Death of a 3-year-old child in March 2017. Child N1 was found unresponsive in the bath; cause of death unascertained. Mother was convicted of two counts of neglect. Child N1 was an only child. Mother had a history of mental health problems and there were incidents of domestic abuse. Family frequently moved between different areas. Mother's cultural and ethnic heritage is Pakistani English, father is Pakistani, and both are of Muslim faith. Mother left the father a number of times and stayed with her family, but felt pressured to return to father by her family. Learning includes: importance of ensuring that communication has been received and is being acted on and timely transfer of records, particularly in cases where families are moving between areas; ensure the perspective and the daily lived experience of the children is the primary focus of professional intervention; importance of gaining the involvement and perspective of fathers to inform assessment and intervention; importance of routinely recording that there has been consideration of the need to make a safeguarding referral; importance of communication and information sharing between agencies and across areas when working with mobile families. Review used a systems methodology approach focusing on multiagency professional practice, developed by Social Care Institute for Excellence (SCIE). Recommendations: to ensure that where enquiries are being made under section 47 of the Children Act 1989, all relevant agencies are involved in strategy meetings or discussions to share and evaluate information, and plan the work.
      
 Title:  Serious case review: Child N1: the overview report. LSCB: Manchester Safeguarding Children Board Author: Valerie Charles Date of publication: 2018  This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC.  This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above.                            Final Version  Page 1 of 33       Serious Case Review  CHILD N1   The Overview Report      Independent Reviewer: Valerie Charles  Approved by the MSCB August 2018 Published November 2018     Final Version  Page 2 of 33  INDEX  1. Introduction            3 1.1 Context of the serious case review                                                           3 1.2 Decision to conduct a serious case review                                                                  4  1.3 Brief background and summary of contacts                                                    4 2. Serious Case Review Methodology                                              5 2.1 Systems methodology          5 2.2 The Review Team           6 2.3 Scope of the Review          7 2.4 Key lines of enquiry          8 2.5 Structure of the review process         9  2.6 Status and ownership of the overview report                                                            9    2.7 Parents contribution to the serious case review                                                         9                               2.8 Diversity considerations of the family                                                                  9 3. Analysis of agency involvement and Key Practice Episodes      9 3.1 Key Practice Episodes          9 3.2 Key Practice Episode 1: November 2013 – Mental Health Assessment 10                            3.3 Summary appraisal of practice within Key Practice Episode 1         11  3.4 Key Practice Episode 2: February 2014 – Move into Manchester      12 3.5 Summary appraisal of practice within Key Practice Episode 2   16 3.6 Key Practice Episode 3: June 2014 – Domestic Abuse Incident                              18 3.7 Summary appraisal of practice within Key Practice Episode 3   19  3.8 Key Practice Episode 4: July 2016 – A&E Hospital Attendance                                20 3.9 Summary appraisal of practice within Key Practice Episode 4                           22 3.10 Key Practice Episode 5: March 2017 – Domestic Abuse Incident                         25 3.11 Summary appraisal of practice within Key Practice Episode 5                27                           4. Conclusion                       28 5. Findings           31  5.1 Finding 1: Referrals to Children’s Social Care                                                           31 5.3 Finding 2: Strategy Meetings                                                                               31 5.5 Subsidiary Issues for further exploration       32                                      Glossary          33            Final Version  Page 3 of 33  Section 1: Introduction 1.1 Context of the serious case review  1.1.1 This review concerns the tragic death of a three year old child, who for the purpose of this review, is referred to as CHILD N1, and who died in early 2017. CHILD N1’s mother said that she found CHILD N1 unresponsive in the bath. The review team wish to extend their sincere condolences to the family and friends of CHILD N1 for their loss.   1.1.2 The task of the review is to establish what lessons can be learned, for the purpose of learning and improvement in safeguarding services and in inter-agency working in order to better safeguard and promote the welfare of children in Manchester.   1.1.3 The extent and quality of professional involvement and support given to CHILD N1 and their family over a four year period, from May 2013 to March 2017, has been considered by the review. During this period the main professional involvement came from universal services, such as midwifery, health visiting, education and GP.   1.1.4 During the period under review the family frequently moved between different geographical areas. There were incidents of domestic abuse and mother’s history of mental health was of concern.   1.1.5 In the year previous to their death CHILD N1 was taken to A&E after mother said that CHILD N1 had ingested some of her sleeping tablets. This incident was referred to Children’s Social Care and an assessment was completed and the case was closed (refer to Key Practice Episode 4 pages 20 – 24).  1.1.6 The week before the death of CHILD N1, domestic abuse between mother and father of CHILD N1 was reported by mother and subsequently mother made an allegation of rape and threats to kill against father.   1.1.7 The review found evidence of good practice and some success in working with the family but also areas that the review felt could be improved upon. These have been presented within this report as findings for Manchester Safeguarding Children Board to address.   1.1.8 The review has found that it could not have been predicted that CHILD N1’s life would end as it did. Similarly, it is not a conclusion of this review that had any professional taken a different action the death of CHILD N1 would have been prevented.    1.1.9 This report was presented to the Manchester Safeguarding Children Board in August 2018.   1.1.10  Throughout the report the use of acronyms is kept to a minimum.  The child is referred to as CHILD N1 (aged 0-3 years during the period under review). Members of the family are referred to in terms of their relationship with CHILD N1 – i.e. mother, father, maternal grandmother etc. This case involves different geographical areas outside of Manchester that  Final Version  Page 4 of 33  the family lived in and these are referred to as Southern Area 1 and Southern Area 2. Professionals are referred to in respect of their professional role.   1.2 Decision to conduct a serious case review  1.2.1 The Local Safeguarding Children Board Regulations 2006 (regulation 5) requires a Local Safeguarding Children Board (LSCB) to undertake a review of a serious case in accordance with the statutory criteria and procedures that are set out in Working Together to Safeguard Children, 2015 (chapter 4)1.   1.2.2 The LSCB should always undertake a Serious Case Review (SCR) where abuse or neglect of a child is known or suspected and either the child has died or the child has been seriously harmed and there is cause for concern as to the way in which the authority, their Board partners or other relevant persons have worked together to safeguard the child.   1.2.3 The case was considered by the Serious Case Review Sub Group at a meeting on 26th April 2017. It was agreed that the criteria for a Serious Case Review was met.   1.2.4 The independent chair of the MSCB approved the recommendation for a SCR on 18th May 2017, and commissioned the review.    1.3 Brief background and summary of contacts  1.3.1 Mother was originally from an area close to Greater Manchester, where she lived for approximately twenty years. She has a history of depression and self-harming and has had contact with mental health services since being aged seventeen years old. Mother has a history of impulsive self-cutting and overdoses (on one occasion, aged eighteen years old, she ingested bleach) and the last overdose was in July 2012. Mother has had three admissions to a psychiatric hospital in the past. A range of medication has been tried and she ceased using medication when she became pregnant.  1.3.2 Mother was known to the criminal justice system from the age of seventeen and received a five month custodial sentence when she was twenty years old. Mother has a history of substance use including cocaine, cannabis and alcohol before she was married. During the period under review professionals did not raise any concerns regarding substance use but were aware of this history.   1.3.3 When mother was aged twenty one she met father on an online dating site. Once married, they moved to Southern Area 1 in 2012. Over the period under review, mother reported that their relationship was on and off and that father was verbally and physically abusive towards her. Mother left father a number of times and stayed with her family, but felt under some pressure by her family to return to father.   1.3.4 Mother became pregnant with CHILD N1 in the middle of 2013 and at fifteen weeks pregnant was still contemplating a pregnancy termination. Mother cut herself on her                                                            1 Working Together to Safeguard Children, 2015 HMSO.  Final Version  Page 5 of 33  abdomen, which she admitted was also an attempt to harm her baby. A referral was made to Children’s Social Care (CSC) in Southern Area 1 but no further action was taken.  1.3.5 CHILD N1 was born in early 2014 at thirty five weeks gestation.   1.3.6 Mother and CHILD N1 left father and moved from Southern Area 1 to live with mother’s family in Manchester in February 2014. In March 2014, mother stated that she felt under pressure by her family to return to father. It appears that over the following six months, mother and CHILD N1 frequently moved between Southern Area 1 and Manchester.  1.3.7 A domestic abuse incident was reported in June 2014 to the police in Southern Area 1.   1.3.8 During the periods of time that mother and CHILD N1 were in Manchester they were living with her family, until they moved into supported accommodation in September 2014. During the period of time in supported housing mother presented well and this was possibly the first time of her not living with her family. Mother and CHILD N1 remained in this accommodation until January 2016, when they moved into their own rented accommodation and were supported by a young person’s homeless support organisation for eighteen months.  1.3.9 CHILD N1 started a government funded nursery place in April 2016 for fifteen hours a week. CHILD N1 had one hundred per cent attendance until their death in March 2017.  CHILD N1 has been described as a very alert, happy, well-presented child who had met their milestones. There were no concerns about CHILD N1, or parents, who presented well with good routines. The nursery thought that the parents lived together as they both dropped off and picked up CHILD N1 separately and together.   1.3.10  The family first became known to Manchester CSC in July 2016, following an incident when CHILD N1 was taken to A&E after mother said that CHILD N1 had ingested some of her sleeping tablets. This incident was referred to CSC and an assessment was completed and concluded that this was an unfortunate accident and that mother had learnt from this. The case was then closed.   1.3.11 In March 2017, a domestic abuse incident was reported to the Greater Manchester police and this resulted in a referral to MARAC and CSC.   Section 2: Serious Case Review Methodology   2.1 Systems methodology     2.1.1 This review is based on a systems methodology approach2 focusing on multi-agency professional practice. The goal is to move beyond the specifics of the particular case – ‘what happened’ and ‘why’ – to identify the ‘deeper’, underlying issues that are influencing practice more generally. It is these generic patterns that count as ‘findings’ or ‘lessons’ from a case,                                                            2 Recommended best practice developed by SCIE. Learning together to safeguard children: developing a multi-agency systems approach for case reviews, SCIE (Social Care Institute for Excellence) 2009.   Final Version  Page 6 of 33  and changing them will contribute to improving practice more widely. A systems approach uses a particular case as a ‘window’ on the whole system.   2.1.2 Using a systems methodology approach for studying a system in which people and context interact requires the use of qualitative research methods to improve transparency and rigour. The key tasks are data collection and analysis. Data comes from involved professionals and others including family members, case files and contextual documentation from organisations.  2.1.3 Due to particular time constraints in order to complete the review in a concise timescale i.e. within three months, it was decided that the review would be based on a systems methodology approach, but would be proportionate to the timescale set. Instead, for example, of conducting individual conversations with the involved professionals (which can be very involved and time consuming) it was agreed that a structured practitioner and manager’s learning event would be held over the course of a full day.   2.2 The Review Team   2.2.1 The membership of the review team includes agencies from Manchester multi-agency child protection system and is represented by senior and specialist agency representatives to oversee the collation and analysis of information and outcomes of the review, as follows:   Housing Provider Service, Lead Service Manager  Service Lead Court and Locality Central Area Service Lead, Children’s Social Care  Manchester Foundation Trust, Named Nurse for Safeguarding Children   Head of Safeguarding, Manchester Health and Care Commissioning (MHCC)  Specialist Protective Services, Greater Manchester Police  Education Case Worker, Children’s Service    MSCB Business Unit Manager  Policy Specialist  Consultant Paediatrician, Designated Dr Safeguarding Children, MHCC  Greater Manchester Mental Health (GMMH),  Safeguarding Children Lead  Programme Lead Manchester Population Health and Wellbeing Team   North West Ambulance Service (NWAS) Safeguarding Practitioner Prevent Training Lead  Directorate Head of Children & Families Legal Services  2.2.2 The Manchester Safeguarding Children Board commissioned Valerie Charles an independent lead reviewer with appropriate experience and training to co-ordinate and manage the review.   2.2.3 Valerie Charles works as an independent consultant and is registered with the Health and Care Professions Council (HCPC). Valerie has been qualified since 1991 and has a professional social work qualification and MA in Child Protection. She has extensive experience of working in children’s services in both the local authority and voluntary sector.  Final Version  Page 7 of 33  She was a senior manager for NSPCC from 2006 to 2012. Valerie has worked in different roles within local safeguarding children boards, including chairing and authoring serious case reviews and has experience in systems methodology case reviews. Valerie has undertaken training for independent reviewers.   2.2.4 Key lines of enquiry were identified from the combined multi-agency chronology. Individual agencies were asked to provide a summary of their agency learning to the review.   2.2.5 The review team identified the ‘case group’ which comprised of practitioners and managers from services that would provide information and participate in the review.   2.2.6 In December 2017, a practitioner and manager learning event was held. Group discussions with the case group were undertaken, facilitated by members of the review team and the independent lead reviewer. The staff roles of those involved in group discussions was as follows:     Social Worker x 2  Children’s Social Care (CSC) Service Lead  Children & Family Court Advisory and Support Service (CAFCASS)  Legal Advice Manchester City Council (MCC)  North West Ambulance Service (NWAS)  Housing Service Manager  Housing Manager   Greater Manchester Police x 7  Nursery Manager  General Practitioner (GP)  Health Visitor (HV) x 1 and Nursery Nurse working with the Health Visiting Team x 1  Health Visitor Team Leader  Named Nurse Safeguarding Children  Mental Health x 4  Education Case Worker  Head of Safeguarding    Manchester Safeguarding Unit, MCC  Consultant Paediatrician  Matron Paediatric Emergency Department  2.2.7 The independent lead reviewer used the information from the combined multi-agency chronology to identify key practice episodes for particular learning in this review.   2.3 Scope of the Review   2.3.1 The scope and timetable of the review were agreed. The time period under review is from Mid 2013 when mother became pregnant with CHILD N1, up until the death of CHILD N1 at the end of March 2017.   Final Version  Page 8 of 33  2.3.2 The following agencies have provided information and contributed to the serious case review in accordance with Working Together to Safeguard Children (2015), Chapter 4 and the associated Local Safeguarding Children Board (LSCB) guidance and relevant learning and improvement frameworks.   Manchester University NHS Foundation Trust   Greater Manchester Mental Health (GMMH)  Foundation Trust (FT)   Pennine Acute Hospitals NHS Trust - midwifery services   Manchester NHS General Practitioner – Manchester Health & Care Commissioning (MHCC), previously Clinical Commissioning Group (CCG)    North West Ambulance Service  Manchester Education Services   Greater Manchester Police (GMP)   Manchester Children and Families Services - Children’s Social Care   Housing   National Society for the Prevention of Cruelty to Children - NSPCC (did not provide any services to the family)  Greater Manchester Fire and Rescue Service (did not provide any services to the family)  A Young Person’s Homeless Support organisation with both a local and national presence  Probation  Children and Family Court Advisory and Support Service (CAFCASS)  Adult Social Care  Chronologies and information was also received from Police, Children’s Social Care and Health in Southern Area 1, Southern  Area 2 and the area close to Manchester  where mother originated from.   2.4 Key lines of enquiry  2.4.1 The review team identified and agreed key lines of enquiry for consideration in addition to analysing individual and organisational practice, as follows:-  1. The extent, to which the impact of mother’s mental health was recognised, assessed and acted upon. 2. Did family history and family dynamics inform assessment and practice? 3. To what extent was it understood why mother and child moved between different areas?  4. How effective was inter-agency working, information sharing, communication and decision making?   5. The extent, to which incidents of domestic abuse and violence were recognised, assessed and responded to.   Final Version  Page 9 of 33  6. Were incidents that indicated a lack of parents’ responsibility/capacity recognised, assessed and acted upon? Were there specific cultural issues that impacted upon parenting capacity, and if so, how far were these recognised and acted upon?   2.5 Structure of the review process  2.5.1 Over the course of this review, between November 2017 and March 2018, the review team met on five occasions. The review findings were presented to the Manchester Safeguarding Children Board in August 2018.  2.6 Status and ownership of the overview report 2.6.1 The overview report is the property of the Manchester Safeguarding Children Board as the commissioning board. 2.7 Parents contribution to the serious case review  2.7.1 Mother has been invited to contribute to the Serious Case Review. Father has not been contactable.  2.8 Diversity considerations of the family  2.8.1 Father’s ethnic origin is recorded as Pakistani and Muslim faith. Mother’s ethnic origin is recorded as Pakistani English and Muslim faith.   Section 3: Analysis of agency involvement and Key Practice Episodes  3.1 Key Practice Episodes  3.1.1 An important tool in the organisation and analysis of data using a systems methodology case review approach is the identification of key practice episodes. These are a selection of practice episodes that were key, in that they were significant to the way the case developed and/or was handled. These were identified by the independent lead reviewer with the benefit of their overview perspective of the case and provide a useful way of summarising the most significant agency contact and involvement during the period under review.  The information cited within the key practice episodes has been sourced from the group discussions with practitioners and managers, documentation and the combined multi-agency chronology.  3.1.2 The five key practice episodes that have been identified for more detailed analysis are:  November 2013 - Mental Health Assessment    February 2014 - Move into Manchester    June 2014 - Domestic Abuse Incident  July 2016 – A&E Hospital Attendance  Final Version  Page 10 of 33   March 2017 – Domestic Abuse Incident  3.2 Key Practice Episode 1: November 2013 - Mental Health Assessment    3.2.1 In November 2013, mother was referred to a consultant psychiatrist by safeguarding midwife in Southern Area 2. This was due to concerns over possible emotional abuse from father, low mood and evidence of old self-harm scars on her arms.  3.2.2 Mother was twenty four weeks pregnant had been visiting her sister in Southern Area 2 when she was admitted to hospital with vaginal bleeding.  While mother was in hospital, father came to the ward and was disruptive and aggressive and was not allowed to see her. It was noted that mother appeared fearful of father.  3.2.3 Mother was seen by a consultant psychiatrist on the maternity observation ward in Southern Area 2. A detailed history was obtained by the consultant psychiatrist: - married for one year, living with father in Southern Area 1 in a relationship which mother described as difficult with repeated arguments and emotional abuse from him. Mother denied any physical abuse. Mother had left father, was staying with her sister in Southern Area 2 and planned to return to Manchester to her family home. Maternal grandmother was reported to be in agreement with the plan, but only for a few months and then mother would have to go back to father.    3.2.4 The pregnancy was reported to be unplanned and mother was ambivalent about it and had twice booked for termination of pregnancy, but not kept the appointment.   3.2.5 Mother had a history of mental health problems and contact with mental health services since she was seventeen years old.  She had a history of impulsive self-cutting and overdoses (on one occasion, aged eighteen years old, she had ingested bleach, and the last overdose was in July 2012). Mother had last cut herself on her abdomen (three months before), which she admitted was also an attempt to harm her baby. She had been admitted to psychiatric hospital three times and she was adamant it had been ineffective. A range of medication had been tried and she had ceased using medication when she became pregnant. Mother’s substance use history included cocaine, cannabis and alcohol (up to one hundred pounds daily) prior to marriage. Mother said she had been to university but did not complete her studies. Mother presented as alert, cooperative and engaging but came across as someone much younger than her age and needed prompting to give details.  3.2.6 The consultant psychiatrist requested an urgent referral to the mental health team in the area she was moving to (Manchester) and felt that mother was a ‘highly vulnerable and conflicted young women.’ She did not have any features of psychosis, but may be ‘suffering a mild depressive episode’, medication was not recommended, and it was noted that ‘moving away from father may offer the most hope’. Consultant psychiatrist noted the longer-term risks as significant, especially if maternal grandmother sends her back to Southern Area 1. 3.2.7 The plan identified by the consultant psychiatrist included:-   an urgent referral to Manchester Community Mental Health Team (CMHT) for close follow up pre and post-natal.  Final Version  Page 11 of 33   medication not recommended – move away from father might help.  safeguarding midwife to liaise with ‘corresponding services in Manchester’, with a view to monitoring her risk of on-going domestic abuse and possible pressure to return to her husband. 3.2.8 A letter to GP in Manchester from consultant psychiatrist was sent (dated 11th November 2013) requesting urgent referral to local (Manchester) CMHT as mother had reported she would be moving back to Manchester.   3.2.9 As well as referring to the consultant psychiatrist for assessment, the safeguarding midwife Southern Area 2 also referred to the Southern Area 2 domestic abuse unit, stating that mother often left father and after a while maternal grandmother (who lives in Manchester) sent her back because she felt she should be with father.  Mother was visited by a support worker on 12th November 2013, following the referral, but said she had changed her mind and was returning to Southern Area 1. Mother had said she did not want to be pregnant, didn’t want any further children and minimised the problems, and said she focuses on what her family want of her, rather than her own choices. Mother’s responses were inconsistent with the previous day. A DASH3 assessment was completed with the outcome of a standard risk. A referral was made to Southern Area 1 Local Domestic Abuse Service. Safety planning and advice on services was provided. Maternal grandmother’s details were provided as it was thought mother might present as a temporary patient in Manchester.  3.2.10 The safeguarding midwife in Southern Area 2, having been informed of the outcome of the support worker visit, then sent a letter (not dated) to GP in Southern Area 1, and as it was felt that mother might present in Southern Area 1, Southern Area 2 or Manchester during pregnancy, the letter was also sent to safeguarding midwifery in Southern Area 1, Southern Area 2 and across Manchester, as well as to GP in Manchester.  3.2.11 Previously, on 16th August 2013, when mother booked in for her first pregnancy at the local hospital in Southern Area 1, the community midwife 1 took a full medical and social history. The risk factors identified met the threshold for a Special Issues form and a Children’s Social Care (CSC) referral to be completed.  3.2.12 On 13th September 2013, community midwife 2 in Southern Area 1, completed the Special Issues form and shared this with the safeguarding midwife in Southern Area 1, the health visitor in Southern Area 1, and it was also held on the delivery suite in Southern Area 1, for staff to access on inpatient admission. Issues identified requiring support included previous history of depression, other mental health issues, anxiety/panic attacks and relationship stresses.   3.2.13 Community midwife 2 in Southern Area 1, also made a referral to CSC in Southern Area 1, which identified the following: - mother disclosed that she misused drugs in the past, is now married, fifteen weeks pregnant and still contemplating a pregnancy termination, states that father is abusive but then retracts this information, has been on anti-depressants since                                                            3 The Domestic Abuse, Stalking and Honour Based Violence (DASH) 2009 - Risk Identification, Assessment and Management Model were implemented across all police services in the UK from March 2009.  Final Version  Page 12 of 33  aged seventeen years, but is now off her medication without the doctors instructions, and father is not aware of the drugs.  3.2.14 On 2nd October 2013, a letter was received by the midwifery service in Southern Area 1 from CSC in Southern Area 1 advising they will be taking no further action as a result of the referral made by community midwife 2. CSC Southern Area 1 have advised this review that they did not receive the referral from community midwife 2 in Southern Area 1, in August 2013 and have no record of sending this letter.  3.3 Summary appraisal of practice within Key Practice Episode 1 3.3.1 There are some clear examples of good practice identified within the analysis of this Key Practice Episode (KPE). These include the identification of appropriate concerns and risk factors and some good responses to these. The referral by the safeguarding midwife in Southern Area 2 for the mental health assessment was appropriate and that assessment appears to have been arranged in a timely manner. The safeguarding midwife in Southern Area 2 recognised the possibility that mother could present in different places during her pregnancy and therefore plans were made to alert colleagues across the different areas.  3.3.2 The assessment of mother’s mental health by the consultant psychiatrist was thorough and identified appropriately the areas of concern and a plan was drawn up in response. However, this plan was never implemented. The consultant psychiatrist letter was addressed to GP in Manchester, although it is noted at a later point in this report (KPE 2) that GP in Manchester did not receive the letter at the time. It appears that GP in Southern Area 1 received the letter at the time. It is not clear to the review why there is no recorded response to the consultant psychiatrist’s letter being received.   3.3.3 The reason for the lack of any recorded response may be that, as the letter was addressed to the GP in Manchester, there was an assumption that the mother was indeed moving and the GP in Manchester would be responding. Such cases of people moving between areas, or expressing intention to move but not doing so, or moving without informing people (all of which were a feature in this case) pose a particular challenge to professionals. It is imperative that there is careful communication across the different geographical areas, and that there is confirmation not just that communications have been received, but also that they are being acted upon. In this instance, it appears that neither the consultant psychiatrist in Southern Area 2 nor GP in Southern Area 1 sought to confirm that the recommendations of this letter were being acted upon.  3.3.4 Whilst there were clear indications that mother was adopting a somewhat transient lifestyle, there was limited exploration in this KPE of the reasons for this and the implications for the mother and for CHILD N1. The day after the assessment by the consultant psychiatrist, the domestic abuse support worker visited and mother had completely changed her mind about moving to Manchester and instead stated she was returning to father in Southern Area 1. She also made some comments of concern about her feelings about being pregnant and about the role of the extended family. Whilst the overall risk was not assessed as high, these comments were of real concern, highlighting a possible pattern of transient lifestyle, mother’s feelings of ambivalence towards the pregnancy, and lack of helpful support from family which added further to mother’s vulnerability and to the risks. This does call into question the risk  Final Version  Page 13 of 33  assessment and whether at this point a more robust response was required, including referrals to Multi Agency Risk Assessment Conference (MARAC) and CSC.   3.3.5 It is not unusual that (predominantly female) victims of domestic abuse do not readily disclose details of their abuse to professionals, or they will retract or be inconsistent in what they do say, particularly to professionals with whom they do not have a relationship.  Mother was given advice about services by the domestic abuse support worker but did not want on-going support. Mother continued to attend antenatal appointments, but throughout the timeline of this review she received no on-going support in relation to issues identified around domestic abuse or mental health problems.   3.3.6 The consultant psychiatrist recommended that the safeguarding midwife in Southern Area 2 should ensure there is follow up from ‘corresponding services’ in Manchester. This is taken to mean that there should be liaison with the safeguarding midwife in Manchester (which did take place via the letter sent by safeguarding midwife in Southern Area 2). This falls short of identifying the need to make a safeguarding referral to CSC. Given the risks identified by the consultant psychiatrist, it is not clear why there was no consideration of such a referral being made. 3.3.7 A referral had previously been made to CSC. Community midwife 2 in Southern Area 1 outlined the risk factors in the referral in September 2013, although it has also been noted that no midwife care plan was completed. This referral was the opportunity for formal assessment of the risks to the unborn child, and could have led to a pre-birth assessment being undertaken. However, a decision was taken that there would be no further action from CSC. At the point of writing it has not been possible to clarify the decision making of CSC in Southern Area 1 – i.e. whether this was based on information that they held or liaison with other agencies. It is of real concern that the response to attempts to clarify this with CSC in Southern Area 1 is that they are unable to trace any record of this referral.  3.4 Key Practice Episode 2: February 2014 - Move into Manchester    3.4.1 In Mid February 2014, mother informed community midwife 3 in Southern Area 1 that she was leaving father and moving the following day to Manchester with CHILD N1 (aged three weeks old).  3.4.2 Mother said that the relationship with father had been a volatile relationship from the beginning. Mother declined a referral to local support agencies. Community midwife 3 in Southern Area 1 informed the health visiting team in Southern Area 1 and GP in Southern Area 1.  3.4.3 In February 2014, health visitor 1 in Southern Area 1 contacted mother and confirmed that the family had moved and that they planned to remain in Manchester. Health visitor 1 in Southern Area 1 contacted health visitor 2 in Manchester and shared the psychiatry report. Health visitor 1 in Southern Area 1 recorded that records were to be transferred as a ‘matter of urgency’ and ‘not safeguarding at present’.   3.4.4 Health visitor 2 in Manchester recorded the following information from that telephone conversation:- mother had ‘fled’ with CHILD N1 from father with a possibility that she may  Final Version  Page 14 of 33  return; mother has a multiple complex personality disorder; seen by psychiatrist; had cut abdomen in attempt to harm baby; and suicide attempt at eighteen years old. Allocation to health visitor was required.  3.4.5 GP records in Southern Area 1 were sent to Manchester at the end of February 2014.   3.4.6 Three days later at the end of February 2014, mother contacted the health visitor team in Manchester notifying them of her new address in Manchester. A moving in visit was made by health visitor 3 in Manchester for mid March 2014.  3.4.7 At the moving in visit by health visitor 3, CHILD N1 was seven weeks old and was feeding poorly. A Family Health Needs Assessment was undertaken which showed who was living in the house at the time. Maternal grandmother was seen and there were no concerns about the environment. Mother said they were living with her extended family, but had been told by them it was only temporary and that she needed to return to father in Southern Area 1, which she did not want to do. Mother had applied to supported housing in Manchester. Health visitor 3 contacted supported housing, who said that they had sent two letters to mother, although mother said she had not received the letters. An appointment was made for mother at supported housing. Health visitor 3 recorded the advice that as there was a long waiting list for rehousing, if mother was pressured to return to father, she could consider presenting as homeless. Mother stated that she was not happy in her marriage, had not seen father for one month but felt guilty that CHILD N1 had not seen their father. Mother did not disclose during the visit, domestic abuse, substance, alcohol or tobacco use. Mother said she self-harmed in the past as she was bored, and was not currently feeling low.  3.4.8 An appointment with the GP that day was made by health visitor 3 regarding CHILD N1’s feeding concerns. Health visitor 3 referred for Sure Start Outreach support. Mother reported that she was awaiting an appointment with the Community Mental Health Team.  3.4.9 In Mid-March 2014, a Manchester common assessment framework (MCAF) was submitted by health visitor 3, detailing self-harm, depression, domestic abuse - mother had left father but felt this was temporary and her parents feel she should return.  There was a request for support for mother to ‘develop a secure attachment’ and facilitate access to Sure Start centres. 3.4.10 At the end of March 2014, during health visitor 3’s home visit, mother felt low and felt like self-harming due to family pressures to return to father. Mother self-reported she was refused the community mental health service support referral.  She had stopped taking the anti-depressants, had some feelings of low mood, felt like self-harming, that her family, TV and newspapers were talking about her, did not have thoughts to harm CHILD N1 (CHILD N1 was said to be a protective factor, stopping her from her self-harming). Mother sometimes wished she was dead and CHILD N1 could live with father. Mother had received lots of texts from father to return but does not like him and does not want to return.  3.4.11 Health visitor 3 records that they contacted the mental health Crisis Team who felt the concerns were regarding housing rather than mood at that time and they had not received a GP referral. Crisis Team advised contact with Women’s Aid, but health visitor 3 was unable to contact them (constantly engaged and no reply). Mother spoke with the Domestic Abuse  Final Version  Page 15 of 33  helpline and safety advice was given about her attempting to leave, including contacting the police. Mother was advised to present the next day as homeless. 3.4.12 Mental Health Service records show that on this day at the end of March 2014 health visitor 3 spoke with Gateway4 rather than the Crisis Team. Mother informed the triage nurse that: - she had thoughts about cutting to cope at present (but no intention to do this at this time - merely a fleeting thought); has had fleeting suicidal ideation - but very clear that she would never act in this way due to having her new child to look after. Mother was adamant that she was not returning to father; identified housing/somewhere to live as her main problem – very stressful. Mother said that the abuse she suffered from father was emotional and not physical. No risks to safety from father or family. Last took an overdose two years ago, this was an impulsive act – clear she would not harm herself at present in any way. Health visitor 3 confirmed that there were no concerns for CHILD N1 at all. The outcome and agreed plan was that at present Gateway would not accept the referral and for health visitor 3 to refer to Women’s Aid (domestic abuse service) to explore possible mother and baby unit and await accommodation.   3.4.13 the following day, health visitor 3 also spoke to GP, and discussed the letter from consultant psychiatrist in Southern Area 2 and the recommended plan. Health visitor 3 was concerned as the recommendations (such as the involvement of CMHT) had not been followed and discussed this with GP. As GP records did not contain a copy of the consultant psychiatrist’s letter, Health Visitor 3 provided them with a copy. GP attempted to call mother and left a message. 3.4.14 Mental Health records show that at 17:50 that evening a mental health social worker had a conversation with GP that was described in records as ‘confusing’. GP wanted to make an urgent Community Mental Health Team (CMHT) referral for mother to be assessed by CMHT, stating that she is a risk to the baby. The mental health social worker asked if assessment was required that evening and GP said no, but stated that they (GP) had advised mother and her health visitor to attend A&E for assessment today (which is not borne out by any other records – i.e. GP or Health Visitor or A&E). There was further discussion, about whether the GP wanted an urgent assessment that evening or not. GP said it was not urgent for that evening so was advised to do this via the Gateway system.  3.4.15 the following day, Gateway received a referral from GP requesting an urgent CMHT assessment for mother as she had been seen by health visitor 3 and has a nine week old baby. The mental health social worker attempted to call mother to clarify situation and level of need, but she was not available.  3.4.16 the following day, Gateway records show that another mental health worker contacted GP for clarification, as it appeared mother was assessed via the telephone at the end of March 2014, prior to the new request from GP. The GP confirmed no further concerns since the referral and telephone assessment by Gateway at the end of March 2014 and no need for any further action from mental health services at that time. GP agreed with plan already in place                                                            4 The Gateway Service is the single point of access for Manchester Mental Health and Social Care Trust's community services.  Final Version  Page 16 of 33  and that mother’s mental health and the health of the baby will be monitored in the surgery and re-refer to services if required in the future.    3.5 Summary appraisal of practice within Key Practice Episode 2 3.5.1 The analysis of this Key Practice Episode (KPE) highlights that there were opportunities to better understand and assess the situation of mother and CHILD N1, their support needs and risk issues.  Mother made a number of contacts with professionals and shows some intention to work positively and wanted some help (although she did also decline some support and could be seen to be less than open or complete in the information she provided). In trying to understand the actions and responses of agencies within this period, the review has noted some delay, confusion, and miscommunication between professionals, rather than a clear, properly assessed and co-ordinated response. 3.5.2 There appears to have been a useful telephone conversation between health visitors mid-February 2014 to handover information from one area to another. Health visitor 2 in Manchester recorded from the conversation with health visitor 1 in Southern Area 1 that mother had a mental health diagnosis (multiple complex personality disorder) – it is not clear to the review where this diagnosis came from. It was highlighted that records needed to be transferred urgently and the reasons for real concern were given although it was also recorded as ‘not being safeguarding at present’. However, this was without an assessment of the current situation, particularly following the move in which mother was said to have ‘fled’ from her husband (father). There was then some delay in a new health visitor meeting with mother – the moving in visit occurring nearly a month after the move. The review has been advised that such visits are not usually arranged until records have been transferred, but – given the age of the child, the stated circumstances of the move and the background history - there was good reason to prioritise an urgent visit.  3.5.3 The MCAF did not result in a co-ordinated multi-agency plan, and was completed by one agency. Health visitor 3 records in the document that there was a need to support mother in developing secure attachment, but there was no assessment that there was a difficulty with this, and indeed in a subsequent conversation with the Gateway triage nurse, health visitor 3 reports that ‘bonding and attachment is as it should be’. This is somewhat confusing and highlights the fact that no clear or co-ordinated assessment of CHILD N1’s needs and of parenting capacity took place.   3.5.4 Agency records at the time reflect some confusion about involvement of mental health services, which has been hard to clarify. Mother told health visitor 3 that she was awaiting an appointment with the CMHT, and then two weeks later that she had been refused the community mental health service support referral.  No record has been found to clarify why she would have made either of these comments. It is possible that she believed from her contact with consultant psychiatrist in November 2013 that a referral was being made and she was awaiting contact, however, there is no record of a referral being made.  3.5.5 There is some discrepancy in the recordings held by the different agencies over telephone discussions which took place and at least one instance of only one agency making a record of an important conversation with another agency. Health visitor 3 records a conversation with the Crisis Team which in fact appears to have been with the Gateway team. In that conversation the Gateway worker records health visitor 3 as saying that there are no  Final Version  Page 17 of 33  concerns for the baby at all, and that bonding and attachment is ‘as it should be’ – in direct contrast to the comments in the MCAF they had completed on previous visit. It is also notable that in the conversation with Gateway there was no mention by health visitor 3 of the consultant psychiatrist letter of November 2013, although it was a focus of the concerns expressed by health visitor 3 to GP the following day. These difficulties and apparent confusions highlight the need to ensure referrals and important conversations are made or followed up in writing.   3.5.6 The consultant psychiatrist letter of November 2013 was a thorough assessment of mother’s situation, listing ‘risks of serious concern’, highlighting a very worrying history and highlighted the need for urgent CMHT involvement, yet nearly five months later this had not happened. The belated attempts to achieve this were not successful and did not involve any clear attempt to reassess the current situation in regards to mother’s mental health in the light of the previous concerns. At the point of receiving the letter the GP recognised that efforts needed to be made to put in place some follow up. However, those efforts appear somewhat confusing and inconsistent. Not enough emphasis was put on ensuring there was an adequate assessment of mother’s current circumstances.   3.5.7 GP appears to have been unclear about the referral processes for referral to CMHT and Gateway system, and was also unclear and inconsistent in messages they gave in attempts to refer. In the phone referral to mental health social worker in April 2014 the GP talks about the referral being urgent, and at one point GP is quoted as saying that baby is ‘at risk’, but then states an assessment is not required that evening. In the phone conversation the following day GP states to a Gateway worker that are no concerns about the baby and the GP then confirms that are no new concerns since the telephone assessment by Gateway at the end of March 2014, and that mental health services do not need to be involved. This was without GP having seen mother to assess current presentation and mental state - one phone call was made to mother by GP but was not successful. Mother attended GP surgery early in April 2014 and was seen by a different GP for new patient health check which includes no record of discussion of mental health.  3.5.8 The Gateway assessment had been a phone call discussion between a Gateway worker and health visitor 3 and then with mother. Whilst the conclusion of that assessment was that there were particular issues in relation to housing that required follow up, there is reason to question why there was not a plan to follow up or assess in more depth mother’s apparent mental health symptoms - hallucinations, low mood and thoughts of self-harm. At that point Gateway was not aware of the consultant psychiatrist letter, as health visitor 3 did not mention it in that phone conversation. Health visitor 3 subsequently faxed a copy of the psychiatrist letter to GP as GP did not have a copy at that time. GP did fax a copy of the consultant psychiatrist’s letter to Gateway, and again this was an opportunity for Gateway to consider a plan to assess mother’s current mental health. They record following the conversation with GP in early April 2014 that referral will now be closed to Gateway and that ‘confusion had arisen’ due to GP having only just received the consultant psychiatrist letter and forwarded this to Gateway without reviewing her current presentation. There is no record (by GP or mental health services) of a plan to review this presentation.  3.5.9 There has been reference to CHILD N1 being described as a ‘protective factor’, in the context of mothers thoughts of self-harm. The review notes that professionals should use this  Final Version  Page 18 of 33  phrase with some caution, as clearly parents can and do self-harm even when they cite children as protective factors, and the use of this phrase can serve to obscure the daily lived experience of a child living with a parent who self-harms, or has thoughts of doing so.  3.6 Key Practice Episode 3: June 2014 - Domestic Abuse Incident  3.6.1 Early April 2014, mother was seen by GP in Manchester when she attended for CHILD N1’s eight week check. Mother was accompanied by maternal grandmother. GP noted that mother seemed settled, was happy to be back in Manchester away from father (although he visits regularly). GP recorded that mother denied any low mood or anxiety; spoke clearly, was appropriately dressed and gave good eye contact. GP also commented that mother was caring well for her premature baby – CHILD N1. GP was aware of the contact with mental health services (KPE 2). Mother declined post-natal check, so it was planned to see mother and CHILD N1 again in three weeks.   3.6.2 In early May 2014, the family moved back to Southern Area 1. Health records were transferred on mid- May 2014.  3.6.3 During April and May 2014, attempts were made by the health visitor 3 to contact mother by phone and home visits but health visitor 3 did not get a response. In Mid- May 2014, a verbal handover from health visitor 3 in Manchester to a health visitor in Southern Area 1 took place. It was recorded that mother had not attended for a mental health assessment and there was also mention of the risk of domestic abuse.  Between Mid May 2014 and Mid-June 2014, immunisations were given at the GP surgery in Manchester. It appears that mother travelled between Southern Area 1 and Manchester for immunisations.   3.6.4 Towards the end of June 2014, Police were called to a domestic incident in Southern Area 1. Mother reported that father had assaulted her and she had marks to her face. The domestic incident involved a verbal altercation over money between mother and father in the bedroom whilst CHILD N1 was present. During the argument, father struck mother several times to the head. Mother left the bedroom followed by father who struck her again to the back of the head which caused her to fall at the top of the stairs. He stood over her and struck her a further 4-5 times until other family members intervened, separating the pair. Father was arrested and charged. ‘DASH’ and ‘child to notice’ forms were completed.   3.6.5 Mother subsequently (Mid-July 2014) retracted her statement5, and the reason she gave was that she was moving to Manchester and wanted ‘to leave this behind’. A prosecution for assault was pursued, with father pleading not guilty, and the charge was dismissed by the court in October 2014.    3.6.6 In early July 2014, the health visitor in Southern Area 1 made a planned visit but family were visiting sister in Southern Area 2. 5 days later in July 2014, CHILD N1 was seen and weighed in the children’s centre in Southern Area 2 whilst mother was visiting her sister and this information was sent to Southern Area 1.                                                             5 Sidebotham, P. et al (2016) Pathways to harm, pathways to protection: a triennial analysis of serious case reviews 2011 to 2014: final report (PDF), - Section 4.2.5 page 80.  Final Version  Page 19 of 33  3.6.7 On Mid-July 2014, health visitor 3 in Manchester made an application for urgent supported accommodation making reference to mental health needs, self-harm, historical drug use, domestic abuse having fled twice from father, has a young baby and is vulnerable. 3.6.8 The health records were requested from Southern Area 1 towards the end of July 2014 but were not received by Manchester until the end of November 2014, following a number of requests.   3.6.9 At the end of September 2014, mother and CHILD N1 moved into supported accommodation in Manchester.   3.7 Summary appraisal of practice within Key Practice Episode 3  3.7.1 There is evidence of some good attempts by professionals to support the family and to share information with other agencies and across areas in this KPE. There are also examples of professionals not passing on information in a timely and effective manner. In this KPE it is apparent that mother had adopted quite a transient lifestyle (moving between different areas) and that there was a pattern of mother repeatedly separating from father. The implications of this for a vulnerable mother with her very young child were not sufficiently recognised or explored by professionals.   3.7.2 Within the visit to GP for CHILD N1’s eight-week check, there is evidence that GP discussed mother’s mental health and arranged follow up and the record noted a history of concerns (domestic violence and deliberate self-harm). Whilst these were all aspects of good practice, it is not clear to the review why no code was added to the child health record for safeguarding concerns, which would have been an appropriate measure at this point (and indeed at other points) to ensure colleagues also were aware of these concerns. It is also unclear to the review what impact (if any) there may have been from the presence of maternal grandmother at the appointment, and whether there was, or should have been, consideration of speaking to mother alone.   3.7.3 It does not appear that there was any questioning by health professionals of the fact that CHILD N1 presented for immunisations in Manchester despite having moved out of the area.   3.7.4 It is clear within this KPE that the family were moving around between different areas, with a pattern of mother and CHILD N1 leaving father and then returning. There is no record of attempts being made to understand the reasons for this or the implications for mother or for CHILD N1.  3.7.5 There was some good information sharing within the telephone handover between health visitors. The review has not been able to identify why, particularly in the light of the expressed concerns, there was significant delay before a moving in visit was undertaken. CHILD N1 was not seen by a health visitor in Southern Area 1 during the ten week period CHILD N1 was reported to be in the area.    Final Version  Page 20 of 33  3.7.6 When a family is so mobile there are clear challenges to ensuring that communication between agencies and across areas is effective so that the needs and risks are adequately understood and responded to. In this case, there were significant delays in crucial health records being transferred. In one instance there was a delay of four months in transferring health records. The review has been advised that this delay is not unique, and that the forwarding of records is often seen as an ‘admin function’ – i.e. is not a task that is prioritised and there is not a practise of routinely escalating the issue of records not being received promptly. In this case it was escalated to a child health administrator team lead but not within the health visiting service.  3.7.7 Positive action was taken by the police in response to the reported domestic incident. Father was arrested and both DASH and child to notice forms were completed. Within the DASH assessment mother identified that she and father had separated several times, but she also indicated that this was the first time an incident had resulted in an injury, and it is noted within the DASH that mother had support from her own family as well as father’s family.  It was a point of good practice that there was subsequent discussion between the police officer and their supervisor, which included discussing the possibility of honour based violence.   3.7.8 The outcome of the referral to CSC (child to notice form) was that CSC in Southern Area 1 decided to take no further action on the basis that this was the first incident reported.  3.7.9 When mother re-appeared in Manchester in mid-July 2014, health visitor 3 was sufficiently concerned about the situation to make an application for urgent supported accommodation, correctly identifying risk factors. At this stage there is clear evidence of domestic abuse and that this is likely to be the reason or trigger to the frequent moves. This was an opportunity to consider whether a referral to CSC was indicated. No such consideration is shown in the records.  3.7.10 Within this KPE the professionals did not identify the lifestyle pattern of the family and the implications of this for the care of CHILD N1. No comment or assessment is made about the impact, or likely impact, on the routines and needs of a very young baby. Professionals were responding to, and accepting, mother’s perspective without highlighting or assessing the daily lived experience of the child and the risks to CHILD N1.  3.8 Key Practice Episode 4: July 2016 - A&E Hospital Attendance   3.8.1 In the early hours of the morning in Mid-July 2016, mother contacted NHS 111, stating that whilst unattended in the kitchen CHILD N1 had taken three of her old sleeping tablets6 at 22:00 on the evening before (four hours earlier). CHILD N1 was reported to be seeing spiders/monsters, was screaming loudly, had slurred speech, was unable to walk and had a temperature. Mother was advised to attend A&E and an ambulance was dispatched, which arrived on the scene at 02:09.   3.8.2 At 02:58 NHS 111 made a safeguarding referral to Children’s Social Care (CSC), (copied to the health visitor) with concerns that mother did not obtain medical advice for four hours and an ambulance was dispatched, as it was assessed that CHILD N1 required to be seen by a                                                            6 Zopiclone - is a hypnotic agent used in the treatment of insomnia.  Final Version  Page 21 of 33  clinician and attendance at A&E might be necessary, and mother was unsure/reluctant about that. Mother said she had been having a clear out of old medications. An ambulance was requested due to ‘mother’s indecisiveness’.  3.8.3 The safeguarding referral information was received by the Emergency Duty Service (EDS) social worker who contacted the ambulance service to confirm CHILD N1 had been transported to hospital by ambulance and also contacted the A&E department. A&E stated that they were awaiting blood tests results, and that CHILD N1 was fine and there had been no safeguarding concerns regarding neglect being reported. There was no further role for EDS and the referral progressed to the day time services.  3.8.4 On examination at A&E CHILD N1 was alert and acting appropriately, all vital signs were normal. A safeguarding referral was considered, and it was felt that mother had acted appropriately and sought help, however, supervision issues were of concern and a referral was made to the health visitor to follow up. A letter was also sent to the GP to highlight that CHILD N1’s bloods may indicate iron deficiency. CHILD N1 was discharged home with advice and follow up from the health visitor and GP.  3.8.5 Multi-Agency Safeguarding Hub (MASH) team received the referral and sent across to the locality CSC team where it was recommended a section 47 enquiry7 and strategy discussion due to risk of significant harm. The strategy discussion, which took place on the following morning of the incident in July 2016, involved police and CSC only.  The police advised that they had no information to share as mother was not known to them. The discussion included that mother appeared to be questioning the need for an ambulance against clinician’s recommendations. This was the first contact with Manchester CSC, and the outcome of the strategy discussion was a decision to progress the Child and Family Assessment (CAFA). 3.8.6 Hospital shared information with health visitor and a home safety visit was planned in two to four weeks, which was subsequently reviewed on receipt of information from the ambulance service and the visit was brought forward to the end of July 2016.  3.8.7 a day later in July 2016, social worker attempted an unannounced home visit, but no access was gained. Similarly, four days after this in July 2016, no access was gained.  3.8.8 after this second unsuccessful visit in July 2016, social worker spoke to health visitor and information was shared about mother’s history of depression and self-harm and that domestic abuse was a feature in the relationship with the father of CHILD N1.  3.8.9 six days later in July 2016, an unannounced home visit was completed by social worker and CHILD N1 was seen with the aunt on the door step, as mother was out. Home visit attempted by health visitor the next day and in early August 2016, but no reply.  3.8.10 at the beginning of August 2016, social worker attempted a further unannounced home visit, but no access was gained and they emailed health visitor highlighting four no access visits.                                                             7 Section 47 enquiry - requires a local authority to make enquiries they consider necessary to decide whether they need to take action to safeguard a child or promote their welfare when they have reasonable cause to suspect that a child is suffering, or is likely to suffer significant harm - The Children Act 1989, HMSO.   Final Version  Page 22 of 33  3.8.11 the following day in August 2016, a successful home visit took place by social worker. Mother explained that she had previously been in when a visit took place, but had not answered the door having been concerned about speaking to a social worker and ‘what might happen to CHILD N1’. She gave an account of what happened, stating that CHILD N1 was on the kitchen counter   having a final drink of milk before bed. She had also left on the worktop four of her old sleeping tablets, as she was having a clear out of her medications. She left the room and returned to find only one tablet was left and CHILD N1 confirmed that they had eaten the other three tablets. There is no record of discussion about why mother had delayed seeking medical advice or about her reluctance or indecisiveness in following the advice to take CHILD N1 to A&E. Mother gave social worker some details of her past, including that she had been a victim of verbal and physical abuse from father. She stated father now only saw CHILD N1 ‘every 5 or 6 months for a few hours.’ Mother mentioned that CHILD N1 attends nursery five afternoons a week. Mother stated she no longer suffers with her mental health and is not receiving treatment, and she denied taking any drugs or alcohol. Mother stated that she copes with CHILD N1 but it can be tough at times.  3.8.12 in mid- August 2016, the CAFA was completed and the outcome was for the case to close to CSC. Management decision was that this was an unfortunate accident and that mother had learnt from this. There was no evidence to suggest that mother was not coping and CHILD N1 was meeting milestones. 3.9 Summary appraisal of practice within Key Practice Episode 4  3.9.1 Within the timeline of this review this incident of Child N1 apparently ingesting medication represents one occasion when there was clear reason for concern about the possibility of CHILD N1 having suffered neglectful parenting – in terms of being left unsupervised with dangerous medication, the subsequent delay in mother seeking medical advice and her reluctance to follow that advice. The incident required an appropriately robust and thorough response to ensure the issues were appropriately highlighted and assessed. The review has identified examples of difficulties and inadequacies in the professional response.  3.9.2 There appears to have been some failure of communication between key professionals in the early stages of this incident. In particular, the ambulance crew were not informed by NHS 111 of the fact that mother had delayed seeking medical advice for several hours, and that she had then exhibited ‘indecisiveness’ on the phone in relation to whether to follow the advice given (to use an ambulance or go to A&E). This then meant that the ambulance crew were not in a position to inform A&E of these factors which could have been crucial in their clinical assessment and in deciding whether or not to make a safeguarding referral themselves.   3.9.3 Whether or not CHILD N1 had actually ingested the medication remains unclear. Mother had reported that they had done so and also that CHILD N1 had been acting very strangely – mother had told the ambulance crew that ‘similar strange behaviour’ had taken place the previous evening without any medication having been consumed, although it appears this information was also not passed on. There was no concern about how CHILD N1 was presenting in A&E. The rationale in the A&E records for not completing a safeguarding referral was that mother had ‘acted appropriately’ – which is not borne out by  Final Version  Page 23 of 33  the information that NHS 111 had not passed on to the ambulance service. Even on the information that was available to both ambulance service and to A&E at the time, it is questionable why neither agency felt a safeguarding referral was required, given that late at night a very young child was thought to have been left insufficiently supervised so that they were able to take dangerous medication.    3.9.4 Within these early responses to this incident there does appear to be some level of over-optimism, or at least lack of professional scepticism by some professionals. This is perhaps exemplified in the discussion between the EDS worker and A&E staff. It was good practice that the EDS worker did call A&E to check that CHILD N1 had arrived at A&E and was safe. The EDS worker recorded that A&E were awaiting blood results, but CHILD N1 was fine and ‘no safeguarding concerns regarding neglect had been reported’. In the light of the reason why CHILD N1 was there, this ought to have been further explored and challenged. Similarly, there is no record of explicit consideration of the immediate protection needs of CHILD N1 in terms of the appropriateness of CHILD N1 going home with mother, and indeed, there is no recorded consideration of the possibility of involving the police to consider the investigation of the incident.   3.9.5 Comments to the review indicate that there are inconsistencies in the use of the MASH, and that this means that all enquiries and assessments undertaken are not done in a way that involves thorough multi-agency information sharing and consideration of the issues. It has been said that this is a problem of limited resources in relation to the large number of referrals received, although other comments have pointed to a practice that has developed of workers from Health, for example, not being fully utilised. In this instance, a decision was rightly taken by the locality CSC team that a strategy discussion was required, but there are clear deficiencies in how this was carried out, not least the fact that Health were not included in the strategy discussion.   3.9.6 There is no recorded reference within the strategy discussion to the fact that there was a significant delay in mother seeking medical advice and because there was no health representative, the importance of this was not considered.    3.9.7 The police advised that checks undertaken on mother, CHILD N1 and address indicate that they were not previously known to police, and therefore police relayed the information on the phone and would not attend a strategy meeting as they ‘held no information’. The police did, in fact, hold considerable information, and the review has identified that this did not come to light at the time as the check undertaken was not sufficiently careful or thorough. CHILD N1’s mother and CHILD N1 were not known to GMP and therefore a nominal was created. The Police National Computer (PNC)8 and Police National Database (PND)9 were not checked and therefore the information shared on these databases was not shared at the strategy meeting. It was not until N1‘s mother reported being the victim of a Domestic Abuse Rape a second nominal was created and attached to the crime. Again this                                                            8 The Police National Computer (PNC) is the Premier National Information system that holds comprehensive details of names, vehicles and property and includes records of a person’s convictions and cautions and other information known to the local police force. 9 The Police National Database (PND) is an information sharing platform between forces. It is a national data store of operational policing information and intelligence provided by police forces across the country, including records covering intelligence, crime, custody, child and domestic abuse investigations.  Final Version  Page 24 of 33  nominal contained no details with regard to the PNC and PND. It was not until the death of CHILD N1 that this information came to light and the nominal were merged.   3.9.8 Following the strategy discussion subsequent assessment was also not sufficiently robust or thorough and did not exhibit appropriate challenge or scepticism. The response to repeated failed attempts to undertake home visits and see CHILD N1 (other than on the doorstep with aunt on one occasion) over a period of nearly three weeks did not result in consideration of whether a different approach was required – such as to  return the matter for reconsideration by a strategy discussion. The health visitor had indicated that there was a history of mental health and domestic abuse, but this did not result in attempts to get further detail on this (i.e. by contacting other agencies or the Local Authority where the family had been living). When mother and CHILD N1 were finally seen there is a lack of recorded challenge or scepticism about what mother gave as the account for the incident, or about her history. She had indicated the history of domestic violence, and her account was accepted without further checks being undertaken, and there was no consideration of this in respect of potential risks to CHILD N1.   3.9.9 Mother minimised the risks from father and the amount of contact he had. Mother stated CHILD N1 attended nursery daily. Had contact been made with the nursery it would have become clear that mother was not being open and honest, and that father was having more regular contact with CHILD N1.  Nursery would also have been a useful source of information about CHILD N1 or about parenting ability.  3.9.10 Within this KPE there was a lack of consideration about the role of father. On the night of the incident there was no consideration of contacting father or involving him. There was no check done as part of the strategy discussion. A PNC check would have revealed that father did not at that stage have convictions, but police did hold information about him, including the previous incident of alleged domestic abuse against mother (see KPE 3) as well as him being accused of another violent and sexually violent crime.  No attempt was made within the social worker’s assessment to contact or involve father10.  3.9.11 The ultimate outcome of CSC involvement was that the incident was ‘an unfortunate accident and that mother had learnt from this’ and therefore the case could be closed (other options could have included a reconvened strategy meeting, or further assessment, or a period of child in need support, or de-escalation to a referral for early help). The assessment that this was based on had been quite superficial and lacking thorough checking or challenge. In the light of some of the basic facts which were clear at the time - including that mother had left CHILD N1 in room unattended on a worktop on which there were dangerous medications and not sought advice and was reluctant to take that advice, she was admitting to avoiding social worker and there was an unexplored history of mental health issues and domestic abuse. This decision to end involvement seems to echo the over-optimistic responses of other professionals to this incident.                                                             10 Hidden men: learning from case reviews Summary of risk factors and learning for improved practice around ‘hidden’ men – NSPCC www.nspcc.org.uk/hidden-men   Final Version  Page 25 of 33   3.10 Key Practice Episode 5: March 2017 - Domestic Abuse Incident  3.10.1 In mid-March 2017 at 09:45, mother reported a domestic violence incident to the police. Father had spat in her face and ‘went to punch’ her and then left. Mother informed police that they have a three year old child and are in an on-off relationship.  3.10.2 Police contacted mother at 11:48 am and apologised for the delay. Mother stated that there had been no further contact from father and police log is classed as low risk 3.10.3 At 13:25 the same day, father contacted the police and made a counter allegation, regarding a verbal row with his ex-wife (mother) earlier, during which she had told him that their child is dead to him and he will not be able to see them again. He stated that mother has mental health issues, has been physical with him in the past, is an alcoholic and smokes weed.  3.10.4 Two days later in March 2017, the incident was allocated to a police officer who visits that day. Mother made a disclosure of rape which occurred the week before, and reported threats to kill. Mother also stated that during the marriage between 2012 and 2014 she was raped by father on four or five occasions whilst living in Southern Area 1 but did not report these incidents. After moving into Manchester in 2014 with CHILD N1, she divorced father and has had an on-off relationship since. He moved back in with mother in Manchester on CHILD N1’s birthday (January 2017) but has since moved out. A DASH risk assessment was completed and scored as medium risk – this risk assessment was subsequently reviewed and two days later the risk level was changed to high risk.   3.10.5 A MARAC referral was created at the time of this police visit and a referral made to CSC by the police officer. Housing was contacted and a request made for locks to be changed. Police provided mother with a mobile phone and emergency numbers if she needed them. Police contacted CHILD N1’s nursery to update them. When visited by the police, mother was seen to be extremely distressed and ‘feeling very isolated and emotional’, was low in mood and said she felt depressed and had an appointment to see her GP. Mother was offered a refuge place, which she refused. Child contact arrangements were discussed and a high risk flag added to the police ‘nominal’.   3.10.6 On the same day as the police visit, mother informed nursery of a domestic violence incident involving father and that the police were called. Mother requested that father should not be allowed to take the child from the nursery. Nursery explained that they would not be able to prevent father from taking CHILD N1 as father had parental responsibility and no court order was in place. Agreed that nursery would contact mother if father came to the nursery and then she could come and collect the child. 3.10.7 Also at this time in March 2017, CSC (MASH) contacted nursery to ascertain if nursery had any safeguarding concerns about CHILD N1. Nursery did not have any concerns. They confirmed that CHILD N1 was always clean and well presented, was making good progress with their learning, had friends and was happy in nursery and when collected by either parent.   Final Version  Page 26 of 33  3.10.8 Again on the same day, the police contacted the worker at the young person’s homeless support organisation11 who had been working with mother for eighteen months since she had moved out of supported accommodation. Police officer advised that mother had disclosed domestic abuse and sexual offences against father which may have resulted in pregnancy. Mother was in a low mood, but was supporting the police in prosecution. Mother was willing to talk to the worker, who tried to contact mother. A further attempt was made to contact mother two days later but this was unsuccessful. Meanwhile the police officer had spoken to mother and had suggested that the worker call in during the afternoon while CHILD N1 was at nursery. The worker did this and made contact with mother. The worker spoke to mother about the information she had been given by police and mother was quite quiet regarding the information. The worker asked mother if she had a social worker and replied that she did but did not know the contact information. The worker asked mother to give her contact details to the social worker. A further meeting was arranged for the following week in 2017.  3.10.9 A day later 2017, the case was also allocated to a social worker.  Nursery informed mother that police and CSC had contacted them about the incident. Mother told nursery that it had all got out of proportion and that everything was now fine.  3.10.10 A social worker attempted a home visit the following day, but no one was present at the address. Social worker called mother on mobile number; mother requested that social worker call back in five minutes. There was no reply when social worker called back.   3.10.11 On the following day at the end of March 2017, a 999 call to the ambulance service at 23:34, reports that CHILD N1 was left unsupervised in the bath for ten to fifteen minutes, found unresponsive in the water. Cardio pulmonary resuscitation (CPR) had not been attempted prior to the ambulance crew arriving.  3.10.12 Mother reported that after running the bath, she went downstairs to get some clothes, she folded the clothes and went back upstairs. Mother said she found CHILD N1 lying in the bath she picked CHILD N1 up and tried to wake them but they appeared blue. 3.10.13 at 00:04 the following day the ambulance contacted police with a concern for a child. They stated that they had attended the address where a three year old child (CHILD N1) had been submerged in water for over ten minutes. CHILD N1 was in cardiac arrest and had been taken to hospital. At 00:34 CHILD N1 was pronounced dead.   3.10.14 Sudden Unexplained Death in Childhood (SUDC) protocol was instigated, and initial investigation completed. A multi- agency professionals meeting was held.  CSC (EDS) was notified of CHILD N1’s death at 01:20am the same day by the hospital. The death was being treated as suspicious and police were present at the hospital. Mother reported that she left CHILD N1 in the bath for ten to fifteen minutes while she went downstairs to fold the washing. The police found washing folded downstairs, and no water was in the bath. Doctor reported that it can take seconds to drown.                                                              11 Young person’s homeless support organisation which works with young people, aged 16-25, across Manchester to help them to live independently.   Final Version  Page 27 of 33  3.11 Summary appraisal of practice within Key Practice Episode 5 3.11.1 As previously highlighted – throughout the timeline of this review professionals had no clear understanding of the pattern of the relationship between the parents, and the extent to which domestic abuse might be present, the number of times mother and father had separated, the reasons for this, the role of the extended family, and the impact of all of this on parenting and on CHILD N1. No concerted or co-ordinated attempt had been made to explore these issues. It should also be reiterated that mother had been inconsistent in some of the things she had said, she had made comments and withdrawn them, and there had not been successful attempts to work with her more intensively. This was the first time that mother talked of a pattern of previous abuse – although it is also notable that she subsequently sought to minimise the problems, saying that things had been ‘blown out of proportion’.   3.11.2 It is notable that in mother’s initial phone call to the police she did not include the alleged history of serious incidents that she disclosed on the visit by the police two days later. It is unknown whether the delay in the visit taking place had any particular significance. The review has explored the delay in police visiting. There is a protocol that police use to risk assess the urgency of a visit. Due to the circumstances, including father not being present, the risk assessment did not highlight the need for an immediate visit.   3.11.3 Once the police did visit, there was some positive work undertaken to make referrals and to offer practical support to mother. Given the allegations of rape and threats to kill, it is concerning that the initial risk assessment was medium risk. This was rightly reassessed and escalated by the Police Public Protection Investigation Unit (PPIU).  3.11.4 The referral to CSC was appropriate given the presenting circumstances. This ought to have resulted in section 47 enquiries, with a multi-agency strategy meeting to share information, assess risks and agree a strategy for the enquiries. It is of real concern that no such strategy meeting or discussion took place. The review has not been able to clarify why the decision was made not to convene such a meeting.   3.11.5 A theme throughout the timeline of this review has been that there was never any concerted attempt to collate all of the information held by the different agencies and to put a co-ordinated plan in place. A strategy meeting would have been an opportunity to bring together all the information that different agencies held. A concern from the police visit in March 2017 was about mother’s presentation - how distressed, emotional and isolated she was feeling. Whilst there was no on-going support provided to mother for her mental health, there was enough information held by agencies to highlight mother’s vulnerabilities, including her previous history of drug use, offending, self-harming and mental health problems. Mother refused the offer of a refuge place. It was a positive response from the police to seek the support for mother of the homeless support organisation worker, although this is not a specialist service for people experiencing domestic abuse or possible mental health issues. Issues around mother being a victim of domestic abuse, or in respect of her emotional or psychological presentation could usefully have been explored within a strategy meeting. It should, however, be stressed that, at the point of writing, it is not known to what extent (if  Final Version  Page 28 of 33  any) mother’s mental state at the time might have had an impact on the tragic outcome on the night of 26th March 2017.   Section 4: Conclusion 4.1.1 A criminal prosecution has resulted in mother being convicted of two counts of neglect – relating to the evening when CHILD N1 died and to the occasion when CHILD N1 was said to have ingested mother’s sleeping tablets. The cause of CHILD N1’s death remains unascertained. The account given by mother is that CHILD N1 was left unsupervised in the bath. This review does not bring any degree of certainty to the many questions around why the tragic outcome ultimately occurred or the factors that might have contributed to that outcome. Instead, the focus here is on understanding whether there are lessons to be learned from the professional involvement in this case. Whilst there are undoubtedly some questions about professional actions (and what factors influenced these), which are not fully understood, there are some clear conclusions that emerge from the scrutiny of the five distinct Key Practice Episodes (KPEs) identified as the focus for this review. 4.1.2 Some comment has been made in this report about the lack of involvement of CHILD N1’s father in the work carried out. Indeed, it is notable that throughout the professional contact with the family the focus was overwhelmingly on mother with little attempt to gain an understanding of fathers role and perspective. It is not fully understood therefore, how far father may have been a protective factor, or a cause for concern at various points. This learning point about insufficient professional focus on the role of fathers echoes findings of other such reviews12.  4.1.3 Mother had a history of mental health problems, which had included inpatient admissions to psychiatric wards. Due to becoming pregnant, the review understands that mother had decided (without explicit medical advice) to stop taking the anti-depressant medication previously prescribed by her GP. Throughout the timeline of this review, mother did not receive any on-going support specifically for any mental health problems. It is not known whether such support was necessary, or whether it would have been useful. This is because there was little attempt made to assess mother’s mental health.   4.1.4 There was one significant assessment of mother’s mental health undertaken in this period by the consultant psychiatrist who saw her once (KPE1). Whilst that assessment did not indicate the need for medication, it did highlight serious risks and highlighted the need for urgent allocation to a CMHT for close follow up during and following the pregnancy. As has been seen, such follow up did not happen. There were problems with communication, particularly ensuring the consultant psychiatrist’s report was received and acted upon. These problems seem to have been compounded by some confusion around the pathways into secondary mental health services. There was thus a delay of some months before attempts to address mother’s mental health needs, and it was therefore identified that an up to date                                                            12 Hidden men: learning from case reviews Summary of risk factors and learning for improved practice around ‘hidden’ men – NSPCC www.nspcc.org.uk/hidden-men   Final Version  Page 29 of 33  assessment of mother’s current mental health presentation was required.  A GP did subsequently make some positive observations about mother’s mental health presentation, but these comments are fairly scant and no thorough assessment is undertaken or attempted.   4.1.5 It should be highlighted that comments to the review from professionals who worked with mother highlight that she generally presented well and not in a way to cause concern about her mental health or her care of CHILD N1.  4.1.6 Families that are quite mobile pose particular problems for professionals trying to track movements and ensure communication between agencies and across areas is effective. Within the time line of this review there are some good examples of professionals responding appropriately to this challenge, anticipating the possibility of family moves and sharing information. However, some clear deficiencies in communication and information sharing have also been noted, such as ensuring the consultant psychiatrist’s report was shared effectively so that the follow up recommended could take place. 4.1.7 Even within the careful scrutiny afforded by this overview, it has been difficult to achieve a clear understanding of some of the significant issues for the family. These include the movements of the family from one area to another, the family dynamics and the pattern of separations within the relationship between mother and father, and the extent to which domestic abuse (including psychological, physical, and sexual abuse) was a feature of this relationship. Similarly, there is no real clarity about the role of the extended family – both on the maternal and paternal sides - whether this was supportive to the parents or a cause of stress or risk. The extent to which cultural factors might have been impacting on the family and on the care of CHILD N1 is also something which remains unclear. 4.1.8 Undoubtedly, the task for the professionals at the time to assess these issues would have been just as difficult – if not more so. This was a family that did not come to notice very regularly, and there was no intensive or prolonged work undertaken with the family in the timeline of this review. It has also been seen that there were instances, for example, of mother not being entirely open in her dealings with professionals, and of avoiding professionals. Father was even less seen or spoken with.  There were, however, many indications that the family was quite mobile, and that mother and father did separate (and reunite) a number of times. There were indications of the reasons for this in some of the comments that mother made. Whilst mother was inconsistent in what she said, and at times, could be said to minimise problems, she did make comments to professionals about the relationship being an abusive one, and about her family telling her she had to return to father. There was insufficient evidence of professionals recognising the possibility of cultural issues being a factor within the dynamic of the parent’s relationship, including exploring the possibility of there being honour based violence13.  4.1.9 Professionals recorded some concerns about these issues, and at points identified them as risk factors. On a number of occasions there were opportunities to recognise that the pattern of the family lifestyle, the nature of the parent’s relationship, or comments about mother’s ambivalence towards the baby, might be of sufficient concern to be further explored                                                            13 A protocol guiding professionals in recognising and responding to situations where honour based violence may be a feature was published in January 2015 - Manchester One Chance Rule FORCED MARRIAGE PROTOCOL - MSAB, MSCB and partners.  Final Version  Page 30 of 33  in more depth. Indeed the review has identified points at which concern around these issues warranted a safeguarding referral to CSC, on the basis that there was reason to be concerned about the risks to CHILD N1.  4.1.10 The involvement of the consultant psychiatrist and the safeguarding midwife in Southern Area 2 within KPE 1, is an example of a time when many of these issues were identified as possibly posing risks for the care of CHILD N1, but the plan put in place at that point did not include making a safeguarding referral to CSC. 4.1.11 Professionals held different pieces of information. No attempts were made to get professionals together, or to complete a co-ordinated multi-agency assessment of parenting and of the care of CHILD N1. Thus it is notable that the voice of the child, or the daily lived experience of the child is not well understood, and it does appear that the perspective of the adults was accepted rather than being sufficiently challenged. The professionals note comments and concerns about different issues - such as mother’s mental health, domestic abuse, or comments from mother indicating her ambivalence towards CHILD N1 - but the next step of ensuring these issues and their impact on parenting is better understood is not taken. 4.1.12 The review has seen that there were times when safeguarding referrals could have been made but were not. However, referrals were made to CSC and there were opportunities within the interventions that did take place for co-ordinating detailed, multi-agency information sharing and assessment. It is perhaps the most significant point of learning from this review, that these opportunities were not taken. The review has identified problems with the convening of strategy meetings. On one occasion a brief phone discussion between just two agencies and based on incomplete information, served as the strategy discussion. On another occasion no attempt was made to hold a strategy discussion. The CAFA assessment (within KPE 4)  was an opportunity to collate and triangulate the information held by different agencies to assess needs, risks and parenting, but the analysis has shown that a rather cursory and optimistic assessment was accepted.  4.1.13 The analysis of the key practice episodes has led the review team to produce two significant areas of learning which are presented as Findings that the MSCB should address. A number of subsidiary questions are posed to the MSCB as it is felt that these are areas which warrant further exploration.             Final Version  Page 31 of 33   SECTION 5: Findings  5.1 Finding 1: Referrals to Children’s Social Care  5.1.1 In this case there were a number of occasions, three of which were in Manchester, when different professionals were in possession of information indicating that there might be a risk of significant harm to CHILD N1. The review has found that there is inconsistency in the making of safeguarding referrals to Children’s Social Care, and that agency recordings do not routinely demonstrate that this course of action has been considered by professionals in such situations.  5.2 Issues for MSCB to consider in regard to learning and improvement 1. Is the MSCB satisfied that there is an appropriate and consistent understanding across all agencies of the threshold for making a safeguarding referral to CSC?  2. Are professionals across all agencies familiar with when and how to make a safeguarding referral?  3. Are they adequately supported in this by reflective and challenging management oversight? Is there a practice of routinely considering whether a referral is indicated and of ensuring that such considerations are adequately recorded?  5.3 Finding 2: Strategy Meetings  5.3.1 Submissions to this review have indicated that there are problems with the system of convening multi-agency strategy meetings in accordance with the procedure for enquiries undertaken following/in response to safeguarding referrals. In one instance within the timeline of this review a strategy discussion involved a brief phone call between only Children’s Social Care and the police. Within the final Key Practice Episode there was no attempt to hold a strategy meeting.  5.3.2 This review is aware that other recent serious case reviews commissioned by Manchester Safeguarding Children Board (MSCB) highlight that the procedure for strategy meetings and discussions is not being robustly adhered to14. 5.4 Issues for MSCB to consider in regard to learning and improvement 1. The MSCB needs to ensure that in all situations where enquiries are being made under section 47 of the Children Act 1989, that in line with the procedure, all relevant                                                            14 CHILD I1 April 2017 MSCB, CHILD K1 July 2017 MSCB – Published in December 2017.  Final Version  Page 32 of 33  agencies are involved in strategy meetings or discussions to share and evaluate information, and plan the work.  5.5 Subsidiary issues for further exploration:- 1) Does training and management scrutiny sufficiently highlight that the voice of the child or the daily lived experience of the child is the primary focus of all agency considerations? Furthermore, do agency recordings routinely demonstrate that all new information received is considered in terms of the impact on the child?  2) It is recommended that there is a piece of work done to ensure that pathways into secondary mental health services are clear to those who might need to refer people for assessments and interventions – particularly primary health services such as GPs.  3) It is recommended that the board seeks reassurance that all professionals are using the Manchester Domestic Violence and Abuse Assessment and Referral form when there is a disclosure of Domestic Violence and Abuse. This can be included within the Safeguarding audit processes for Children's and Adult's.  4) When police checks are being completed to inform child protection investigations are they now rigorous in checking with all available sources of information, such as the PNC and/or PND?  5) It is recommended that work is undertaken to ensure that NHS 111 hand over all available safeguarding information to ambulance staff when they make referrals for ambulance service to become involved.   6) It is recommended that knowledge and awareness of Forced Marriage/’so called’ Honour Based Violence and Abuse is increased and the One Chance Policy is promoted. A seven minute briefing is one way that an increased awareness of the issues could be achieved.     Final Version  Page 33 of 33   Glossary  A&E Accident & Emergency CAFCASS Children & Family Court Advisory and Support Service CCG Clinical Commissioning Group CMHT Community Mental Health Team CSC Children’s Social Care EDS Emergency Duty Service GMMH Greater Manchester Mental Health GMP Greater Manchester Police HV Health Visitor LSCB Local Safeguarding Children Board MCC Manchester City Council MHCC Manchester Health and Care Commissioning NSPCC National Society for Prevention of Cruelty against Children NWAS North West Ambulance Service PPIU Public Protection Investigation Unit (GMP) SUDC Sudden Unexplained Death in Childhood  