix Three DSCB and Individual Agency Action Plans Derby Safeguarding Children Board Action Plan  Recommendation Actions required Outcome required Responsible person Timescale Evidence of action taken Ongoing monitoring Date signed off by LSCB 1 Ensure that families of children with complex needs should always, with their agreement, be subject to a CAF to ensure that the emotional needs of families with children with complex medical needs should be assessed and responded to. Derbyshire Hospitals Foundation Trust will develop procedures to address multiagency working around children with complex medical needs. The Early Help Assessment implementation programme will reiterate message for use in such cases. Early Help assessments are completed and appropriate services in place for children with complex medical needs Chair of the Policies and Procedures Group April 14 The DHFT has developed procedures to be implemented The DSCB Policy and Procedures group have completed the new Early Help Assessment to be rolled out across all agencies Quality Assurance Group  2 Commission research to determine the extent to which men are, or aren’t involved in assessments and the reasons for this. Undertake local audit and refer to national research and set out findings and recommendations Identify an action plan to address any Men are engaged effectively to promote the welfare of their children Chair of the Quality Assurance Group Sept 14 A task and finish group is being commissioned to undertake this work Quality Assurance Group  52  shortfall 3 Clarify whether a child protection medical should be carried out if a child has been examined by a paediatrician. Revise guidance “Medical Examination in Cases of Suspected Child Abuse”. A clear process is in place so that child protection medical examinations are appropriately completed  Chair of Policy and Procedures Group March 14 Guidance agreed and implemented, also included in revised safeguarding procedures Policy and Procedures Group  4 The independent chair of the LSCB to discuss with the author of the HMCTS IMR ways in which the LSCB may communicate their concern about the way in which emergency protection orders are heard. Independent Chair to liaise with the Justice’s Clerk Emergency Protection Orders are effectively used Independent Chair of the Board  Jan 14 These discussions took place during finalisation of the SCR. Confirmation has been given that these concerns have been picked up both locally and nationally. Serious Case Review Group Jan 14 5 Ensure that strategy meetings include representation by the appropriate professionals, are properly recorded and that there is clarity about key matters and an agreed plan. Communicate expectation to all relevant staff and address in revision of the safeguarding procedures.  Agencies work well together and share information effectively to safeguard children, especially when things do not go to plan Chair of Policy and Procedures Group  June 13 Confirmation of communication to staff has been received. The revision of the safeguarding procedures reflects this requirement. Internal case file and multi-agency DSCB audits show strategy, discharge & planning meetings used where necessary. June 13 53  6 Clear advice should be given to magistrates so as to enable them to determine the essential issues in emergency applications and to avoid extending the scope of their decision making unnecessarily. The Justice’s Clerk should issue advice to magistrates locally and raise learning from this case with the President of the Family Division. Emergency applications are effective Independent Chair of the Serious Case Review Sub Group Jan 13 Guidance has been issued and arrangements are in place to review EPO applications to ensure that court processes comply with guidance in Re X. The local Criminal Justice Board has been advised of the learning from this case. The President of the Family Division has been advised of the learning from this case.  Serious Case Review Group Dec 14       54  Children’s Social Care Action Plan   Recommendation Actions required Outcome required Responsible person Timescale Evidence of action taken Ongoing monitoring Date signed off by LSCB 1 Change the management and case direction arrangements for Reception managers to improve clarity and continuity  Move additional DHoS post to cover Reception teams Management of Reception managers is clear and consistent with a single overview of critical cases. Service Director EISS Jan 2013 Post transferred, recruitment underway n/a 20/05/13 2 Ensure social work investigations under S47 are completed fully prior to strategy meetings, to include interviews with parents and family (unless contra-indicated) and full agency checks including GPs. Produce S47 checklist and guidance for Reception staff and managers  Ensure sufficient staff are available S47 investigations are thorough and enable good decisions to be made on available information HoS Safeguarding March 2013 Checklist is available Annual audit of S47s show social work investigations which are thorough and provide the necessary information for decision making 22/07/13 3 EPO decision making process should  allow maximum consideration of the facts in each Review current process  EPOs are only sought when there is no safe alternative and there is sufficient Service Director EISS/ HoS Legal March 2013 Draft procedures have been produced for consultation. Training with SW Peer audit of each EPO shows effective decision making in line with procedure  55  circumstance, with a legal planning meeting in all but the most urgent situations Produce amended procedures for EPOs evidence to support the application Services and their managers undertaken  and successful applications 4 Transfer arrangements between teams must be reviewed to ensure safe hand-overs at a minimum number of points  Transfer protocol to set out key principles for safe transfers. Amend the internal transfer protocol to apply to IDCS and ensure full compliance by all staff.  Assess and promote Children are transferred between workers on a minimum number of occasions, and always according to safe transfer principles. HoS Safeguarding & HoS IDCS    March 2013    Internal transfer protocol up-dated and in place;  Report of awareness raising event or process between IDCS and Reception staff.   Audit of transfers shows compliance with new protocol and meets key principles for safe transfers. 20/05/13 56  staff awareness around respective roles of Reception & IDCS  Ensure direct conversations take place between Reception & long-term workers Ensure interim safe care plans are in place to cover the transition period during transfers Arrangements in place to facilitate direct communication between workers not yet fully operational  5 Multi-agency strategy and discharge meetings must be used at any point where there have been significant concerns and a co-ordinated response is needed, with an independent chair if necessary. This should specifically include at the conclusion of Court Communicate expectation to all relevant children’s social care staff  Amend procedures as necessary. Agencies work well together and share information effectively to safeguard children, especially when things do not go to plan HoS & DHoS Safeguarding & HoS IDCS   March 2013 Amended procedures and account of communication to staff. (Audit to be completed) Internal case file and multi-agency DSCB audits show strategy, discharge & planning meetings used where necessary. 22/07/13 57  proceedings when the outcome is unexpected. 6 Explore alternative means of providing supervision of contact in emergency situations, including a protocol with hospital about what is safe and viable on wards  Scope options, confirm and produce guidance  Negotiate protocol with Derby Hospitals NHS Foundation Trust  Reception staff are free to undertake essential safeguarding tasks and assessments Service Director EISS / HoS Safeguarding June 2013 Protocol and appropriate provision under discussion. See above re audit of S47 investigations.   58   Combined Health Action Plan  All the key learning points from this review will be summarised and shared with all health professionals via a bulletin and learning events. The following table details only those specific recommendations and actions that have arisen from the key learning points.   Recommendation Actions required Outcome required Responsible person Time scale Evidence of action taken Ongoing monitoring Date signed off by LSCB 1 Guidance on medical examination in suspected child abuse, to include specific guidance on injuries in non-mobile babies and escalation processes, will be made available to all practitioners in all agencies To be included in revised guidance “Medical Examination in Cases of Suspected Child Abuse”.  A clear escalation and challenge process is in place when doctors and other health professionals feel that medical evidence has been misinterpreted by the courts and there is clear guidance available about medical examination of injuries in non-mobile babies Designated and Named Doctors Jan 2013 Guidance recently agreed and being implemented  Guidance & Escalation processes discussed with Safeguarding GP Leads on 27.11.13  Report via Health QA Hub to Safeguarding Quality Assurance Sub-Group  Paper to be agreed by the City and County Policies and Procedures Group  Designated Doctor and Chair of Policies and Procedures sub-group April 2013 2 Systems in primary care will be agreed to ensure: The Named Doctor will work with GP The mental health of parents on long-term medication for Named Doctor Primary Care Nov 2013 Audit to be carried out when systems Report via Health QA Hub to Safeguarding  59   Recommendation Actions required Outcome required Responsible person Time scale Evidence of action taken Ongoing monitoring Date signed off by LSCB  The identification and flagging of adult patients with mental health problems on long term medication with vulnerable children  The holistic assessment of these patients and communication with other professionals where appropriate Safeguarding Leads to develop good practice guidance  mental health problems is reviewed, initially by the GP, if significant life events occur agreed Discussed at the Safeguarding GP Leads meeting on 27.11.13 and at the GP training on 12.11.13 & 17.11.13.There is general agreement for linking families where the children have complex medical needs /disability. There will be further discussions on processes. Quality Assurance Sub-Group 3 Appropriate practical steps will be taken to ensure the availability of the immediate opinion form and the form  will be amended as a guidance Supplies in examination areas to be checked The immediate opinion form is  always used at the time of the initial examination and a modified format is developed and Designated and Named Doctors Dec 2012 Form is in place and audit currently in progress to look at use, but noted at peer review to be used consistently. This is reported via Report via Health QA Hub to Safeguarding Quality Assurance Sub-Group  60   Recommendation Actions required Outcome required Responsible person Time scale Evidence of action taken Ongoing monitoring Date signed off by LSCB document for report writing and court work used as guidance when doctors are writing reports and preparing for court the annual Peer Review Annual report for the Community paediatricians. Amended form to be produced  Designated and Named Doctors May 2013 Form to developed and implemented (Amended form not yet finalised but used in current form for report writing and felt to be very helpful) Usage to be audited  Report via Health QA Hub to Safeguarding Quality Assurance Sub-Group  61   Recommendation Actions required Outcome required Responsible person Time scale Evidence of action taken Ongoing monitoring Date signed off by LSCB 4 The existence or not of clinical photographs will be included in all formal child protection reports Guidance to be given to doctors and reinforced regularly at peer review   The existence of clinical photographs of injuries will be made known to the statutory agency staff working with a case so that they can be used in legal proceedings if required  Designated and Named Doctors Feb 2013  Audit via peer review and exception reporting  No exceptions noted at peer review  (DHFT) This will be audited & reported as exception reporting via peer review audit for Community Paediatricians. Report via Health QA Hub to Safeguarding Quality Assurance Sub-Group  5 Specific training events to address concerns raised in the review will be provided and incorporated into regular training programmes Ad hoc training sessions to be organised Appropriate training is available via basic and update training:    For all doctors in understanding court processes and presenting evidence in court For community Designated and Named Doctors and Safeguarding Nurses Aug 2013 Training events provided. Event being planned for spring 2014 Report via Health QA Hub to Safeguarding Quality Assurance Sub-Group  Work with the Board training sub-group to incorporate into training programme Aug 2013 Ongoing training programme agreed 62   Recommendation Actions required Outcome required Responsible person Time scale Evidence of action taken Ongoing monitoring Date signed off by LSCB based Child and Family teams in recognition of physical abuse 6 Derby Hospitals Foundation Trust will develop procedures to address multiagency working around children with complex medical needs  Procedures will be developed The needs of  children with complex medical problems in the hospital setting are addressed holistically; Child and Family teams are included in all planning and other agencies as appropriate Named Doctor and Named Nurse DHFT Sept 2013 Procedural document. This has been discussed and will be included in the Trust policies which are currently being updated Report via Health QA Hub to Safeguarding Quality Assurance Sub-Group  Procedures will be audited in 2013/14 cycle March 2014 Audit report 7 Derby Hospitals Foundation Trust will develop procedures to address continuity of consultant care and senior medical input throughout care Presentation and good practice learning presentation at Clinical Governance meeting There is continuity of consultant care of children admitted about whom there are safeguarding concerns and there Named Doctor DHFT March 2013 Key learning points sheet produced  Completed March 2013 Report via Health QA Hub to Safeguarding Quality Assurance Sub-Group  63   Recommendation Actions required Outcome required Responsible person Time scale Evidence of action taken Ongoing monitoring Date signed off by LSCB episodes when there are safeguarding concerns Practice to be audited is continued senior medical involvement throughout the admission and in discharge planning. Named Doctor DHFT Sept 2013 Audit report Audit currently in progress 8 Derbyshire Healthcare Foundation Trust: Child Health Services will ensure that current practice is audited and remedial plans developed as required in respect of: The use of CAF’s and the team around the family approach Safeguarding and communication issues to be incorporated into ongoing development of the TPP community child health information system Where there are identified vulnerabilities within a family or the child has complex/ additional health needs a Common Assessment Framework assessment (CAF) is completed and Heads of Service and Service Line Managers for Child & Family, Children’s Specialist, CAMHS, Safeguarding Children and Looked After Children End 2014 Audits completed with recommendations and action plans   Exception reporting from supervision records  Operationalised through the Safeguarding Children Operational Meeting and the Safeguarding Children and Vulnerable Adult Committee and reported via Health QA Hub  64   Recommendation Actions required Outcome required Responsible person Time scale Evidence of action taken Ongoing monitoring Date signed off by LSCB Assessment of impact on parents of a child’s complex health needs  To be addressed in the audit cycle 2013/14 appropriate further actions taken, including an holistic assessment of the impact this may be having on the parents  Teams to Safeguarding Quality Assurance Sub-Group 9 Derbyshire Healthcare NHS Foundation Trust: Mental Health Services will ensure that current practice is audited and remedial plans developed as required in respect of: Assessment of impact on patients with mental health if they Trust to remind all staff regarding the importance of communication with relevant professionals, and the subsequent recording of those interactions.  All mental health practitioners who are working with adult patients who are parents are liaising and communicating appropriately with children’s services professionals, including general Heads of Service and Service Line Managers for Child & Family, Children’s Specialist, CAMHS, Safeguarding Children and Looked After End 2014 Audits completed with recommendations and action plans   Exception reporting from supervision records  Operationalised through the Safeguarding Children Operational Meeting and the Safeguarding Children and Vulnerable Adult Committee and reported via  65   Recommendation Actions required Outcome required Responsible person Time scale Evidence of action taken Ongoing monitoring Date signed off by LSCB have children with longer term health needs Communication, both seeking and sharing information,  with relevant professionals  Comprehensive history taking to address a Think Family agenda To be addressed in the audit cycle 2013/14 practitioners to ensure that the impact of parental mental health problems on children and the impact of child health problems, for example extended or repeated hospital admissions, on parents are considered and addressed Children Teams Health QA Hub to Safeguarding Quality Assurance Sub-Group 10 Good practice guidance is provided on criteria for identifying those vulnerable children who should be discussed at practice liaison meetings  The Named Doctor and Named Nurses will work with the GP Safeguarding Leads to develop good practice guidance Vulnerable children who should be discussed at the liaison meeting with the health visitor/link nurse and safeguarding GP leads for the practice are Named Doctor Primary Care, Child & Family Team Managers and GP Safeguarding Leads Sept 2013 Good practice guidance produced  Audit of practice This has been discussed at the Safeguarding GP Leads meeting on Report via Health QA Hub to Safeguarding Quality Assurance Sub-Group  66   Recommendation Actions required Outcome required Responsible person Time scale Evidence of action taken Ongoing monitoring Date signed off by LSCB identified.  27.11.13. There is further discussion with the manager of HV’s teams and will be jointly audited in Feb 2014 11 GP practices to consider using external input from the Named or Designated Professionals for significant event reviews where safeguarding is an issue The Named Doctor will ask the Primary Care Clinical Governance Team will be asked to consider this matter Significant event reviews in Primary Care where safeguarding is an issue are robust in their outcomes   CCG Clinical Governance Leads April 2014 Decision at minuted meeting  This was discussed with the Safeguarding GP Leads meeting on 27.11.13 and there is general agreement from the GP Leads. Further discussion needs to take place with the Clinical Governance team  Report via Health QA Hub to Safeguarding Quality Assurance Sub-Group  67   Homestart Derby Action Plan  Recommendation Actions required Outcome required Responsible person Time scale Evidence of action taken Ongoing monitoring Date signed off by LSCB 1 Referrals for Homestart Services must include information about vulnerable children All referrers will be asked if there is any other relevant information regarding safeguarding when referrals are taken.   Specific concerns about a family are shared with Homestart workers Manager July 13 Referrers have provided additional relevant information  Manager 21/10/13 2 Staff and volunteers should be able to respond confidently to injuries to non-mobile babies Safeguarding training will include raising concerns if any bruising to face/head is noted on non-mobile babies. Injuries to non-mobile babies have been appropriately assessed and responded to Manager July 13 Volunteers have been made aware at safeguarding training of risks to non-mobile babies Manager 21/10/13    68  Her Majesty’s Court Service (HMCTS) Action Plan  Recommendation Actions required Outcome required Responsible person Time scale Evidence of action taken Ongoing monitoring Date signed off by LSCB 1 All applications for Emergency Protection Orders are to be referred to the senior family lawyer on site Direction to staff to be issued by the Justices’ Clerk All such emergency applications will be reviewed to ensure that court processes comply with guidance in Re X. Justices’ Clerk Jan 13 Completed  Justices’ Clerk 18/02/13 2 All applications for Emergency Protection Orders are to be supervised  during current proceedings and reviewed at conclusion Direction to staff to be issued by the Justices’ Clerk All such emergency  applications will be reviewed to ensure that court processes  comply with guidance in Re X Justices’ Clerk Jan 13 Completed Justices’ Clerk 18/02/13 3 All Legal Advisers to receive refresher training in Emergency Protection Orders Training to be delivered. To ensure that all members of the Legal Team, in particular the Family specialists have up to date knowledge of the law in this area. Justices’ Clerk 2013 Completed Justices’ Clerk March 2014  