Death of child under 3-years-old (Child U1) in January 2018. A post mortem concluded that the death was a result of internal bleeding caused by significant trauma impact to the abdomen. Partner of Child U1's childminder was found guilty of the child's murder, and the childminder was found guilty of causing or allowing the death of a child. Both received prison sentences. Child U1 was born in March 2016, and had an older sibling who was under 4-years-old at the time of their death. Child U1's father had no contact with the family. Child U1 first attended hospital with an episode of minor gastro-intestinal bleeding in April 2016. There were frequent hospital visits in 2016/17 including surgery; initial concern regarding non-accidental injury (NAI) but this was discounted and a medical cause was thought to be responsible. A strategy meeting concluded that there were no safeguarding concerns in relation to Child U1. Family are Mixed Race British. Key findings: a decision that the injuries were due to a medical cause rather than NAI meant professionals did not query an alternative diagnosis; deference to the medical clinicians involved made challenging medical professionals difficult. Recommendations highlight the need for: professional curiosity, professional challenge and information sharing within and between agencies; assessments to include an understanding of care arrangements and an assessment of the carers; and an understanding of differential diagnosis, and when bruising is present where NAI should be considered.
      
 Title:  Child U1 serious case review. LSCB: Manchester Safeguarding Partnership Author: Anne Morgan Date of publication: 2020  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.                            Final Report   Manchester Safeguarding Partnership Child U1 Serious Case Review  This report was commissioned and prepared on behalf of the Manchester Safeguarding Partnership Independent Reviewer: Anne Morgan Ratified by MSP Children’s Executive Group on 27th February 2020  Published by the MSP on the 15th April 2020   2  Author: Anne Morgan Independent Safeguarding Children Consultant     CONTENTS   PAGE 1.0 INTRODUCTION 3 2.0 RATIONALE FOR CARRYING OUT A SCR 3 3.0 REVIEW PROCESS 3 4.0 FAMILY COMPOSITION 8 5.0 FAMILY HISTORY PRIOR TO PERIOD UNDER REVIEW 8 6.0 NARRATIVE AND ANALYSIS FOR PERIOD UNDER REVIEW 8 7.0 KEY AREAS TO BE EXPLORED 18 8.0 ADDITIONAL LEARNING 24 9.0 RECOMMENDATIONS  25 10.0 AREAS OF GOOD PRACTICE 25 11.0 CONCLUSION 25 12.0 NEXT STEPS 26 13.0 APPENDIX 1 POEM 27                 3  1.0 INTRODUCTION   1.1 Child U1 was taken to a Manchester hospital on the 21st January 2018 in cardiac arrest. Attempts to resuscitate were unsuccessful. A post mortem examination concluded that child U1’s death was as a result of internal bleeding caused by significant trauma impact to the abdomen. On the 24th May 2019 the “cousin”1 of child U1’s mother was found guilty of causing or allowing the death of a child and two counts of attempting to pervert the course of justice. Cousin’s partner was found guilty of the murder of child U1. They both received prison sentences.  1.2 In the months prior to their death, child U1 had attended hospitals in Manchester on several occasions with episodes of unexplained bruising and bowel bleeding. The first attendance resulted in two multi-agency meetings. The first; a strategy meeting at which the medical opinion was that unless medical diagnosis could be identified Non Accidental Injury (NAI) had to be considered as a differential diagnosis. At the second meeting the medical opinion provided for the bruising, was that NAI no longer felt to be a concern, however no medical diagnosis for the bruising was identified. This continued to be the view of health professionals on subsequent admissions. 2.0 RATIONALE FOR CARRYING OUT A SCR  2.1 A meeting of Manchester Safeguarding Children Board’s Serious Case Review (SCR) Sub-group was held on the 27/02/2018 and a decision made to carry out a SCR. This serious case review has taken place because MSCB had concern regarding agencies identification of child abuse in relation to child U1. This decision was ratified by the MSCB chairperson on the 08/03/2018 and was based on the criteria as laid out in Working Together to Safeguard Children 2015 (Working Together)2;3 which refers to Regulation 5 of the Local Safeguarding Children Boards Regulations 2006 sets out the functions of LSCBs. This includes the requirement for LSCBs to undertake reviews of serious cases in specified circumstances. Regulation 5(1)(e) and (2) set out an LSCB’s function in relation to serious case reviews, namely: 5(1)(e) undertaking reviews of serious cases and advising the authority and their Board partners on lessons to be learned. (2) For the purposes of paragraph (1) (e) a serious case is one where: (a) abuse or neglect of a child is known or suspected; and (b) either — (i) the child has died; or (ii) the child has been seriously harmed and there is cause for concern as to the way in which the authority, their Board partners or other relevant persons have worked together to safeguard the child. “Cases which meet one of the criteria (i.e., regulation 5(2)(a) and (b)(i) or 5(2)(a) and (b)(ii) must always trigger an SCR”.  Child U1’s abuse met regulation 5(2) (a), abuse is suspected, and 5(2)(b)(i), “ the child has died4 and there is cause for concern as to the way in which the… (agencies)… have worked together to safeguard the child”.                                                             1 Child U1’s mother had a large extended family and had always thought that in relation to the “cousin” they were a blood relative. Following child U1’s death she became aware that this was not the case. 2 HM Government: Working Together to Safeguard Children. A guide to inter-agency working to safeguard and promote the welfare of children March 2015 p 75:  3 The death of child U1 and consequent decision to carry out a SCR took place before the publication of Working Together to Safeguard Children. A guide to inter-agency working to safeguard and promote the welfare of children; September 2018   4  2.2 The review was delayed in its start date due to the Safeguarding Children’s Board’s decision to wait until the criminal court case relating to child U1’s death had taken place. This was to avoid any possible challenges at court in relation to witnesses who were also participating in the review.  3.0 REVIEW PROCESS  3.1 Scope and focus of the SCR   3.1.1 The panel identified the following key areas to be explored as part of the review. They were: 1. Professional Curiosity 2. Professional Challenge 3. Interagency Communication 4. Impact of referrals being made “Out of Core Hours” 5. Agencies working together  3.2 Organisations Involved in the Review 3.2.1 It was agreed that the following organisations would be required to contribute to the serious case review; Manchester Children’s Social Care Greater Manchester Police  Manchester University NHS Foundation Trust GP Practice Additionally the review panel had access to Manchester University NHS Foundation Trust’s Serious Incident Report, written by an independent investigator. 3.2.2 The review panel was made up of senior representatives from the following organisations with the SCR author as chair. The author was Anne Morgan, an Independent Safeguarding Children Consultant commissioned by MSCB. She has considerable experience in carrying out reviews and is trained in the use of a systems approach. The following table identifies the agencies/professionals who were panel members.  Agency Role Independent Author  Independent Safeguarding Children Consultant Manchester Council Children’s Social Care Service Manager (North assessment) Greater Manchester Police Service Detective Constable – Investigation and Safeguarding Review Team   NHS Manchester CCG  Designated Nurse for Safeguarding Children  MSCB MSCB Safeguarding Board Co-Ordinator Manchester Council Legal Department Deputy Head of Children and Families (Legal) Group Manchester University NHS Foundation Trust Named Nurse Safeguarding Children Manchester University NHS Foundation Trust Named Doctor Safeguarding Children Manchester Council Education Department Education Case Worker 5  NHS Manchester CCG Designated Nurse for Adult Safeguarding  Barnardos Assistant Director North of England Early Years  Locality Manager  The Professionals involved in the Practitioners Event are listed below. Some members of staff were unable to attend the event and were therefore spoken to separately. This included middle grade doctor 2 and the author of the Manchester University NHS Foundation Trust SI report. Agency Role Manchester Children’s Social Care  Service Manager – South Assessment Teams Manchester Early Years Locality Manager Manchester Children’s Social Care Social Work Team manager  Manchester Children’s Social Care Senior Practitioner Manchester Children’s Social Care Community Social Work Team Manager Manchester University NHS Foundation Trust  Team Leader Children’s Community Nursing Team Manchester University NHS Foundation Trust  Consultant Paediatric Surgeon hospital 2 Greater Manchester Mental Health Trust Head of Adult and  Child Safeguarding Greater Manchester Mental Health Trust Clinical Lead, South Manchester Primary Care Psychological Therapies Service Greater Manchester Mental Health Trust Senior Practitioner, Community Mental Health Team Greater Manchester Mental Health Trust High Intensity Therapist (Psychological Therapies) Manchester University NHS Foundation Trust  Health Visitor Manchester Children’s Social Care Hospital Social Worker x2 Manchester Children’s Social Care Community Social Worker Greater Manchester Police Detective Inspector  Manchester University NHS Foundation Trust  Named Nurse Safeguarding Children Hospital 1 (no contact with child U1 Manchester University NHS Foundation Trust  Consultant Paediatrician Hospital 1 Manchester University NHS Foundation Trust  Senior Specialist Nurse Safeguarding Children Hospital 1 Manchester University NHS Foundation Trust  Consultant Paediatrician and Neonatologist hospital 1  Manchester University NHS Foundation Trust Consultant Paediatrician/Named Doctor Safeguarding hospital 1  6   Manchester University NHS Foundation Trust  Senior Specialist Safeguarding Nurse Hospital 2 (observing) Manchester University NHS Foundation Trust  Nurse ED Hospital 1 Manchester University NHS Foundation Trust  Consultant Immunologist Hospital 2 Manchester University NHS Foundation Trust  Consultant Paediatric Rheumatologist hospital 2 Manchester University NHS Foundation Trust  Consultant in Emergency Medicine Hospital 1 Manchester University NHS Foundation Trust  Middle Grade Doctor Hospital 1 Manchester University NHS Foundation Trust  Head of Health visiting Service (south) Manchester University NHS Foundation Trust  Consultant Paediatric Intensivist hospital 2 Manchester University NHS Foundation Trust  Consultant Paediatric Intensivist Hospital 2 Manchester University NHS Foundation Trust  Consultant Paediatrician  Hospital 2 Manchester University NHS Foundation Trust  Specialist Doctor in Ophthalmology Hospital 2 Manchester University NHS Foundation Trust  Consultant Paediatric Surgeon Hospital 2 Manchester University NHS Foundation Trust  Consultant Paediatrician Hospital 1  GP Practice GP   3.3 Time period to be covered 3.3.1 The period covered by the review is from child U1’s birth in March 2016 to their death in January 2018.     7  3.4 Methodology   3.4.1 Working Together 2015, Chapter 45 identifies the principles to be adhered to in carrying out any Learning Review. This includes:  “Professionals and organisations protecting children need to reflect on the quality of their services and learn from their own practice and that of others.  Good practice should be shared so that there is a growing understanding of what works well. Conversely, when things go wrong there needs to be a  rigorous, objective analysis of what happened and why, so that important  lessons can be learnt and services improved to reduce the risk of future  harm to children”.    This review was carried out in line with those principles and is proportionate to the incident.    3.4.2 A chronology was produced by the agencies involved, and the professionals working with the family identified.  3.4.3 The model used was based on a broad systems approach.   3.4.4 Practitioners were met with, initially as a group and conversations were held with other key professionals who were unable to attend.  3.4.5 Family Involvement: Child U1’s parents were informed of the decision to carry out a SCR and invited to meet with the review author and a member of the review panel. Child U1’s mother took up this offer to meet and provided the following information. She reported that her pregnancy had not been planned and that once she told the father she was pregnant he effectively disappeared from her life. During her pregnancy she had been supported by her “cousin” attending hospital appointments with her and she continued to help once child U1 was born. Child U1’s mother worked unsocial hours at the weekends and her “cousin” started looking after child U1 on her (child U1’s mother’s) return to work. She paid her to look after child U1 three days a week. At no time was she aware that her “cousin’s” partner was looking after child U1. When chid U1 started to become unwell she took photos and wrote notes to describe the symptoms. She reported that her “cousin” had done the same. Child U1’s mother was absolutely “floored” when child U1 had to have bowel surgery and was sure her child must have had a blood disorder. She had not made the connection between child U1 being cared for by her “cousin” and child U1 becoming unwell. She said that she felt that the NHS was amazing and she had appreciated the help and concern provided in relation to child U1, although she did feel that she had to repeat herself at times and that not all the information relating to child U1 was always available for the hospital staff. She didn’t want any blame to be put onto the doctors as she felt that if she did not suspect her “cousin” and partner then how could anyone else. She felt that children’s social care had assessed her “cousin” as not being a risk and that chid U1 never showed any fear of either the “cousin” or partner. Child U1’s mother felt she had been well supported by all the agencies involved including child U1’s sibling’s school. She was however concerned that the police gave out her address in court which caused her to be inundated with reporters which she found very difficult to cope with.   3.4.6 She was asked if she would like to provide a pen-picture of child U1 to be included in the report and provided a poem which is attached in Appendix 1.                                                              5 HM Government: Working Together to Safeguard Children. A guide to inter-agency working to safeguard and promote the welfare of March 2015 children p.75    8  3.4.7 The process was supported by the panel members identified above.    4.0 FAMILY COMPOSITION Age at Time of Incident  Relationship to subject Ethnicity Place of Residence  Under 3 years old Child U1 subject Mixed Race British Manchester 25 years old Mother Mixed Race  British Manchester Not known Father Not known Not known Under 4 years old Sibling 1 Mixed Race British Manchester 39 years old “Cousin” White British Manchester 28years old “Cousin’s” partner White British Manchester  Genogram attached as Appendix 2  5.0 FAMILY HISTORY PRIOR TO PERIOD UNDER REVIEW  5.1 No relevant family history   6.0 NARRATIVE AND ANALYSIS FOR PERIOD UNDER REVIEW 6.1 Child U1’s mother had a normal pregnancy and delivery with child U1 being born in March 2016. During this time she was supported by her “cousin” and “cousin’s” partner. She was seen by the health visitor and the family allocated to universal services6. In April 2016 child U1 attended hospital 1 with an episode of minor gastro-intestinal bleeding. There were no other concerning features present at this attendance, specifically no bruising was noted and follow up was appropriate. Child U1 was seen by the GP in May 2016 with wind, loose stools, vomiting and a rash. It was felt child U1 may have a lactose intolerance and started on lactose free milk which they appeared to tolerate. 6.2 In January 2017 Manchester Multi-agency Safeguarding Hub (MASH) received a referral from mental health services in relation to child U1’s “cousin’s” family. This was the second referral for early help within a year and related to the family’s need for support in relation to the “cousin’s” partner’s poor mental health. He was receiving psychological support for anger anxiety and depression. The “cousin’s” children were already receiving support from Child and Adolescent Mental Health Service (CAMHS) and school counselling services to support their own needs (both children have special needs). Mum’s “cousin” was referred to a self-                                                           6 NHS England: National Health Visiting Service Specification March 2014; NHS Confederation   9  help group for support (which was what “cousin” requested) and the case closed. The assessment appears to have been thorough with all agencies known to the family contacted and the support offered appropriate.  6.3 Child U1’s mother returned to work and child U1 started to be cared for by mother’s “cousin”. Child U1 was next seen at Hospital 1 on the 04/04/2017 having passed blood in their stools, thought to be infective gastro-enteritis. Child U1 was reported to have 2 further episodes over the next 24 hours. All blood and urine results were within accepted limits. No bacterial or viral infection was identified. 6.4 On the 07/05/2017 mum’s “cousin” was admitted to hospital following an overdose of medication. Once conscious she reported that her partner suffered from anxiety and depression and that his mood was not good. Her own two children were with their father for the weekend. She did not mention that she was also caring for child U1. Following assessment she was discharged back to the care of the GP for support with and a referral made to Children’s Social Care (CSC). This was appropriate based on the information provided.  6.5 On Saturday the 08/07/2017 (aged under 2 years) child U1 was admitted to the Paediatric unit of hospital 1. Child U1 was diagnosed with an ear infection and possible eczema (due to a rash on the back of the neck). Blood tests showed mild anaemia, for which Child U1 was started on iron medicine (Sytron). A follow up appointment was arranged with Consultant Paediatrician 1 in 4 weeks.  6.6 Child U1 was seen by the GP on the 13/07/2019 with bruising. Records note that swelling on the “forehead looks due to mild trauma”. However there was no recording regarding any explanation as to how this occurred and no further examination to check for any other bruising. Safeguarding did not appear to have been considered. Child U1 was seen four days later by a different GP. Mum told the GP that child U1 had haemorrhagic urticaria which was managed with piriton7. Child U1’s mother reported that child U1 was getting worse –spontaneous large bruising, feverish most days, and her hair falling out in clumps. She felt that the swelling on child U1’s body may be due to an allergy to iron medicine child U1 was taking; she had given child U1 an anti-histamine which she said had reduced the swelling. There does not appear to have been any discussion between the two GPs or curiosity as to the apparent worsening of symptoms. A letter was however written to Consultant Paediatrician 1 by child U1’s GP requesting advice regarding the suspected allergic reaction to the iron medicine. This communication between GP and paediatrician was good practice, enabling the medical staff involved in child U1’s care to have all the information available in relation to child U1. However the presumption that this was an allergy was not tested out (allergy to Sytron is very rare) and consideration was not given to other possible causes for the bruising.   6.7 At the paediatric review of child U1 in clinic on the 25/07/2017 apart from mild anaemia no concerns were identified, with no re-occurrence of the swelling.   6.8 On Friday 08/09/2017 child U1’s mother called an ambulance. She reported that child U1, aged under 2 years old, had a non- blanching rash8 to the chest, back and right forearm. The rash had been noted by child U1’s cousin that evening when she was caring for child U1. Child U1’s mother also noted a swelling to child U1’s forehead (left side). Child U1 also had a haematoma9 on the right side of the forehead which was noted to develop during                                                            7 Piriton is an anti-histimine which is used to reduce allergic reactions  8 A non-blanching rash can be an indication of meningitis and is therefore always treated seriously 9 A localized bleeding outside of blood vessels, due to either disease or trauma including injury or surgery 10  contact with the ambulance crew.  Child U1 was taken to hospital 1 Emergency Department (ED). Initial thoughts were that child U1 was ‘unwell’ and meningitis was initially suspected, with no concerns identified in relation to safeguarding. However when seen by the Paediatric middle grade doctor 1 she was concerned that child U1’s bruising may be due to non-accidental injury (NAI) if no medical cause was found. She recorded her findings on a child protection admission pro-forma and detailed body maps. Consideration of NAI when there is no clear medical rationale for a child U1’s presentation was good practice and reflected the lateral thinking required when there is no clear diagnosis. Child U1 was admitted to the children’s ward and further investigations were carried out the following morning. The on-call Paediatric Consultant 2 telephoned the Paediatric Haematology Consultant at hospital 2 who suggested further blood tests if initial investigations were normal and the need to consider NAI as a possible diagnosis. Child U1 was reviewed by middle grade doctor 2. She recorded her concern about the skin marks and stated that non-accidental injury should be top of the differential diagnosis list. She then liaised with the on call paediatric consultant 2 to seek agreement to contact children’s social care and the police. Images were taken by middle grade doctor 2 using the ward camera these were subsequently uploaded to the electronic records system. No formal medical photography was available at the weekend, the use of the ward camera was good practice and provided clear photographic evidence for the police and children’s social care. It also provided images which could be used to compare and contrast with any future presentation. Access to medical photography out of hours has been identified in the hospital SI and addressed within their action plan. 6.9 Middle grade doctor 2 contacted the duty social worker 1 on the 09/09/2017 and explained that ‘not definitely injuries but if they are, they are significant’. It was agreed to hold a strategy10 meeting that evening and child U1’s mum was informed. The meeting was attended by duty social worker 1, a police representative, middle grade doctor 2 and a ward staff nurse. Middle grade doctor 2 was able to explain to the other professionals that there was no medical cause found for the bruising, although a previous similar presentation to the GP in July made this a possibility. She also pointed out that there was nothing medical to explain the zig-zag marks on child U1’s skin. It is usual practice for the relevant paediatric consultant to attend strategy meetings rather than the middle grade, this would have shown leadership and commitment to the safeguarding concerns and would occur in the majority of cases regardless of the time or day of the week the meeting was called. The outcome in this instance was unlikely to have been affected due to the middle grade’s knowledge and commitment.   6.10 Both mum and mum’s “cousin” were seen at the end of the meeting, neither could offer any additional information about anyone else caring for child U1. The plan agreed was for a skeletal survey and for child U1 to remain as an inpatient until the investigations were completed. Mum was to be allowed to stay with child U1 with ‘1:1’ supervision by nursing staff. The strategy meeting was held at the weekend when not all agencies can be contacted to gain information, however access to child U1’s “cousin’s” CSC’s records would have been available and would have identified three separate referrals for early help related to her partner’s mental health and the need for family support. These were not discussed at the strategy meeting and do not appear to have been considered in the subsequent CSC assessment. 6.11 Child U1 was reviewed again by Paediatric consultant 2 on Sunday 10/09/2017. He explained to mum that the bruises were still unexplained and needed to be explored for both                                                            10 A Strategy Meeting is held when there is reasonable cause to suspect that a child has suffered or is likely to suffer significant harm. The purpose of the meeting (of which there may be more than one) is to share available information and determine whether or not to proceed with Section 47 (child protection) enquiries. 11  medical and non-medical causes. Communication with the family was good. Mum reported that her grandmother had a haematological condition although it is not specified which one. 6.12 Child U1’s care was handed over to Paediatric Consultant 3 on Monday 11/09/2017 There is no agreed practice regarding handover where there is a safeguarding concern over a weekend, however continuity of care could have provided a more consistent approach to the safeguarding concerns highlighted at the initial strategy meeting. Paediatric Consultant 3 reviewed child U1 on his morning ward round and took a verbal handover from the weekend Consultant 2. When examined by Paediatric Consultant 3, child U1 was found to have fading bruising and petechiae11. Child U1’s skeletal survey showed no evidence of bony injury. Formal medical photography was also carried out. The ward images taken by middle grade doctor 2 do not appear to have been available for viewing at this point due to the various IT systems in use. This would have aided paediatric consultant Paediatric Consultant 3 to have a clearer view of the changes since admission. He did however see images of the swelling and bruising from this admission and of a previous similar episode in July 2017 on child U1’s mum’s phone. No analysis of these photographs was recorded in child U1’s records which would have identified fading bruises nor were they taken to the subsequent strategy meeting on the 13/09/2017. This was attended by Paediatric Consultant 3, the senior specialist Nurse for safeguarding, child U1’s health Visitor and social worker 2. The police were not represented at this meeting as they as they had been advised prior to the meeting that the medical opinion was that the findings were not indicative of inflicted injury. The documentation suggests that this was due to the skeletal survey being normal. This showed a lack of understanding of the medical opinion expressed at that first meeting. The medical opinion conveyed by Paediatric Consultant 3 at this meeting was that the initial swelling and redness on the left side of the head was not related to an injury, (due to the way it had healed without any bruising present), rather it might be due to an undiagnosed medical problem as similar swelling was seen in July 2017 (by GP). This presumes that the previous swelling was due to a medical problem rather than a missed injury. The Serious Incident (SI) enquiry carried out by the hospital was of the opinion that: “The medical opinion conveyed to children’s social care on this occasion appears to have been premature in ‘ruling out’ non-accidental injury as a possible  explanation”  6.13 Neither the chair nor any of the attendees at the initial strategy meeting were present at the second meeting. This change of professionals led to a lack of continuity, with new professionals being given a completely different view from paediatric consultant 3 than that raised by the middle grade medical staff. The middle grade doctor only undertook out of hours on call at the hospital, being based in community paediatrics in office hours. She was not on duty in the hospital at the time the second meeting was held and therefore not available for this meeting. This and the transfer of chid U1’s care to another consultant resulted in a lack of continuity at the second meeting and lessened the opportunity for inter-professional challenge with professionals accepting the consultant’s view as to the cause of child U1’s symptoms. The meeting was chaired by a Senior Practitioner who did not have the same level of experience in considering differential diagnoses as would a team manager. The relative inexperience of the chair appears to have, along with the absence of the police and of the middle grade doctor who articulated the initial concerns, contributed to the acceptance without challenge of the change in medical opinion about the injuries. As a result, the meeting concluded that there were no safeguarding concerns in relation to child                                                            11 Petechiae are formed when tiny blood vessels called capillaries break open. When these blood vessels break, blood leaks into your skin causing a rash 12  U1. In retrospect it is likely that child U1 facial bruising and swelling was due to inflicted injury. Following the meeting “No Safeguarding concerns” was recorded in child U1’s health records and influenced thinking at child U1’s future hospital attendances. Mum’s care was reported to have been appropriate whilst resident on the ward. Child U1 was therefore discharged from the ward in the care of mother with agreement that CSC would commence a Child and Family Assessment (CAFA). Medical follow up was already in place with Paediatric Consultant 1 from a previous presentation in July and the family was to be allocated a health visitor to provide additional support. Due to vacancies within the health visiting service at that time and the presumption that there was a medical cause for child U1’s presentation, this was not identified as a priority by that service. Whilst ED notifications were scrutinised there was no assessment of child U1’s health needs or the support mother may have required.   6.14 On the 27/09/2017 CSC’s assessment was concluded. The assessment was based on the assumption that child U1’s presentation at hospital was due to a medical cause and focused on the support requirements of child U1’s mother rather than who was caring for child U1. Whilst child U1’s mother advised the SW that her “cousin”, aunt and mother all cared for child U1 at various times this was not explored in detail and therefore the extent of the “cousin’s” care was not fully understood. Had this occurred a clearer picture of the stresses already present within that family may have been identified and the opportunity to consider how this could impact on child U1’s care was lost. It would also have identified the need for a formal childminding assessment to occur due to the hours’ child U1 was receiving paid care.  6.15 On the 02/10/2017 the “cousin’s” partner was referred back to mental health services as his mood had deteriorated despite his medication. He was subsequently placed on the waiting list for therapeutic assessment.  6.16 On the 03/10/2017 CSC closed the case.  6.17 Child U1 attended hospital 1 on the 11/10/2017. This was four weeks after the last attendance. Child U1 was referred by the out of hours GP with a similar history to their past admissions (i.e. bruising and petechiae) and was admitted overnight under the care of Paediatric Consultant 3 and was discharged home the next day. The ward entry noted that there was a “strong family history of haemorrhagic urticaria”. None of the health professionals who saw child U1 on this occasion took a social history to identify child U1’s carers nor did they consider alternative diagnosis. 6.18 Neither CSC or the hospital safeguarding team were made aware of the admission as non-accidental injury was not considered to be an issue and symptoms put down to a medical cause possibly haemorrhagic urticaria, although the rash on child U1’s body was not typical of this.  It may have also have been influenced by the fact that child U1 had presented with similar symptoms put down to allergy (GP attendance in July 2017), and the fact that the consultant’s previous assessment had ‘discounted’ non-accidental injury in favour of a medical cause, mum’s appropriate response and interaction with child U1. This fixed thinking meant that there was no consideration of an alternative diagnosis or discussion with CSC. In fact the bruising was consistent with many of the signs associated with NAI12.                                                            12 NSPCC Core Info Bruises on Children 2012 NSPCC 13  6.19 On the 23/10/2017 child U1 was seen by a GP trainee following a telephone consultation by one of the GPs at the practice who requested child U1 attend the surgery13. The GP trainee noted that mum reported that child U1 had haemorrhagic urticaria triggered by viral illnesses. Bruising was noted on chid U1’s forehead lumber spine right and left thigh and upper chest. The impression was that the child was at “low risk of NAI due to the hospital ruling out NAI three months previously”, with a plan by the GP trainee “to wait and watch”. Safeguarding however low a risk was a concern identified at this consultation and should have been discussed with the trainee’s supervisor or the GP practice’s safeguarding lead and a clear plan of action agreed.  6.20 On the 02/11/2017 child U1, aged under 2 years old, was taken to hospital 1 by ambulance. This was 3 weeks after the previous attendance. The ambulance record states that child U1 had been off food the previous day; had vomited overnight and then developed black stools and lethargy in the morning. It also states ‘no history of trauma however patient has been with dad14 all weekend’. On examination child U1 was found to have petechiae on the face and back of chest, and bruises on the abdomen and legs. The ‘abdominal bruises being new according to mum’. Child U1 received resuscitation fluids and antibiotics. Given the past history and the evidence of new bruising consideration should have been given to the possibility of NAI and a discussion held with CSC. Child U1 was reviewed by Paediatric middle grade doctor 3 who noted a history of previous admissions with unexplained bruising, thought to be haemorrhagic urticaria, all precipitated by viral illness with no safeguarding concerns. This would no doubt have influenced the lack of consideration of differential diagnosis. The bruising and petechiae were recorded using the electronic body maps which was good practice. It would however have also been good practice to carry out medical photography of child U1.  An ultrasound15 of child U1’s abdomen was carried out. This showed fluid in the abdomen, likely blood or pus. Following discussion with colleagues at hospital 2 further tests were carried out and once stabilised child U1 was transferred to the Paediatric High Dependency Unit. That evening, further discussion between hospital 1 and 2 took place and on the evening of the 02/11/2017 child U1 was transferred to hospital 2 by ambulance.  A verbal handover took place and information regarding previous admissions and safeguarding concerns were shared. This was good practice, however the lack of consideration of trauma on this occasion continued the fixed thinking in relation to a medical cause for child U1’s condition.  6.21 Child U1 was examined by the Surgical Consultant and was taken to theatre the same evening, where part of the bowel was removed due to areas of dead tissue being present. The surgeon’s report noted that ‘no identifiable reason was found’ to explain the observations and in view of the unusual findings to seek review by immunology, haematology and cardiology teams. Whilst this was appropriate further consideration should have been given to the possibility of NAI particularly as child U1 also had bruising on the legs, arms, and abdomen. At interview, as part of MFHT’s SI Investigation, the surgeon reported that he felt that the presentation was not like anything he had seen previously where there had been NAI. Whilst it is accepted that the expert opinion remains that the operative findings were not suggestive of trauma it appears there was an assumption that there was a single unifying diagnosis that linked the skin and the intraabdominal findings, with the possibility of inflicted injury not being considered. This led to a perpetuation of the fixed thinking in relation to a medical cause for child U1’s condition, despite pattern of                                                            13 GP trainees work under supervision. Why this did not happen in this case is being followed up with the practice concerned and is outside of the scope of this SCR  14 This was inaccurate. Child U1’s father had no contact.  15 An ultrasound scan, is a procedure that uses high-frequency sound waves to create an image of part of the inside of the body and can be used to diagnose a condition 14  findings not being suggestive of a recognisable medical pathology and meant that child U1’s condition was further medicalised.  6.22 Following surgery child U1 was transferred to Paediatric Intensive Care Unit (PICU) and remained there until the 05/11/2017 where they were transferred to the surgical ward. During the time in PICU there were reviews by the Immunology, Gastroenterology and Haematology teams. Further investigations were planned including a skin biopsy and blood screen for clotting abnormalities. This was all appropriate however the exclusion of inflicted injury from the list of possible diagnoses resulted in lack of discussion with the safeguarding team and / or CSC. The lack of safeguarding knowledge in PICU was identified in another Manchester SCR child C in 2014 where the PICU staff did not question the possibility of inflicted injury as a cause of the bruising. It is of concern that the learning from that review has not been fully embedded. 6.23 Child U1 was discharged home on the 08/11/2017. Follow up was arranged in 2 weeks with the Immunology consultant. 6.24 Following this admission an ED notification was sent to the health visitor identifying the need for resuscitation and surgery. There was no liaison with the health visitor during child U1’s stay in hospital and no evidence of consideration of the need for additional support following child U1’ surgery. The surgical discharge summary was only sent to the GP, and was six weeks after child U1’s discharge, resulting in the opportunity for meaningful follow up being missed. Had it also been sent to the referring consultant there would have been the opportunity for that consultant to reflect on the presence of bruising at the time of transfer and on the chronology of presentations over the preceding five months, consider the implications of the surgical findings and the ongoing absence of an identifiable medical pathology. This could have been an opportunity to reconsider inflicted injury as a possibility and discuss with the consultant at hospital 2. 6.25 This further medicalisation of child U1 shut down the opportunity for further discussion and challenge and apart from a peer review at hospital 1 following child U1’s admission for and transfer to hospital 2 for surgery no concerns were raised in regard to diagnoses. This peer review identified child U1 as a complex case however there was no clear plan in place to review child U1again. Had the discharge summary from hospital 2 been available for discussion the outcome of that discussion with the additional information available may have enabled professionals to reflect on the previous management of child U1. 6.26 There are clear processes for referring perplexing or complex cases for discussion at both hospitals. In this instance there was a meeting between 3 of the consultants involved, however as safeguarding was not being considered the normal process of including the named doctor in that discussion was not considered. Had this occurred there may have been the opportunity to reconsider treatment options. 6.27 Child U1 was not brought to planned appointments with Paediatric Consultant 1 at hospital 1 on the 14/11/2017 and 28/11/2017, (child U1 had previously been discharged from dietetic service due to not being taken to appointments). Following the second non-attendance with Paediatric Consultant 1 child U1 was discharged from his care. A letter was sent to the parents but the investigation could find no evidence of information sharing with the GP or health visitor. Manchester University Foundation Trust NHS hospitals have a policy that requires consideration of liaison with other professionals working with family when children are not brought to their appointments. In this case it would have been appropriate to discuss with the consultants at hospital 2 and the GP before discharge to ensure holistic provision of care for child U1.  Evidence suggests that those children who are not brought to appointments 15  are some of the most vulnerable in our society16 and unlike adults are unable to make an informed decision regarding attending. The paediatrician recalled when asked that he was probably aware of child U1’s ongoing treatment at RMCH and therefore assumed that they would be following this up. This resulted in a lack of overview and a more holistic approach to child U1’s care by a paediatrician, a factor identified in other Manchester SCRs17. 6.28 Child U1 attended hospital 2 on 23/11/2017 for a planned clinic appointment and saw the Immunology consultant who had by default become the lead clinician and was also seen by the Paediatric Rheumatologist and Paediatric Surgeon. A plan was made for a skin biopsy should child U1 have any further episodes of unusual bruising. Being seen by all three consultants at the same time was good practice enabling discussion around an agreed plan of care. However there was no challenge in relation to the cause of the bruises, with an acceptance of the diagnosis of “haemorrhagic urticaria”. This re-confirmed the view that child U1’s problems were all medical in origin and there was no consideration of any alternative reason for the bruising and petechiae. 6.29 On the 30/11/2017 child U1 aged under 2 years old attended hospital 2. This was 3 weeks after the previous discharge with presentation similar to previous attendances. No safeguarding concerns were identified. Child U1 was admitted and reviewed by the Paediatric Immunology Consultant who noted bluish-purple spots on the forehead and ear with extensive swelling. Child U1 was noted to look well “apart from that” and a plan was made to keep them in and repeat medical photography the following day. This was all appropriate management when considering a medical cause, however consideration to any differential diagnosis including NAI was absent within this management plan. Child U1’s admission bloods were normal other than a mildly raised marker of inflammation. The consultant recorded his view that the forehead swelling ‘looked odd because without the rash it could be hereditary angioedema18’. No other explanation was sought or offered for the bruising other than the history presented by mum. This included her telling the Paediatric immunology consultant that when child U1 got frustrated they would bang their head although there was no recording of this occurring on this admission. He thought that the bruising was in a location consistent with this. On the 01/12/2017 child U1 underwent an ultrasound of the forehead. This was reported as showing ‘appearances similar to features seen in soft tissue bruising’. In view of the unusual pattern of presentation, and the reported head banging the Paediatric immunology consultant made a verbal referral to the duty Safeguarding Paediatric Consultant 4 for a  re-evaluation of child U1’s history and presentations to hospital  6.30 Child U1 was reviewed by Paediatric Consultant 4 on the 01/12/2017. Child U1 was seen in the presence of mum and it was noted that they had a good interaction with each other. Paediatric Consultant 4 recorded all previous contacts and the associated photographs and investigations. Additionally the extensive family history (medical) which included easy bruising, urticaria, unknown bleeding and severe eczema was recorded. However no social history was taken, and there was a presumption made, not only by Paediatric Consultant 4, that child U1 was cared for totally by mum despite hospital records noting that child U1’s mum’s “cousin” regularly looked after the child (first admission). This medical examination should have included a full social history including all adult carers; when and where they looked after child U1 and whether there was any correlation between carers and child U1’s hospital admissions. This consultant was however not alone in not carrying out a full social history. It is not evident in many of child U1’s previous admissions. Taking a social history would have identified that bruising occurred following child U1 spending time with “cousin’s”                                                            16 French LRM, Turner KM, Morley H, et al. (2017) Br J Gen Pract, Characteristics of children who do not attend their hospital appointments, and GPs’ response: a mixed methods study in primary and secondary care. DOI 17 MSCB Child K1 2018 18 Angioedema is an area of swelling of the lower layer of skin and tissue just under the skin or mucous membranes. The swelling may occur in the face, tongue, larynx, abdomen, or arms and legs. Often it is associated with hives, which are swelling within the upper skin. 16  family and could have given the opportunity to reconsider the cause of the bruising from a social as well as a medical perspective.  6.31 As part of this assessment mum expressed some concerns about child U1’s behaviour, including rigid thoughts and poor interaction with other children. This was the first time such behaviour had been reported. It would have been good practice to feed this back to the health visitor and GP to follow up and consider as part of any diagnosis. Instead an MRI scan was recommended to exclude a medical cause. Paediatric Consultant 4 felt that overall that child U1’s presentation was most likely explained by a multisystem disorder or vasculopathy19, however this was again a possible diagnosis being considered which was not backed up by clear evidence relating to child U1’s presentation.  Although not able to be more specific. Paediatric Consultant 4’s notes recorded the view that there was no cause for further child protection procedures. Paediatric Consultant 4 commented that the forehead bruising was bigger than would usually see in trauma and this episode when taken on its own is more likely medical even with the petechiae on child U1’s left ear. This observation appears to ignore the possibility that there had been substantial blunt impact trauma at the site of the bruise. One possible explanation for the co-existence of petechiae on the ear and a bruise on the forehead is NAI with a minimum of two separate impacts. Contact with the paediatricians at hospital 1, who had been involved with the previous safeguarding referral may have been beneficial in aiding analysis of child U1’s presentation. 6.32 This assessment continued to re-enforce the view that there was a medical reason for child U1’s presentation. In discussion as part of MFT’s SI Paediatric Consultant 4 felt that the assessment was not as analytical as it could have been partly due to the long hours he had been on duty and the fact that child protection was not really being considered. This issue has been addressed within the hospital SI and therefore not addressed within this report. The impact however was that it influenced the thinking of consultants from other specialities subsequently continued to re-enforce the view that there was a medical reason for child U1’s presentation.  6.33 Further investigations were requested by the Consultant immunologist and consideration was given to a diagnosis of Ehler’s Danlos disease20, however, like the diagnosis of haemorrhagic urticaria, child U1’s symptoms were not fully consistent with either diagnosis.  Child U1 was also reviewed by the Consultant Paediatric Gastroenterologist and a plan was made for further investigations to exclude inflammatory bowel disease (normal). The MRI brain scan was reported as normal. Child U1 was discharged on the 05/12/2017 with follow up in immunology clinic on the 19/12/2017 which was attended. The electronic discharge summary was sent to the GP. 6.34 As with previous attendances, there appears to have been a pre-occupation with an underlying medical cause for child U1’s signs and symptoms during this episode of care with insufficient consideration given to alternative diagnosis. This was influenced by the obvious good rapport between mum and child U1 however it lead to a lack of professional curiosity and respectful uncertainty when assessing child U1, and no recording or analysis of social history or a timeline of events prior to admission. Medicalisation of children by tertiary units is an issue that has been identified in other SCRs nationally where because of the nature of their expertise there is an inborn bias to look for a medical diagnosis21. Where there is the opportunity to discuss such cases with colleagues whether it be consultant colleagues, consultants from other specialities or Multi- Disciplinary Team meetings the reflection and                                                            19 Vasculopathy is a general term used to describe any disease affecting blood vessels  20 A heritable disorder of connective tissue that is characterized by easy bruising, joint hypermobility (loose joints), skin laxity, and weakness of tissues. 21 LB Croyden 2017 17  review of the case helps with the analysis and provides the opportunity for this inborn bias to be addressed. 6.35 Child U1 next attended hospital 1 on the 14/01/2018 aged under 2 years old. This was 5 ½ weeks after the previous discharge. Child U1 attended in the early hours of the morning with a female adult, not mum. The adult (later identified as “cousin” had previously contacted Emergency Department (ED) for advice (saying child U1 had lupus22). She was advised that as child U1 was under the care of hospital 2 she should take the child there. The adult advised that she looked after child U1 overnight whilst mum was at work. Child U1 was seen by the ED Doctor who noted previous episodes of ear swelling and also that they were under hospital 2 for complex bruising. On examination child U1 was found to have a cut and swollen right ear. This was not thought to be due to trauma, with the assumption being made that it was due to a medical cause. Child U1 was also noted to have bruising to the abdomen and legs, similar to documented in previous notes, and under investigation for cause. The ear was dressed and advice given to attend hospital 2 the following day for review by their usual team. Mum was contacted regarding the attendance and a discharge letter was sent to the GP. 6.36 Whilst there is documentation regarding an adult who was not mum attended with chid U1 her name and the care arrangements are not documented. There appears to have been a lack of curiosity by ED staff about child U1’s care arrangements and other involved adults. 6.37 As with previous attendances, staff accepted a medical cause for child U1’s bruising, with no alternative explanation explored. The cut to the ear was thought to be due to swelling and skin breakdown, and whilst this is possible, it would be unusual and should have prompted a more careful evaluation. Additionally the aunt (“cousin”) gave a diagnosis of lupus, however at this time staff would not have had access to hospital 2’s records and would not have seen that this had never been a consideration. This lack of accessibility to information between hospitals 1 and 2 had an impact on this case in that there was a presumption that the adult with child U1 was providing them with accurate information. The lack of access to information has been addressed within MFT’s SI.   6.38 ED discharge documentation was shared with the GP but there is no evidence that information was shared with the health visitor, hospital safeguarding team or children’s services. Given that child U1 had presented overnight to ED without a parent, additional information sharing would have been appropriate at this point, as would contact and enquiries with children’s social care. 6.39 In the afternoon of that day (14/01/2018) child U1 attended hospital 2 with mother. The ED doctor referred them to the Immunology team where they were seen by a junior grade doctor. The doctor documented that child U1 was very chatty, bright and full of energy. The ED doctor noted small bruises to both thighs and the upper back. She did not re-examine child U1’s ear as it had already been seen by the ED Consultant and been dressed. She discussed the case with the Immunology Consultant on-call and as blood results were normal Child U1 was discharged with a follow up appointment with the Immunology consultant on the 16/01/208. The ED discharge letter was sent to the GP, however contact with the health visitor to inform them of the continuing attendances would have enabled more support in the community. 6.40 On the 16/01/2018 child U1 attended ED with mother. This was two days after the previous attendance. This was due to concerns that the ear was starting to smell. Child U1 was seen directly by the Immunology Consultant. In his notes he has documented that child U1 looked well. His impression was that the wound was infected and child U1 was started on                                                            22 An auto-immune disorder 18  oral antibiotics. Child U1 was referred to the Children’s Community Nursing Team for review and redressing of the ear. A written referral was sent in addition to a telephone conversation with the Community Nurse and the ED discharge letter was sent to the GP. This was good communication with those community staff, however the ED notification received by the health visitor provided minimal information, as had the previous ones resulting in little information on which to make an effective analysis of the situation.  6.41 Child U1 was reviewed by a Children’s Community Nurse on the 18/01/2018, attending with mum and mum’s “cousin”.  Child U1’s behaviour was happy and normal, and there appeared to be good interaction with mother who displayed good parenting skills. Child U1 sat on “cousin’s” knee for part of the appointment. The ear was redressed and arrangements made for a follow up on 22/01/2018. 6.42 On the 21/01/2018 child U1 was taken by ambulance to hospital 1 in cardiac arrest. Resuscitation was unsuccessful. Following death the SUDC (Sudden Unexpected Death in Children) process was followed. Post-mortem results showed no evidence of any medical cause for child U1’s presentations at hospital 1 or 2. 7.0 KEY AREAS TO BE EXPLORED 7.1 PROFESSIONAL CURIOSITY 7.1.1 Professional Curiosity23 has been described as having the capacity and communication skill to explore and understand what is happening within a family rather than making assumptions or accepting things at face value. It requires practitioners to practice ‘respectful uncertainty’ – applying critical evaluation to any information they receive and maintaining an open mind. In safeguarding the term ‘safe uncertainty’ is used to describe an approach which is focused on safety but that takes into account changing information, different perspectives and acknowledges that certainty may not be achievable. It can require practitioners to think ‘outside the box’, beyond their usual professional role, and consider families’ circumstances holistically. Professional curiosity requires being open to the unexpected, and incorporating information that does not support initial assumptions of an assessment of what is happening. As the tri-annual review of SCRs states “that where staff are alert to concerns and able to demonstrate:…….   professional curiosity and awareness of possible maltreatment and  cumulative risk…..  practitioners are able to challenge parents and  explore a child’s vulnerability or risk while maintaining an objective,  professional and supportive manner timely and appropriate referrals are more likely to occur”24.  7.1.2 In this case following child U1’s admission to hospital 1 on the 09/09/17 no concerns regarding bruising were raised within the ED department, with a presumption being made because of the previous history of bruising that the presentation was due to medical causes. This showed a lack of curiosity as to how the bruises had occurred and no consideration of cause. It was following admission to the ward that concerns were raised and CSC informed. The paediatric consultant’s (consultant 3) view, expressed at the second meeting, that child U1’s presentation was based on a medical cause because the skeletal survey showed no fractures was flawed. It did not take account the fact that physical injuries can occur without                                                            23 MSCB Professional curiosity & challenge – resources for practitioners 24 DfE Pathways to harm, pathways to protection: a triennial analysis of serious case reviews 2011 to 2014 Final report May 2016 Peter Sidebotham, Marian Brandon, Sue Bailey Pippa Belderson, Jane Dodsworth, Jo Garstang, Elizabeth Harrison, Ameeta Retzer and Penny Sorensen University of Warwick, University of East Anglia p141 19  fractures occurring and that professionals are required to keep an open mind to NAI when there is no clear medical diagnosis. Additionally mother’s presentation and openness, along with observation of good parenting reassured both health and social care professionals who concluded that all was well rather than probing more deeply to consider the unexplained presentation and who apart from mum was caring for child U1. 7.1.3 Professionals, rather than becoming more curious about the unexplained nature of bruising continued with the assumption that child U1’s further presentations were due to medical causes with no consideration to other causes and the routine social history taking and discussion regarding care arrangements not being discussed. This lack of curiosity extended to the surgical admission when child U1 had part of the bowel removed with no clear explanation for how the bowel problem had occurred and the penultimate attendance when child U1 presented with a problem with the ear. Ear injuries which include a split are more likely to be non- accidental than accidental in origin.  7.1.4 The verbal reports taken from mum and her “cousin” about medical interventions were consistently taken at face value by the health professionals involved with the family, for example when haemorrhagic urticaria was being considered by the consultant paediatrician it then became reported as a diagnosis and noted as such. Child U1’s “cousin” gave the diagnosis of lupus on a further attendance. The detail was neither questioned nor verified by professionals seeing child U1.  7.1.5 GPs and health visitors who are more likely to see children in their own environment and have a more holistic view of the family including any social factors that may affect health and wellbeing however in this case neither the ongoing hospital attendances appeared to have been considered nor any enquiries carried out as to care-givers when mum was working and child U1 was not discussed in a formal multi-disciplinary team (MDT) meeting with the health visitor. Nationally, it is expected that GP surgeries have robust safeguarding governance and practice arrangements in place, this should include regular MDT meetings to discuss vulnerable patients, child U1 would have met the criteria as a vulnerable patient and exploration of the child’s presentation could have taken place following the strategy meeting and further attendances.  7.1.6 The social work assessment considers the three aspects of care relating to the child, i.e the child’s needs, the parents’ ability to meet those needs and the family and community support available. In this instance child U1’s daily life was not explored in detail and did not consider the care arrangements for child U1. The SW was advised that a number of people cared for child U1 including grandmother, a friend and mum’s “cousin”. This was seen in the context of a young mother having a job and having plans in place to care for child U1. The SW assessment therefore did not explore those care arrangements in detail or consider an assessment of child U1’s mum’s “cousin” and the impact caring for child U1 may have on her family dynamics (knowing her family had been referred for early intervention on three occasions previously due to “cousin’s” partner’s depression and anger and his dependence on her). 7.1.7 Lord Laming in the Victoria Climbie Enquiry (2003) suggested that ‘healthy scepticism’ and ‘respectful uncertainty’ should be fundamental to the assessment process. Lack of professional curiosity has been identified in other Manchester reviews25 as well as many national enquiries26. To enable workers to see that their optimism may not be a true representation of what is going on, it is important that safeguarding supervision challenges                                                            25 MSCB SCR C1 2014 26 DfE Pathways to harm, pathways to protection: a triennial analysis of serious case reviews 2011 to 2014 Final report May 2016 Peter Sidebotham, Marian Brandon, Sue Bailey Pippa Belderson, Jane Dodsworth, Jo Garstang, Elizabeth Harrison, Ameeta Retzer and Penny Sorensen University of Warwick, University of East Anglia p141 20  and tests preconceived ideas and assumptions made during limited contact. However safeguarding supervision was not evident in this case as following the strategy meeting none of the professionals concerned considered there to be a safeguarding concern. 7.2 PROFESSIONAL CHALLENGE 7.2.1 Many SCBs including Manchester SCB have produced a resource for practitioners “MSCB Professional curiosity & challenge – resources for practitioners”. It identifies that differences of opinion, concerns and issues can arise for practitioners at work and it is important they are resolved as effectively and swiftly as possible. Having different professional perspectives within safeguarding practice is a sign of a healthy and well-functioning partnership. These differences of opinion are usually resolved by discussion and negotiation between the practitioners concerned. It is essential that where differences of opinion arise they do not adversely affect the outcomes for children, young people or adults and are resolved in a constructive and timely manner.  7.2.2 The traditional medical model, with its associated institutionalised systems and hierarchies common in many acute hospital settings has also been noted to affect colleagues’ ability to challenge. Within this type of working environment, which focuses primarily on medical diagnosis and interventions, doctors are often regarded as the professionals with the most expertise. They are often afforded a status and power superior to that of other professionals. This sets off a set of associated power differentials between and within disciplines which, in a child protection context can result in an over-reliance on medical diagnosis and/or the clinicians managing the medical investigation. This hierarchical approach can lead to professional deference and makes challenging medical professionals and their decisions especially hard27.  7.2.3 In this case it was middle grade doctors who initially had concerns regarding child U1’s presentation and following discussion with the consultant on call middle grade doctor 2 made the referral to CSC. The middle grade doctor attended the initial strategy meeting and raised those concerns with both police and CSC. The doctor was clear that NAI had to be considered as a cause for child U1’s presentation. However as a medical reason could not  be ruled out it was agreed further tests occur and a second meeting take place once the skeletal survey had taken place.  7.2.4 The police did not attend this second meeting because the skeletal survey was normal. No one challenged this decision or raised with them that not all children with physical injuries have fractures. The make -up of the second meeting was totally different to the first and it appears that the information provided at the first meeting and the rationale for the middle-grade doctor’s initial concerns were not explored. Instead the assessment of the consultant who had taken over child U1’ care was accepted with no concerns raised despite many of the bruises being consistent with NAI28. Doctors are often expected to make a definitive decision. It is therefore important that agencies understand that when medical evidence is not diagnostic, the opinion will describe a degree of certainty rather than positively excluding a diagnosis of NAI and it is therefore not possible to “rule it out”29.  7.2.5 The medicalisation of child U1 shut down the opportunity for further discussion and challenge and apart from a peer review at hospital1 following child U1’s admission for abdominal surgery and transfer to hospital 2 no concerns were raised in regard to diagnoses by any of the health care staff working with the family. The peer review at hospital 1 identified child U1 as a complex case however there was no clear plan in place to review again at peer                                                            27 NSPCC and SCIE briefing March 2016. For more information see nspcc.org.uk/lipp or scie.org.uk/lipp 28 NSPCC CORE-INFO: Bruises on children 2012 NSPCC 29 NSPCC and SCIE briefing March 2016. For more information see nspcc.org.uk/lipp or scie.org.uk/lipp 21  review or discuss with hospital 2. There was no such review at hospital 2. Whilst there are processes in place for referring perplexing or complex cases for discussion this was not considered in child U1’s case. Tertiary hospitals in particular can find this process useful enabling them to consider cases with their peers enabling challenge and the opportunity to reconsider treatment options and whether CSC should be involved. 7.2.6 However difficult it is all professionals have a responsibility for their actions in relation to case work. This includes challenging the views of more senior or experienced practitioners as well as professionals from other agencies. Health professionals can sometimes have doubts about the approach of children’s social services, but they do not always challenge them due to the assumption that the social workers know best30. Conversely social workers and police in this case felt that where NAI was being discounted by medical staff there was little they could do and the use of the named doctor for safeguarding as a sounding board for challenge was not considered. This lack of use of the named doctor was not unique to this case and has been identified in other Manchester reviews31 as well as in other national SCRs32. 7.3 INTERAGENCY COMMUNICATION; WITHIN AND BETWEEN AGENCIES 7.3.1 Working Together to Safeguard Children 201533 (and more recently Working Together to Safeguard Children 2018) identifies the need for effective sharing of information between practitioners and local organisations and agencies as essential for early identification of need, assessment and service provision to keep children safe. Serious case reviews have highlighted that missed opportunities to record, understand the significance of and share information in a timely manner can have severe consequences for the safety and welfare of children34. It identifies early sharing of information as the key to providing effective early help as well as being essential to effective child protection services and that all organisations should have arrangements in place which set out clearly the processes and the principles for sharing information between each other, with other professionals and with the LSCB.  “Effective safeguarding work depends on collaborative multi-agency working: no one professional retains all of the required knowledge or skills”35  The Tri-annual report by Sidebotham et al identifies the importance of good multi-agency working in which different practitioners “contribute knowledge and expertise, acknowledging their own priorities,  while  respecting the knowledge, expertise and priorities of other team  members36   The report sees good communication as central to effective multi-agency working and that it depends on:  practitioner skills  effective systems and processes  a culture that values and promotes information sharing                                                            30 NSPCC Paediatrics and accident & emergency: learning from case reviews Summary of risk factors and learning for improved practice for the health sector May 2014 31 MSCB Child K 2018 32 LBTH SCR Child A 2018 33 HM Government (March 2015) Working together to safeguard children: A guide to interagency working to safeguard and promote the welfare of children, p. 16 DfE 34 HM Government (March 2018) Working together to safeguard children: A guide to interagency working to safeguard and promote the welfare of children DfE  35 DfE Pathways to harm, pathways to protection: a triennial analysis of serious case reviews 2011 to 2014 Final report May 2016 Peter Sidebotham*, Marian Brandon**, Sue Bailey**, Pippa Belderson**, Jane Dodsworth**, Jo Garstang*, Elizabeth Harrison*, Ameeta Retzer* and Penny Sorensen** *University of Warwick **University of East Anglia p165 36 Ibid p. 153 22   a culture that enables shared information to be appraised and used to inform decision making and planning (p14). 7.3.2 In this case the middle grade doctor was unable to feed- back face to face the outcome of the initial strategy meeting to the consultant on call due to workload (there was one rather than two middle-grade doctors working over the weekend due to staff shortages), and had no contact with paediatric consultant 3 as she was working in the community. This meant that whilst her rationale regarding NAI was clearly documented there was a missed opportunity for discussion and professional challenge before he went to the second strategy/professionals meeting. 7.3.3 At the initial strategy meeting the middle grade doctor was very clear that whilst a medical reason for child U1’s presentation, NAI had to be considered as a strong possibility. However information shared at the second meeting did not reflect those concerns and as there was no continuity in personnel information provided was therefore second and third hand. This was compounded by the lack of understanding that child abuse should always be considered until there is a clear alternative diagnosis and that where there are differences of medical opinion these need to be addressed by the doctors’ involved37. Research carried out to explore why information sharing does not always occur identified that agencies such as social care and the police often wrongly interpreted medical advice about cause of injury as being definitive rather than it was one of a variety of causes38. In this case the decision made that there were no safeguarding concerns meant that CSC was not made aware of child U1’s further attendances to either hospital. Additionally the safeguarding nurse who attended the second meeting did also not appear to have been updated by nursing staff who had concurred with the middle grade doctor’s conclusions. She did not challenge or consider alternative diagnosis and therefore did not challenge paediatric consultant 3’s decision. The recording of no safeguarding concerns in the records giving further credence to the medical diagnosis. 7.3.4 Child U1 was not discussed by the HV and GP at the practice MDT, this would have provided an opportunity to examine the concerns regarding child U1’s hospital presentations. Nor was the decision to discharge child U1 following two non –attendances at hospital 1 shared or discussed with other health professionals working with the family. This resulted in a lack of general paediatric overview of child U1.  7.3.5 Additional failures in information sharing were caused by differing record bases between hospitals, delaying access to body maps, medical photography and paper records. This has been addressed within MFT’s SI investigation and therefore no recommendation relating to shared records has been made. 7.3.6 All of these issues meant that information sharing reduced the ability of agencies working together to safeguard child U1 and are reflected in other national SCRs39. 7.4 IMPACT OF SAFEGUARDING REFERRALS BEING MADE “OUT OF CORE HOURS” 7.4.1 “Working Together 2015 states that where it is considered that a child has suffered significant harm or is likely to do so, a referral should be made immediately to local authority children’s social care. This includes when those concerns are identified “out of hours”. Where                                                            37 Lord Laming; The Victoria Climbie Enquiry; Recommendation 67 “When differences of medical opinion occur in relation to the diagnosis of possible deliberate harm to a child, a recorded discussion must take place between the persons holding the different views. When the deliberate harm of a child has been raised as an alternative diagnosis to a purely medical one, the diagnosis of deliberate harm must not be rejected without full discussion and, if necessary, obtaining a further opinion. (paragraph 9.65)” 38 DfE Information sharing to protect vulnerable children and families SCIE July 2016 39 DfE Pathways to harm, pathways to protection: a triennial analysis of serious case reviews 2011 to 2014 Final report May 2016 Peter Sidebotham*, Marian Brandon**, Sue Bailey**, Pippa Belderson**, Jane Dodsworth**, Jo Garstang*, Elizabeth Harrison*, Ameeta Retzer* and Penny Sorensen** *University of Warwick **University of East Anglia  23  there is a safeguarding concern CSC then have a responsibility to respond by calling a strategy meeting to assess risk and agree how best to manage that risk. The strategy meeting should include a as minimum “CSC, health and police with the professionals being senior enough to make decisions on behalf of their agencies”.   7.4.2 In this instance the first strategy meeting was out of core hours and documentary processes (i.e. medical photography) not available in the same way as it would have been during the week40. The strategy meeting would normally have been attended by a consultant however in this case a more junior member of staff was left to attend and because of clinical commitments and an emergency on the ward was absent from the meeting for some time. Work pressures also meant that she was not able to feed- back face to face with the paediatric consultant on call regarding the outcome of the meeting. 7.4.3 Out of hours the paediatric consultants provide safeguarding advice and support to their less experienced colleagues. In most instances this works well, with the duty paediatrician providing support in diagnosis and referral. However in this instance the middle grade doctor was left feeling unsupported and with no available safeguarding doctor with whom to escalate her concerns.  7.4.4 Professor Sir Bruce Keogh’s research showed that “There is evidence that junior hospital doctors feel clinically exposed during the weekend”. His research was examining exploring poor patient outcomes following weekend admission and would appear in this instance to apply to safeguarding as well as diagnostic outcomes.  7.4.5 When the second strategy/planning meeting occurred none of the original health or social care professionals attended (the police did not attend as they had been told that child U1’s skeletal survey showed no fractures). The middle grade doctor was working in the community and the case had been passed to a different consultant by the on call consultant, with no discussion taking place to enable her to express her concerns although they were clearly documented. Additionally the meeting was chaired by a senior practitioner who would not have had the experience to challenge the lack of police presence or the change in medical opinion. This resulted in the initial concerns expressed not being adequately understood or considered at this meeting.  7.4.6 Changes in professionals causing a lack of continuity of care has been shown to cause changes in emphasis on particular areas of concern. This often happens when there are different professionals working 9-5 and out of core hours. It was evidenced in this case and has also been identified in relation to both other local and national SCRs41.  7.5 AGENCIES WORKING TOGETHER 7.5.1 Working Together 2015 and later 2018 re-iterate the need for agencies to work together effectively to safeguard children and that safeguarding partners, with other local organisations and agencies should develop processes to enable that to happen and that to be effective, these arrangements should link to other strategic partnership work happening locally to support children and families42.                                                            40 Guardian Newspaper Hospital patients admitted at weekends ‘15% more likely to die’ accessed 08/10/2019 41 DfE Pathways to harm, pathways to protection: a triennial analysis of serious case reviews 2011 to 2014 Final report May 2016 Peter Sidebotham, Marian Brandon, Sue Bailey Pippa Belderson, Jane Dodsworth, Jo Garstang, Elizabeth Harrison, Ameeta Retzer and Penny Sorensen University of Warwick, University of East Anglia 42 https://www.trixonline.co.uk/website/index.htm accessed 18/10/2019 24  7.5.2 MSCB procedures are clear in relation to agencies working together. In this case whilst there was evidence of interagency working at both strategy meetings the lack of professional challenge and fixed thinking resulted in no further action in relation to child U1.   8.0 ADDITIONAL LEARNING 8.1 FIXED PROFESSIONAL THINKING 8.1.1. One of the most common, problematic tendencies in human cognition … is our failure to review judgements and plans – once we have formed a view on what is going on, we often fail to notice or to dismiss evidence that challenges that picture.’43 8.1.2 Child protection inevitably involves working with uncertainties and making difficult decisions and complex judgements on the basis of incomplete information in highly stressful contexts44. There is a substantial body of research evidence that has clearly identified the unconscious tendency for early evidence bias in human decision making; that is, an initial summing up of a situation strongly influences the analysis of subsequent or new information leading to fixed thinking and faulty conclusions45. 8.1.3 One of the striking aspects of this SCR is the extent to which professionals developed fixed thinking about child U1’s presentation. Despite there being no clear medical cause for either the bruising or necrotic bowel non-accidental injury was not seriously re-considered on any subsequent hospital attendance. The December admission to hospital 2 was an opportunity for this to occur, however this did not occur and the fixed thinking continued. This meant that every time child U1 presented to the hospital there was no discussion, analysis or enquiry as to what else may have caused the bruising and petechiae. Nor was there any enquiry as to who was looking after child U1 at the time. There was a poor understanding of what the risk to child U1 was and the extent of the NAI. 8.1.4 Within the community the lack of MDT and discussion relating to child U1 meant that the medicalisation of child U1 was accepted with no thought regarding other causes for child U1’s presentation.  8.1.5 Serious Case Reviews have repeatedly found that professionals were either unwilling or slow to revise their judgements in the face of new or contradictory evidence and that this selective interpretation of information, only using that which confirmed their preferred view about a particular case, became a “pervasive belief” which influenced the professional response46. These pervasive beliefs were found to remain, even where there was considerable evidence or lack of progress in interventions and services offered. Supervision in this case may have enabled professionals to consider alternative causes for child U1’s bruising. 8.2 ASSESSMENTS 8.2.1 Assessments of families require a child centred approach and are fundamental to safeguarding and promoting the welfare of every child. A child centred approach means                                                            43 Fish et al (2008) SCIE Report 19: Learning together to safeguard children: developing a multi-agency systems approach for case reviews: p9 44 Burton S (2009) The Oversight and Review of Cases in the Light of Changing Circumstances and New Information: How do people respond to new (and challenging) information? Safeguarding: Briefing 3. London: Centre for Excellence and Outcomes in Children and Young People’s Services. 45 Broadhurst et al ( 2010) Ten pitfalls and how to avoid them What research tells us; NSPCC https://www.nspcc.org.uk/globalassets/documents/research-reports/10pitfalls-initial-assessments-report.pdf 46 Sidebotham et al (2016) Pathways to harm, pathways to protection: a triennial analysis of serious case reviews 2011 to 2014; Department for Education   25  keeping the child in focus when making decisions about their lives and working in partnership with them and their families47 It also means professionals need to understand the daily lived experience of the child. 8.2.2 The assessments did not consider alternative causes to the bruising despite the strong evidence available that a normal skeletal survey does not preclude child abuse. CSC (CAFA) and GP/hospital/health visiting assessments did not enable a true picture to emerge, with little social history explored and a failure to identify who was caring for child U1 when they were caring for the child and how that related to child U1’s injuries. The lack of consideration of other carers also meant that whilst interaction between child U1, mother, and mother’s cousin was reported to be good the opportunity to observe child U1 with the “cousin’s” partner was not available as part of CSC’s assessment and little understanding of child U1’s daily lived experience. The health assessments were also very influenced by what child U1’s mum and “cousin” reported and taken at face value rather than be explored in depth. All of these factors affected decision making in relation to child U1. A factor identified in the NSPCC learning from SCRs48. More recently CSC have introduced a qualitative assessment audit to ensure assessments are completed to an agreed standard. 9.0 RECOMMENDATIONS 9.1 Manchester Safeguarding Partnership are assured by MFT that the action plan relating to their SI investigation is completed within the agreed timescales and audited to ensure actions embedded in practice. 9.2 The Learning Event following publication of this SCR highlights the need for: Professional curiosity Professional challenge Information sharing An understanding of differential diagnosis and when bruising is present where NAI should be considered. 9.3 Manchester Safeguarding Partnership request partner agencies carry out appreciative enquiry as part of any assessments to assure information related to child care/carers arrangements are included and risk assessed. 10.0 AREAS OF GOOD PRACTICE 10.1 The two middle grade doctors concerns in relation to child U1’s presentation and middle grade doctor 2’s insistence on a referral to CSC was notable. 11.0 CONCLUSION  11.1 It is important to remember that: “When it comes to safeguarding, it is reasonable to assume that most people                                                            47 HM Government (March 2015) Working together to safeguard children: A guide to interagency working to safeguard and promote the welfare of children; DfE 48NSPCC; Infants: learning from case reviews Summary of risk factors and learning for improved practice around working with children aged two and under November 2017. NSPCC 26  come to work each day wanting to do a good job” 49  Child U1 was reported by all who came into contact with them as a happy bubbly child who related well to the adults seen to be caring for them. Identification of child abuse can be difficult and in complex cases such as this it requires skilled working, the ability to show professional curiosity and challenge and an understanding of professional roles within interagency working.  Additionally it requires supportive training and supervision good interagency working and sharing of information. For a variety of reasons this did not always happen with child U1.     12.0 NEXT STEPS  This report has been accepted by Manchester Safeguarding Partnership, who will take the recommendations from the report and ensure a robust action plan is put in place for agencies involved and this is monitered until completion.                                                                                               49 Munro E. The Munro Review of Child Protection: Final Report - A child-centred System. London: Stationery Office; 2011. 6. Department of Health (DH).19 Jul 2011 27         Appendix 1  Our Angels eyes have a sparkle and laugh Is contagious Their face lights the room, Yet their hair is outrageous  Their grin gives you feels, their giggle so catching Their singing is wild and their dance moves are matching Their hands are so gentle but their stomp is intense A dancing-ninja-turtle It doesn't have to make sense   They would empty your fridge for a right royal dinner And if you have cake, they'll be on to a winner Our angel is stronger than most but happier than all Little legs small and mighty Never mighty and small A day never passed without their performing productions They've given stories to tell with guaranteed laughter eruptions Any table is their stage, personality’s their performance They lived with no regrets and the rewards are just enormous   There are just so many memories from being mummy’s second wish To coming such a long way from starting out as 'baby fish'  The little baby, the terror... The lovable achiever They achieved everything they wanted and would give you baby fever   Our angel is blessed from both side of the gate So many wave from earth But our angels await To welcome 10 perfect fingers and 10 tiny toes All their spirits eternal, Now an angel, off to heaven our baby goes  We will love and miss you forever and ever. I will hold you in my heart until I can hold you in heaven 