Death of a baby boy during the hours following his birth in September 2013. Mother was 16-years-old at the time of the incident; she had concealed or denied her pregnancy and given birth, unassisted in her bedroom at home. Post mortem revealed that Baby W died from a tissue blocking his airway; mother pleaded guilty to infanticide and was sentenced to a 2-year Youth Rehabilitation Order (YRO). Mother was known to universal services only; she did not present with any physical symptoms of pregnancy prior to Baby W's birth. Any signs that could have been attributed to pregnancy were given another explanation, for example weight loss and poor attitude towards food led to concerns that mother was developing an eating disorder. Father was unaware of mother's pregnancy and birth of Baby W until contacted by police; father was 6-years older than mother and had a history of contact with the police and probation services. During her pregnancy mother presented to GP a number of times with concerns of low mood and depression and self-referred to an Improved Access to Psychological Therapies (IAPT) service for support with her anger as a result of depression. Mother was asked and denied her pregnancy on a number of occasions, by professionals and family members. Identifies one missed opportunity to provide mother with age appropriate advice around sexual activity, contraception, sexual health and healthy relationships. Identifies lessons to be learnt, including: need for awareness raising and development of procedures and guidance around concealed or denied pregnancy; importance of young people receiving sexual health and contraception advice; and increased GP knowledge of the support that school nursing services can provide young people. Makes various recommendations.
      
 Title:  Serious case review: relating to Baby W: overview report. LSCB: Lincolnshire Safeguarding Children Board Author: Ceryl Teleri Davies Date of publication: 2015  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.                           Serious Case Review: Baby W Overview Report  1      SERIOUS CASE REVIEW    Relating to Baby W  Date of birth and death: 5th September 2013    OVERVIEW REPORT  Prepared by:-  Ceryl Teleri Davies  Independent Author Date: 3rd April 2015               Serious Case Review: Baby W Overview Report  2                                                              CONTENTS  1. INTRODUCTION  1.1 Summary of the circumstances leading to the Serious Case Review 1.2 Context to the Serious Case Review 1.3 The Serious Case Review process 1.4 The Terms of Reference  1.5  Independent Panel and Independent Overview Author  2. THE FACTS AND FAMILY  2.1 Family composition and Genogram 2.2 Family history  2.3 Overview of the integrated chronology of events and agency involvement 2.4 Summary and conclusion of the Integrated Chronology 2.5 Information from the family  3. ANALYSIS  3.1 Analysis: The Agency Narrative Reports  3.2 Missed opportunity and key practice episodes  3.2 Analysis by Theme 3.3 Summary: Overall response to the SCR Terms of Reference 4. LEARNING  4.1 Good Practice example 4.2 Lessons to be learnt 4.3 Implementation of learning  5. IMPLEMENTATION OF THE LEARNING   5.1 GP Primary Healthcare services 5.2 Improved access to Psychological services 5.3 Health Overview report 5.4 The Police 5.5 Education  5.6 Recommendations of the overview author 5.7 Recommendations by the Independent Overview Report Author 5.8 Progressing Recommendations and dissemination of learning     Serious Case Review: Baby W Overview Report  3   SERIOUS CASE REVIEW OVERVIEW REPORT: BABY W  1. INTRODUCTION  Anonymity: The details relating to the family and individuals are anonymised where possible. Some specific dates, and dates of birth, are omitted to aid anonymity. Agency names are included, other than the School and the GP Practice to avoid making the identification of the family members possible.   Please see below a table summarising the family members and their designated names for the purpose of this report.   Designation  Relationship to Baby W  Baby W Subject child  Sarah Mother of Baby W  Daniel  Father  MG  Sarah’s mother & Maternal grandmother PG Sarah’s father & Paternal grandfather  SF MG’s partner and Sarah’s step-father MU Maternal Uncle and half-brother to Sarah    1.1 Summary of the circumstances leading to the Serious Case Review  The Lincolnshire Safeguarding Children Board (LSCB) agreed on the 28th of April 2014 to commission a Serious Case Review (SCR) into the death of Baby W, a white British male, who it was understood, was born and died on the 5th September 2013. At the time of his birth, his mother, Sarah, was aged 16 years and 11 months, a young person herself.  Sarah concealed/denied her pregnancy and gave birth alone, unassisted in her bedroom at home.  It is believed that Baby W died shortly after his birth, with his body hidden.  The initial belief was that he was stillborn however a post mortem examination revealed that he had died from a tissue blocking his airway. The post mortem examination and police enquiries confirmed that Baby W had been born full term and that a deliberate act caused his death. As a result, Sarah was charged with causing the death of her son and was subsequently remanded into Local Authority Care to await her trial. The Coroner’s inquest was opened and adjourned on the 28th of March 2014 pending the outcome of the criminal trial of the mother. However, on Serious Case Review: Baby W Overview Report  4   the 21st of July 2014, Sarah pleaded guilty to infanticide and was sentenced on the 8th of September 2014 to a 2 year Youth Rehabilitation Order (YRO).   1.2 Context to the Serious Case Review  There are several aspects that make this SCR unusual. Firstly, there was limited history of inter-agency involvement with the family; in fact, there was only one opportunity identified for any form of joint working between agencies. Secondly, no agency concerns were raised about Sarah or any other family member. Thirdly, Sarah presented as a typical young person and was not known beyond universal service provision. Therefore, Sarah did not present as a vulnerable young person, to the contrary, she presented as an articulate and intelligent young woman. Sarah was a young woman with a record of good attainment who achieved good GSCE results with a post 16 progression plan in place. This is further encapsulated by the key fact that Sarah did not present with the typical signs and symptoms of pregnancy, in particular there were no visible physical cues of pregnancy. Any possible sign that may be attributed to pregnancy were allocated another explanation e.g. the sickness she felt was explained as a result of GSCE exam pressures and stress as a result of her relationship with her father. Also, during her pregnancy there were concerns that she was developing an eating disorder based on the signs and symptoms of weight loss and poor attitude towards food.  Indeed, Sarah’s presenting weight and low mood were the primary concerns voiced by MG, the GP and indeed Sarah herself. Sarah asserts that she told the GP that she was definitely not pregnant and would not have allowed an examination by a medical practitioner. In addition, Sarah has explained that she was unaware of potential services and support available at the school and would not have accessed them if she had been aware, as she had a concealed/denied pregnancy.  In summary, there were no reported or presenting concerns around Sarah’s emotional, social or behavioural development and contact with agencies were not deemed to be out of the ordinary or beyond universal service provision.   To further contextualise the issues, a key theme weaving throughout this SCR is the nature of the circumstances and presented facts. Research exploring concealment and denial of pregnancy is relatively recent and has primarily focussed on attempting to understand the characteristics of women who conceal or deny their pregnancy and the link between concealed pregnancy and infanticide (Earl et al, 2000; Friedman, 2005; Vallone, 2003; Nirmal et al 2006; Wessel & Buscher, 2002).  The author could not identify international Serious Case Review: Baby W Overview Report  5   based research which assessed this issue from a global perspective. But it has been suggested that,  There is a paucity of quality research addressing undetected pregnancy, which has resulted in the problems associated with this issue being unrecognized and unaddressed in policy statements (Ali & Paddick, 2009, p.647).  Whether Sarah concealed, denied or did both during her pregnancy is debatable. A review of the literature indicates that the measurement of the full nature and extent of this issue not only varies on the basis of the exact definition employed, but also as a result of the methodology adopted across the limited research studies conducted. The majority of the literature available appraises the exact definition of this phenomenon around various categories of denial described as pervasive, affective and psychotic denial (Friedman et al, 2007). In addition, categories of essentially ‘forgetting’ the pregnancy (ibid) and ‘cryptic pregnancy’ (Del Giudice, 2006) are suggested and critiqued. Also, the definitions of concealed and denied pregnancies are used interchangeably with the phrase ‘negated pregnancy’ suggested to consolidate both terms (Jenkins et al, 2011). From the information shared by Sarah it appears that she ‘affectively’ denied her pregnancy and later may have concealed her pregnancy. It would not be constructive for the purpose of this review to debate the exact application of the various definitions as denying and concealing a pregnancy are distinct concepts, but closely interlinked (Friedman et al, 2007) within a continuum of definitive behaviours.   It is suggested that there are a continuum of pregnancy denial behaviours, ranging from full awareness of pregnancy with concealment, to suspicion of pregnancy, to full-blown denial (Jenkins, 2011, p.287).   Despite the fact that concealed pregnancies and infanticide have remained stable in the UK (Jackson, 2002), there are several ranges of prevalence rates cited within the studies reviewed. A concealed/denied pregnancy where a woman presents in labour or gives birth in secret is thought to occur more rarely than other concealed/denied pregnancies, with a prevalence of 1 in 2500 births (Nirmanl et al, 2006; Wessel & Buscher, 2002; Jenkins, 2011). However, this may not be a true reflection of the incidence rate, as studies have their limitations and may only include those women who delivered in hospital and had received no antenatal care.   There are clear challenges of predicting and identifying women likely to conceal/deny a pregnancy. Evidence suggests that there is no clear typology for women who conceal/deny Serious Case Review: Baby W Overview Report  6   their pregnancy (Jenkins et al, 2011). However, it should be noted that concealed/denied pregnancies are not regarded as a ‘teenage phenomenon’, in fact, women who conceal/deny their pregnancy are described as predominately single, educated or employed.  Living within a rural area and the perceived family reaction to the pregnancy is also thought to be a potential contributory factor to denial/concealment (Thynne et al, 2012). A key finding is the indication of the risk that women who conceal/deny their pregnancy on one occasion may be at risk of future concealed/denied pregnancy. A striking similarity across the literature is the concurrence of the challenge in identifying denied/concealed pregnancies based on any consistent common characteristic or behaviour. Therefore, the challenge of adopting a specific assessment or risk matrix to assist in the early identification of women at risk of concealing/denying their pregnancy is evident. This is a concern and a barrier to designing assessment and risk matrix tools to quantify a risk score. Not only does the review of literature exemplify the challenges and complexities faced by agencies when addressing these types of cases, but the very nature of concealed/denied pregnancies limits the scope of professional help or support without a degree of knowledge, further action or enforcement.   Historical practice data from Lincolnshire indicates that over a 10 year period before 2000, four out of twelve Part 8 Reviews completed were as a result of concealed pregnancies (Earl et al, 2000). Therefore, Lincolnshire commissioned a piece of research in the aim of investigating the link between concealed pregnancy and child protection. As an outcome of this piece of work, a list of risk indicators were outlined, which can be further developed for current multi agency use, keeping in perspective the challenges illustrated above. It is suggested across the literature that doctors should be more aware of the possibility of denial or concealment of pregnancy and should have a low threshold for pregnancy testing in women of childbearing age who present with symptoms compatible with pregnancy. However, this may be a challenge to operationalise and monitor in practice. The primary or typical bodily cues used to self-diagnose pregnancy were noted as absent for Sarah e.g. abdominal swelling. Therefore, Sarah is an example of a woman who did not present with the normative signs and symptoms of pregnancy, with limited cues identified or presented with an alternative reasonable explanation rationalised e.g. sickness due to exam stress. On the basis of the information presented, it appears that no individual had direct or indirect knowledge of Sarah’s pregnancy. Therefore, the opportunity for anyone to hold a significant belief and possess the evidence of Sarah’s pregnancy did not present itself to trigger the need to ask or reasonably enforce further investigation or action. It has also been reported that Serious Case Review: Baby W Overview Report  7   questions around explanations are confusing for women who have concealed/denied pregnancy, with thought processes before, during and after birth almost impossible to access due to a ‘disassociated state’ (Jackson, 2002). Whilst there will be discussion around some useful learning and recommendations for practice development, there is no evidence to suggest that agency actions would have resulted in a different outcome for Baby W, as Sarah’s behaviour was unpredictable and unpreventable. This is a view also voiced by Sarah.   1.3 Serious Case Review Process  1.3.1 As outlined, the Local Safeguarding Children’s Board (LSCB) agreed on the 28th of April 2014 to commission a Serious Case Review (SCR) into the death of Baby W. The scope of this SCR was to cover the timeframe just prior to the conception of Baby W, from the 1st of October 2012 to the date of Baby W's death on the 5th of September 2013. The rationale for starting the review in October 2012 is as a result of evidence suggesting that Sarah was sexually active in October 2012, and to, therefore consider what, if any, other services could have been offered to influence the outcome in this case.  1.3.2 Regulation 5 of the Local Safeguarding Children Board Regulations 2006 requires LSCBs to undertake reviews of serious cases in accordance with procedures as set out in ‘Working Together to Safeguard Children’ (HM Government, March 2013). The Serious Case Review criteria apply to all children, including those with a disability and are set outlined in Regulation 5 of the Local Safeguarding Children Boards Regulations (2006):  (1) The functions of a LSCB in relation to its objective (as defined in section 14(1) of the Act) are as follows – (e) Undertaking reviews of serious cases and advising the authority and their Board partners on lessons to be learned. (2) For the purposes of paragraph (1) (e) a Serious Case Review is one Where – (a) Abuse or neglect of a child is known or suspected; and (b) Either – (i) The child has died; or Serious Case Review: Baby W Overview Report  8   (ii) The child has been seriously harmed and there is cause for concern as to the way in which the authority, their Board partners or other relevant persons have worked together to safeguard the Child. Working Together 2013 states that SCRs and other case reviews should be conducted in a way which;   recognises the complex circumstances in which professionals work together to safeguard children;  seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did;   seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight;   is transparent about the way data is collected and analysed; and   makes use of relevant research and case evidence to inform the findings. 1.3.3 The time frame for the Review was extended as a result of a need to change overview authors.  1.3.4 The authors of the ANRs and the Health Overview Report were senior practitioners or senior managers. 1.3.5 On the 12th May 2014, the National Panel was notified of the decision to commission a SCR. Following this, on the 22nd May, Ofsted was notified of the SCR and advised of the unlikelihood of meeting the 6 months timescale due to the parallel criminal process.  1.3.6 The scoping meeting was convened on the 12th June 2014, to establish the Terms of Reference, Process and Timeline. The process of collating information for the Agency chronologies commenced on the 20th June, with the ANR Author’s briefing held on the 1st July.  1.3.7 The criminal trial of Sarah commenced on the 21st July 2014, with Sarah pleading guilty to the charge of Infanticide due for sentencing on the 8th September 2014. Following the outcome of the trial, the process of interviewing agency staff members to inform the ANR’s was commenced.  1.3.8 In August 2014, the agency chronologies and merged chronology were completed and circulated to panel members. All the ANRs and the Health Overview Report were quality Serious Case Review: Baby W Overview Report  9   assured, signed off and submitted to the LSCB in September 2014. The ANR’s were presented to the LSCB panel in October, with the final versions agreed.   1.3.9 The family interviews commenced following the sentencing of Sarah to a 2 year YRO.  1.3.10 The aim was to finalise the SCR process in the December, however, due to the need to appoint a new Independent Overview Author the timescale was amended to aim for the completion of the process in February/March 2015.  1.3.11 Appointment of Ceryl Teleri Davies as Independent Overview Author on the 9th January 2015.  1.3.12 Serious Case Review panel meeting held on the 13th February and 3rd March 2015.  1.3.13 On the 2nd of April the LSCB Strategic Management Group convened to sign off the final SCR Report. 1.4 The particular questions outlined within the Terms of Reference are summarised below:-  1. Was the service delivery and help provided based on Baby W's mother's presenting circumstances, or was it based on the analysis of all the information and observations available? 2. Was all appropriate available information gathered and shared in a timely and appropriate manner to facilitate the right services being provided to Baby W's mother on the part of both professionals and the family? 3. Was the communication with baby W's mother age appropriate and effective, and was her voice heard? 4. Were presenting issues, concerns and risks appropriately considered and analysed and acted upon in an appropriate way? 5. Was service delivery timely, effective and in line with the agency's practice, safeguarding best practice and LSCB policy and guidance? 6. Did the service offered to Baby W's mother meet her needs? 7. Are there alternative services that could have been commissioned that could have better meet Baby W's mother's needs? 8. Did individual agency resources have any implications for service delivery?  Serious Case Review: Baby W Overview Report  10   Based on the nature of agency involvement with this family, a decision was undertaken to focus on a methodology including, agency narrative, review of case files, formulation of a inter agency chronology, staff interviews, and family interviews. However, the LSCB was also mindful that if any agency considered that there was any relevant information outside this timescale, it would be included in their agency narrative report (ANR). A review of each agency report is outlined within section 3.1, with each term of reference reviewed separately within section 3.3 1.5 Independent Panel and Independent Overview Author 1.5.1 The membership of the SCR Panel was agreed by the SCR Subgroup on the 12th June 2014, which consisted of senior managers and/or designated professionals from the key statutory agencies.   1.5.2 The Serious Case Review Panel members were:-  AGENCY       NAME  Independent Chair of the SCR panel Leila Barron  Lincolnshire County Council Roz Cordy  Lincolnshire Police  Guy Leach/Perce Bosworth Clinical Commissioning Groups Jan Gunter Lincolnshire Partnership NHS Foundation Trust Liz Bainbridge Humberside, Lincolnshire, North Yorkshire (HLNY) Community Rehabilitation Company  Kim Plant Education  Representative from School   1.5.3 Independent Overview author The Independent Overview Author is Ceryl Teleri Davies, who has compiled the Overview Report, the Executive Summary and contributed to the Integrated Action Plan produced by the Lincolnshire Safeguarding Children Board. The author is a qualified Solicitor and Social Worker, with a Master’s degree in both work areas, a postgraduate diploma in Community and Criminal Justice, and qualifications in Mental Health. She has extensive practice-based experience across social care, criminal justice and mental health services, including work on Serious Case Review: Baby W Overview Report  11   a multi-agency basis to support children, young people and vulnerable adults at practitioner, middle and senior management level.   Ceryl Teleri Davies is not employed by any of the Lincolnshire Safeguarding Board Agencies.   2. FAMILY INVOLVEMENT  2.1 Family composition and Genogram  2.1.1 The family resided in a small rural village with limited community resources and very little in the way of public transport. As a result, Sarah was dependent on other family members to transport her to larger towns to access resources, such as shops and entertainment facilities.   2.1.2 Sarah is described as having a close relationship with her mother, Baby W’s maternal grandmother.   2.1.3  The family is of White British origin and live in a mainly White British area of the county. There were no records indicating any specific religious affiliation for the family.  2.1.4 Prior to the death of Baby W, the maternal family members were unknown to the police and social care services. There was also no involvement with health services beyond universal health provision.   2.1.5 Please see Genogram below. Serious Case Review: Baby W Overview Report  12   Genogram:                     Juliet S Michael  S Richard  B Maternal grandmother Maternal grandfather Step-father  Sarah: Mother  (16 yrs old) Daniel: Father   Baby W  05.09.2013 Paternal uncle   Serious Case Review: Baby W Overview Report  13   2.2 Family history   2.2.1 There was limited information in the ANRs of the early history of either parent, reflecting the limited concerns about either parent or their immediate families during their childhood. Sarah had not experienced direct contact with either the police or social services and was unknown to all services beyond universal service provision. Daniel has a history of previous contact with the police and probation services dating back to 2011.   2.2.2 The picture that emerged from agency records and the record of meetings with the family members is one of a supportive network of maternal family members all living within the local area. The family led a busy life with a network of friends and extended family members. Sarah had a fairly close group of similar minded girls as friends through most of her school life, but did not present as having one or two special friends. During year 11, Sarah is reported to drift from her group of friends – this was not due to a particular split or fall out, just a gradual parting. She also had a group of older friends who she socialised with outside of school.   2.2.3 Sarah’s relationship with her mother is described as good, ‘normal’ and at times strained.   2.2.4 Approximately five years ago her parents separated at which point she remained in the care of her mother. Her parents are now divorced, which was finalised a few days prior to Baby Ws’ birth. Her father elected to move to another area, resulting in the maintenance of contact via the telephone, rather than face to face. However, Sarah voiced that the calls from her father reduced, despite his expectations that contact would be maintained by her initiation of telephone calls. The relationship between Sarah and her father is described as difficult, and has been so for several years. Sarah is reported as noting that she does not wish to have contact with her father and has not spoken to him since 2012.   2.2.5 Sarah has one sibling, an older sibling who is her half-brother as they do not have the same father. Sarah’s relationship with her half-brother is described as a ‘good relationship’.  Serious Case Review: Baby W Overview Report  14    2.2.6 Sarah describes that she has not had a serious intimate relationship and does not see a ‘boyfriend’ relationship as a priority.   2.2.7 In February 2013, MG began to have concerns about the health and well-being of her daughter.  She had an instinctive impression that Sarah may be pregnant, but this was based on her suspicion rather than any direct knowledge of Sarah’s pregnancy.  When asked directly, Sarah denied this possibility. MG noticed that her daughter lost contact with her friends, became withdrawn, spending a lot of her time alone in her bedroom.  She became lethargic and did not appear to be eating properly.  She lost weight, her menstrual cycle stopped and she was experiencing mood swings.  Sarah also started showing signs of a slightly swollen stomach and took to wearing loose fitting tops and was reluctant to undress in front of her mother. There were also concerns that Sarah may be suffering from an eating disorder. Again, in June 2013, both her mother and her half-brother asked her directly if she was pregnant, again the response was ‘no’ and she elected not to have a pregnancy test. Despite all these apparent difficulties, Sarah managed to attend school and sit her GCSE exams.  2.2.8 Baby W’s paternity was determined through DNA testing, with his father identified as a local man, Daniel, who is five years older than Sarah. Baby W’s father had been unaware of Sarah’s pregnancy, or the birth and death of Baby W until he was contacted by the police. Sarah and Daniel were not in an established intimate relationship, with the school, family members and class friends noting that they had been unaware of Sarah’s relationship/acquaintance with Daniel. The police are satisfied of the accuracy of Daniel’s assertion that he was unaware of Sarah’s pregnancy with Baby W.  Historically, Daniel had attended the same school as Sarah.  2.2.9 Baby W was the first child of Sarah, but the second child of Daniel as he has a child from a previous relationship. Daniel’s previous relationship is described as ‘volatile’.  Serious Case Review: Baby W Overview Report  15   2.2.10 Sarah has explained that she first became aware of her pregnancy in April/May 2013, but did not take a pregnancy test to confirm this belief and did not voice this belief to anyone.  She described that she "went into denial" with regards to being pregnant and "carried on with life".  In addition, she is adamant that no further thought was given to her pregnancy even when her mother and GP asked her directly if she was pregnant.  Sarah describes that she did not experience the ‘normal’ signs and symptoms of pregnancy. This ‘denial’ was acknowledged when her waters broke and she went into labour.  2.2.11 On the 3rd and 4th of September 2013, Sarah complained of sickness and a ‘stabbing stomach pain’. As a result, she spent most of this time unwell in bed.   2.2.12 Baby W was born early in the morning on the 5th September, but it was not until much later in the evening that Sarah was unwell and the ambulance called.  Sarah did not inform her mother at the time of the birth as she did not acknowledge she had given birth to her son. She describes birth as a painless and a disassociated ‘out of body’ experience of which she has limited recollection of. She gave birth alone in her bedroom; concealing Baby W’s body. His body was discovered several hours later when the ambulance crew attended the property due to concerns around Sarah’s health and MG discovering the placenta and several blood stains. Throughout this time, Sarah did not call her family for support or to request medical assistance.  2.3 Overview of the integrated chronology of events and agency involvement  2.3.1 The aim of this section is not to reproduce the full integrated chronology, but to highlight significant events to illustrate an account of what is known in agency records. The following extracts from the integrated chronology are the Independent author’s view of the significant practice events which occurred prior to Baby W’s birth and death. An outline of the key practice episodes and one missed opportunity will be explained in section 3.2.   2.3.2 The Terms of Reference stipulated the time frame to be examined as from the 12th October 2012 to the 5th September 2013, essentially a period of approximately 3 Serious Case Review: Baby W Overview Report  16   months prior to the conception of Baby W. Information from agency records prior to this timeframe illustrate routine ‘everyday’ contact with agencies.                  2.4   Summary of the Integrated Chronology  2.4.1 The merging of all known contact into the integrated Chronology has provided an overview of agency involvement, albeit the limited involvement of agencies.    2.4.2 In summary, the emerging picture revealed that there was limited information available to the agencies involved with Sarah. On an ‘everyday’ basis Sarah presented as a typical young woman with no significant presenting needs. Sarah is described as a bit distant, kept herself to herself, but without being cold or aloof, just a little reserved. Sarah is described as having good communication skills, but, for whatever reason, either consciously or unconsciously she did not communicate to her mother or another potential support source that she was pregnant.  2.5 Information from the family  2.5.1. The family were invited to participate in the SCR, Sarah and MG agreed to contribute to the review, whilst Daniel elected not to be part of the SCR.  2.5.2. To enable Sarah to participate in the review, the SCR timescale accommodated the parallel criminal proceedings, to ensure that she could voice her views/perspectives, following the end of the criminal processes and when she was considered, by those professionals currently providing her with support, to be sufficiently settled to undertake this task. MG also participated in the review once the criminal proceedings ended.  2.5.3. On the 5th November 2014, Sarah and MG were interviewed in the family home, both together and separately. The key points established during this interview were that:-  Serious Case Review: Baby W Overview Report  17    Sarah presented as controlled, articulate and illustrated no outward signs of vulnerability.   Sarah voiced that she did not feel any particular impact of the change of tutor for her school tutor group. She described that she had several groups of friends, but no close confidants.   She described the relationship between her parents as acrimonious and continued to feel angry towards her father.   It was described that Sarah had a ‘normal relationship’ with her mother and was able to discuss particular ‘sensitive/personal’ issues with her.   She also explained that she would not have told her GP about her pregnancy and described her situation as a ‘denied pregnancy’.   She described that not all women experience the pregnancy ‘norm’ and explained that she did not experience the typical signs and symptoms associated with pregnancy.   There were concerns that Sarah was presenting as very thin and may be at risk of developing an eating disorder. She showed a picture of herself on the beach on holiday in August 2013. The picture reflected a very slim young woman with no physical signs of pregnancy at the 8 month stage of her pregnancy.   She described the birth as an ‘out of body’ experience and could not recall the particular details.   She feels that it would be beneficial to incorporate the reality of pregnancy within sex education, in particular the notion that not all pregnancies adhere to the ‘norm’ or are indeed ‘happy’.   She clearly outlined that she did not feel that there was anything that could have been done differently by services.    3.1 ANALYSIS: THE AGENCY NARRATIVE REPORTS (ANRs)   3.1.1. All the ANRs and the Health Overview report produced for this SCR have addressed the Terms of Reference of the SCR. The ANRs were informed by agency records, procedures and as required interviews with key professionals. All reports were helpful in drawing clear analysis of agency involvement and any lessons to be learnt. In Serious Case Review: Baby W Overview Report  18   addition, the Primary Healthcare ANR and Health Overview report made reference to a range of research to inform the recommendation and shape their learning. The key point to highlight is that Sarah did not receive health services outside the remit of universal health services.   3.1.2 PRIMARY HEALTHCARE: GP SURGERY:  As outlined within the ANR, Sarah was registered with a GP surgery covering two GP surgeries with 23,000 registered patients. During her visit to the GP surgery, Sarah saw two GPs, one of which she saw on one occasion and the other on six separate occasions. Therefore, the continuation of service Sarah received by the GP was consistent. Also, Sarah was seen by the GP with and without her mother, who was described as being a supportive presence who promoted the voice of her daughter.   During her visit to the GP surgery on the 22nd October 2012 (should be noted that this was approx. two months before Baby W’s conception), despite raising gynecological concerns, she was not advised regarding contraception, despite previous history noting that she was sexually active at this time. In addition, there is no record of a discussion around Sarah’s sexual history, including contraception or partner(s). There is also no record of whether or not Sarah was asked if she was pregnant or encouraged to attend any of the sexual health services available at the Practice. Sexual history should have been documented and each GP should be aware of the range of sexual health services available locally. An opportunity was missed to provide basic health advice around sexual health and contraception, and by doing so, the opportunity to possibly affect her future sexual behaviour was not taken. The GP Sarah saw on this occasion, was a GP registrar and therefore a qualified doctor, but this GP had not been trained to the required safeguarding level in line with the GMC 0 – 18 years guidance for all doctors (2012) and as a result did not have the skills or knowledge to identify young people’s potential vulnerability when sexually active.  She did not demonstrate the professional curiosity that a more experienced and knowledgeable GP would exercise in order to elicit more information.  The ‘reactive’ service was driven, in part, by the supervising GP’s knowledge of the family history, rather than adopting a questioning approach to Sarah’s presenting needs. However, it is questionable whether this would have impacted on Sarah’s behaviour or future decisions.   Serious Case Review: Baby W Overview Report  19   During the course of her pregnancy, Sarah saw her regular GP six times, with her mother present on all but one of these consultations. Sarah visited her GP due to her presenting low mood primarily linked to the breakdown of her relationship with her father. The first occasion was when Sarah visited her GP on the 21st May 2013 (when she was approx. 5.5 months pregnant) to discuss family relationships; she was advised to self-refer to the IAPT service. A decision was undertaken not to directly refer her to the mental health service as it was thought that Sarah’s presenting needs would not meet the Child and Adolescent Mental Health  Service (CAMHS) referral criteria at the time, however, with her presenting needs she would have been eligible to receive tier 2 CAMHS. The GP was unaware that a telephone triage assessment system could fully assess a young person’s mental health needs. During her GP visit on the 22nd June 2013 (when she was approx. 6.5 months pregnant), Sarah presented with depression and anxiety, as she refused counselling and did not present as a suicide risk, she was prescribed fluoxetine. NICE guidance should have alerted the GP to the potential seriousness of prescribing anti-depressants to a young person with moderate depression.  Advice concerning the risks involved could have been obtained from an adolescent health expert, which may have informed the judgement regarding Sarah’s clinical treatment.  The GP’s reasoning for prescribing medication was due to the concern about her presenting mental health needs and her refusal to engage with counselling. A possible option here would have been to adopt a more proactive approach to accessing therapeutic support for Sarah, but the GP’s rationale was that Sarah was competent and could elect to make her own choices. Sarah was reviewed by the GP on a regular and consistent basis, firstly, on the 4th July 2013 (when she was approx. 7 months pregnant), on the 22nd July 2013 (when she was approx. 7.5 months pregnant), on the 6th August 2013 (when she was approx. 8 months pregnant) and on the 22nd August 2013 (when she was approx. 8.5 pregnant). As Sarah’s mental health improved, the delay in self-referring to IAPT was not considered an issue. When prescribing anti-depressant medication the GP did not ask Sarah whether there was a possibility that she could be pregnant.   On the 6th August, prior to Sarah’s mental health review appointment with the GP, her mother asked the GP in a ‘light hearted manner’ to discuss with Sarah the possibility that she may be pregnant. When her mother’s concerns were voiced to Sarah by the GP, she responded in a ‘jokey’ but empathic manner that she could not possibly be pregnant. Her physical appearance appeared ‘normal’ as she did not present with any of the usual Serious Case Review: Baby W Overview Report  20   pregnancy ‘cues’ and therefore the matter was not pursued further by the GP. This illustrates the complexity of these cases as the very nature of concealed/denied pregnancies limits the scope of professional help or support without a degree of ‘further action’ or enforcement. Within this case, on the basis of the presenting signs and symptoms, further concerns were reasonably not triggered by the family or professionals. Whilst it was reasonable for the GP not to pursue the matter further by physically examining Sarah, a discussion around sexual health, activity and contraception would have been timely and responded, in part to the parental concerns raised. Sarah’s mother and half-brother had also asked Sarah if she was pregnant, she continued to deny her pregnancy.   In summary, the GP advice and treatment may appear as reactive rather than proactive on occasion, but it must be noted that this GP knew Sarah since birth.  However, Sarah continued to clearly state that she could not possibly be pregnant, even when directly asked by her GP. Also, Sarah is described as not presenting any physical signs of pregnancy, with her weight and appearance described as ‘normal’. During the visit on the 6th August, the GP was invited by MG to ask whether Sarah was pregnant, no pre-natal examination or pregnancy test was offered, a reasonable response to this situation. The risk of sexual activity at a young age should have been fully explored and assessed with Sarah to consider the appropriateness of a formal referral for specialist sexual health and contraception advice.   3.1.3 IMPROVED ACCESS TO PSYCHOLOIGICAL THERAPIES SERVICES (IAPT) Lincolnshire Partnership NHS Foundation Trust (LPFT) is an NHS provider of mental health and social care and treatment for a population of some 719,000 people in Lincolnshire, as well as mental health services for people who live in other areas of the East Midlands.  LPFT provide a wide range of integrated mental health services to children and adults across Lincolnshire. The Trust also provides specialist drug and alcohol services, services to people with a learning disability and other specialist services for social care and physical healthcare. As a statutory NHS provider, LPFT have a legal duty to safeguard children and adults at risk from harm. All LPFT staff are trained to recognise signs of abuse and know how to report any concerns.  Serious Case Review: Baby W Overview Report  21   LPFT advise those not already using services to contact their GP for help or referral. However, people can also refer themselves via the Single Point of Access (SPA) for psychological therapy services and DART. Designed for both routine or urgent referrals and enquiries, the SPA contact centre is staffed by qualified and skilled professionals 24 hours a day, seven days a week, 365 days a year. The team provides advice and guidance through a triage process, where the urgency of care required is assessed.    IAPT is a service offered to individuals prior to a formal mental health diagnosis. On the 8th July 2013, LPFT received a self-referral from Sarah to LPFT’s Improved Access to Psychological Therapies (IAPT) service. The main reason for this referral was Sarah’s own acknowledgment or her need for support with her anger as a result of depression. During July 2013 several attempts were made to contact Sarah. Sarah self-referred to this service; however her referral form contained limited information, primarily due to the limited questions asked on the form. It should be noted that the service has revised their referral form to inform a more comprehensive approach to gathering the initial referrer information.   On the 26th July 2013, Sarah undertook a telephone assessment by a Cognitive Behaviour Therapy (CBT) practitioner. As part of the assessment process, Sarah was questioned regarding having children, which were all answered negatively, however, no questions were directly asked about the possibility of pregnancy. The referral form for this service has now been amended to include such questions. It is questionable in light of the continued concealment and denial of the pregnancy whether such questioning would have elicited a positive response to this question. On the 2nd September 2013, Sarah was sent a letter offering the 5 session day class as mutually agreed at assessment, due to commence on the 11th September 2013, but obviously she did not attend these sessions due to the events of the 5th September.     3.1.4 HEALTH OVERVIEW REPORT: This Report focused on the review of all local health service providers who had direct involvement with Sarah and her family.  The key matters arising have been outlined in the previous two sections above.   3.1.5 THE POLICE: Lincolnshire Police is an organisation employing approximately 2000 staff, around 1100 of which are Police Officers. Within Lincolnshire Police, the Serious Case Review: Baby W Overview Report  22   Public Protection Unit (PPU) has responsibility for a number of aspects of policing, not least of which is Child Abuse Investigation, but in this regard it is limited to intra familial abuse and offences committed by persons in positions of trust. Other sexual offending against children is investigated by mainstream Criminal Investigation Department (CID) Detectives, supported where appropriate by PPU staff.   The PPU is a specialist unit of highly trained staff and is responsible for the management and investigation of crimes involving:   Safeguarding Adults;  Safeguarding Children;  Sex and Dangerous Offender.  The Public Protection Unit can also advise on investigations of Domestic Abuse, Honour Based Violence and Forced Marriage.  Lincolnshire Police were informed by Cambridgeshire police of the death of Baby W on the 5th September. Other than the incident relating to the death of Baby W, no other police incident relating to Sarah are noted within the relevant time frame for this SCR.   3.1.6 THE SCHOOL: From September 2008 until the completion of her studies on the 28th June 2013, Sarah attended a local 11-18 mixed comprehensive school with approximately 1500 students on roll including approximately 250 in the Sixth Form. Sarah is described as well behaved, pleasant, well presented and popular with her peers. Throughout her schooling she remained within the same tutor group with established peers. Her parents were regarded as supportive with good attendance at parent evening events. Sarah is described as wearing the same uniform as the other female pupils and is described as thin in appearance. As part of her timetabled lessons, Sarah should have been participating in her usual PE lessons.  However, due to absences in the January and February, complaints of lower back pain in the March and her choice not to participate from May onwards, Sarah’s involvement in PE sessions was limited. Overall, Sarah was a popular and well liked student and a relatively high achiever. It is also noted that outside of the school environment Sarah socialised with an older group of friends.   Serious Case Review: Baby W Overview Report  23   Sarah had a history of absences due to headaches, flu and other daily ailments, which followed a yearly pattern of absences during winter months and patterns following general bouts of sickness across the school. It is noted that her absences tended to occur when there were significant absences within the school with similar illnesses. Sarah had only 5 sessions of unauthorised absences during her entire time at the school, although in each school year she had a number of absences due to illness, all of which were authorised and explained by her parents. During January and February 2013, Sarah’s tutor, of five years, was absent from school. This meant that Sarah did not have access to the person who had been the first port of call for her entire school career. However, Tutor time was covered by other staff members known to Sarah, with evidence of communication and diligence in following up absences (15 ½ days). Sarah’s attendance, in the second week after the Christmas break in 2013, dropped below the figure at which the school would normally involve the Education Welfare Officer (EWO). On this occasion the EWO was not informed, but this was the exception rather than the norm as attendance monitoring procedures were followed diligently to address all other absences. Also, it was reasonable that the school did not contact the EWO as the school had a good relationship with the parents, there was ongoing communication, there had been previous health history to explain absences, Sarah was a high academic achiever and the absence explanations given were considered to be genuine. In response, the school have implemented a collective staff attendance monitoring system to ensure that several staff members discuss the decision regarding the trigger and the requirement to refer to the EWO, with the absence trigger also lowered to 85% due to the amendments of national guidelines. As a result, all students are now referred regardless of circumstance to the EWO, who together with each of the three College teams decide on the best course of action. Attendance of students whose attendance dips below 90% is monitored, discussed with the EWO and internal interventions implemented as appropriate.  The school nurse sessions are advertised and pupils can go and see this professional to receive confidential advice and support during lunch time on a weekly basis. In addition, as part of Personal, Social, Health & Economic Education (PSHEE) the school has an extensive programme of timetabled lessons from years 7 to 10. This comprehensive programme focuses on a range of topics ranging from personal identity and social relationships to STIs, conception, pregnancy and abortion. This programme has clear objectives and uses a range of teaching resources. On the 18th March 2011, as part of the Serious Case Review: Baby W Overview Report  24   school pregnancy/safe sex/healthy decision making unit of study in PSHEE, Sarah took home a virtual baby for the weekend, an exercise encouraged for all year 10 female pupils.   The school clearly report that no member of staff had knowledge of Sarah’s pregnancy, either directly from Sarah or from another pupil. This obviously means that the school could not have offered or implemented a support plant for Sarah during her pregnancy, however there is evidence that the school offer a comprehensive support package for a pregnant student (please see: good practice section). The documents reviewed and the ANR present a picture of a school with an open and caring culture. The school are to be commended for their proactive approach to developing their learning and practice. For example, the changes implemented to their safeguarding training which now explicitly refers to pregnancy scenarios. In addition, the school have introduced an out-of-hours phone line for staff to contact the Lead Child Protection, Vulnerable and Looked After Children Officer if and when required.    3.2 Missed opportunity and key practice episodes  This SCR identified one missed opportunity and three key practice episodes for agencies to potentially respond differently to presented events. The aim is to look in more detail at these areas, look at what happened, or should have happened, and explore why. However, it is the view of the Independent Overview author that alternative professional advice or action would not have altered the sad and tragic outcome for Baby W.   3.2.1 Missed opportunity:  Prior to Baby W’s conception, Sarah visited the GP on the 22nd October 2012, as part of this consultation an opportunity was missed to have a discussion around sexual activity, sexual health matters, contraception and healthy intimate relationships.  Author’s comment  This was a missed opportunity to discuss and offer basic advice around sexual health matters.  Advising Sarah around contraception and the availability of support services should have been a routine part of service provision and may have provided alternative options for Sarah to prevent any unwanted pregnancy. Despite this missed opportunity, it should be clearly noted that there is no guarantee that the provision of sexual health Serious Case Review: Baby W Overview Report  25   advice would have changed the outcome in this case as this was prior to the conception of Baby W.  3.2.2 The first key practice episode  During the GP consultation on the 22nd June 2013, Sarah was prescribed Fluoxetine to address her low mood and anxiety.   Author’s comments  When prescribing anti-depressant medication to a young person the GP should have considered the suitability of discussing the matter with a specialist young person mental health practitioner. Also, the advice outlined in the NICE guidelines (2005) on treating depression in children and young people should have been considered. However, the GP did closely monitor and review Sarah’s progress in a timely and consistent manner. But despite this, the GP did not make any enquiries with Sarah whether there was any possibility that she may be pregnant prior to prescribing this anti-depressant medication. This was a possible opportunity to explore issues further with Sarah.   3.2.3 The second key practice episode:  The GP advised Sarah to self-refer to receive support from IAPT rather than directly referring Sarah to this service or consulting beforehand with the Child and Adolescent Mental Health Services (CAMHS).   Author’s comments Directly exploring potential interventions and support from either IAPT or CAMHS would have been a more proactive solution for a young woman.  However, the GP did consider Sarah’s wishes and feelings when discussing treatment options. But, the crucial point here is that a direct GP referral for support regarding Sarah’s mental health needs may have assisted in provided the opportunity for receipt of services and a fuller assessment of her needs, sooner rather than later.   3.2.4 The third key practice episode: During the second week after Christmas in 2013, Sarah’s attendance dropped below the figure at which the school would normally involve the Education Welfare Officer (EWO). A decision was undertaken not to refer to the EWO.   Serious Case Review: Baby W Overview Report  26   Author’s comments  On this occasion the EWO was not informed, but this was the exception rather than the norm as attendance monitoring procedures were followed diligently to address all other absences. It was reasonable that the school did not contact the EWO on this occasion as the school had a good relationship with the parents, there was ongoing communication, there had been previous health history leading to absences, Sarah was a high academic achiever and the explanations given for the absences considered to be genuine.   3.3 Analysis by Theme The SCR Terms of Reference identified several themes to be examined:-   The basis of service delivery;   Timely and appropriate service delivery;   Hearing the voice of Sarah and age appropriate communication;   The requirement to commission alternative service;  The impact of agency resources.   These will be explored in detail for each agency in section 3.4   A key theme across the limited agency intervention was Sarah’s presentation as a typical young woman, with no particular unique needs requiring support beyond universal service provision. Throughout Sarah’s contact with services, there was only one occasion where any joint agency working was possible, which was described above. In fact, the only key theme exemplified is the fact that Sarah’s behaviour adheres to some of the key messages extracted from the literature/research reviewed, in particular, the notion of the challenge for agencies in predicting and identifying concealed/denied pregnancies.   3.4 Summary: Overall response to the SCR Terms of Reference:- 1. Was the service delivery and help provided based on Baby W's mother's presenting circumstances, or was it based on the analysis of all the information and observations available? a) Primary Healthcare: GP Surgery: The service delivery provided by the GP was mostly reactive rather than proactive, with a greater degree of professional curiosity required to get a sense of Sarah’s lifestyle and sexual history. However, the explanations provided by Sarah, the support Serious Case Review: Baby W Overview Report  27   provided by her mother and her presenting symptoms all reasonably indicated an alternative diagnosis to that of pregnancy. In addition, when directly asked about the possibility of pregnancy, Sarah clearly responded that this was not a possibility. It appears that the service provided by the GP was consistent and timely, with evidence that the GP did listen to Sarah’s presenting needs and wanted to offer her choice regarding her treatment. Also, Sarah’s last consultation with the GP prior to the birth of Baby W was positive and illustrated a picture of a young woman’s difficulties essentially under control. b) IAPT: Sarah self-referred to the IAPT service and when asked “Are there any special needs we need to know about (e.g. a disability, physical health problem etc)” responded “No” as she did when questioned as part of the assessment completed by the CBT therapist.  The format that Sarah used to report her needs were via a standardised IAPT self-referral form, the form has since been updated and includes requests for greater detail in line with IAPT assessments and national NHS minimum data sets.   c) Health Overview Report: The services delivered to Sarah by the GP were predominantly based upon her presenting concerns. This is not uncommon within General Practice, allocated appointment times are usually short and as such the focus is upon the presenting issues that an individual identifies.  When discussing her presenting low mood, Sarah was seen by a GP with ongoing knowledge of her family for several years, which did not indicate any safeguarding concerns.  The services offered through the IAPT, prior to the events of 5th September 2013, were based upon the information that Sarah herself provided, either through the self-referral form or during the initial telephone assessment. The IAPT service offer was applied in accordance with the local service level agreement at that time. The mental health trust have identified that a specific question be added to the assessment criteria regarding whether or not an individual is /or could be pregnant, however, it is unlikely that such as question would have elicited a positive response from Sarah. Advice to contact your own GP for help or referral was advertised on the service providers’ website for those individuals who were not currently accessing services from the specialist mental health provider; this is indeed the case Serious Case Review: Baby W Overview Report  28   for Sarah, who sought support from her registered GP. During the timeframe for this review it was accepted that a direct referral could be made by an individual aged over 16 years old, therefore the self-referral by Sarah was not deemed out of the ordinary, and did not contravene any local standards or expectations. However, it would have been a more proactive approach to assist Sarah with her referral or refer on her behalf.  d) Education: The school’s general monitoring of Sarah’s attendance was proactive and thorough. However, there was one occasion when Sarah’s attendance was below the threshold at which the school should have referred her to the EWO. Despite the school’s omission to implement this action, on the analysis of the information presented, there were explanations for Sarah’s absences, her parents communicated well with the school, her behaviour was positive and her attainment was good, it does not appear imperative to Sarah’s educational care that this referral was not completed. Also, it is extremely doubtful whether this referral at this stage of her education would have had any particular impact on the outcome in this case.   2. Was all appropriate available information gathered and shared in a timely and appropriate manner to facilitate the right services being provided to Baby W's mother on the part of both professionals and the family?  a) Primary Healthcare, GP surgery: Generally, all information was gathered in a timely manner and shared in an appropriate manner. The exception here is regarding Sarah’s consultation with the GP on the 22nd October 2012 when a more in-depth assessment of sexual health needs should have been conducted. However, a reasonable diagnosis of her presenting mental health was gathered in light of Sarah’s presenting needs, but a more proactive approach may have been useful. Also, the GP advised Sarah to self-refer to IAPT, rather than adopting a more proactive approach. Though it should be noted that the GP did not contravene local standards by advising her to self-refer.   Serious Case Review: Baby W Overview Report  29   Further on in the consultation process when Sarah was asked whether she was pregnant, the GP’s decision not to physically examine Sarah was completely reasonable in light of Sarah’s presenting needs and her right to refuse, in particular as there were no other presenting concerns or reason to share this information with other agencies.  b) IAPT: With regards to the IAPT service, a self-referral from Sarah was received by and responded to in an appropriate and timely manner. When no response was achieved via telephone contact, Sarah was contacted in writing. Sarah was assessed via a telephone appointment at a mutually agreed date and time. In terms of appropriateness, IAPT was the correct service for an adolescent who was no longer in education and experiencing feelings of low mood in relation to her father leaving. A referral directly from the GP would have provided more appropriate information regarding Sarah’s psychological and social history and the relevance of prescription of anti-depressant medication.  c) Health Overview Report: It appears as though reliance upon the self-reporting of Sarah’s needs and her ‘emphatic’ denial of pregnancy may have dissuaded the GP from undertaking a more rigorous assessment around her mother’s stated concern regarding the possibility of pregnancy. This was also supported by the GPs declared perception that the mother seemed ‘fairly light-hearted’ about the possibility of Sarah’s pregnancy. Further appropriate questioning may have been undertaken as an integral aspect of assessing and understanding the presenting concerns and behaviours. However, Sarah is an articulate and informed young woman able to voice and demonstrate her position; equally there were no presenting safeguarding concerns.  d) Education: All appropriate support systems and services are openly and readily available within the school. Without the requisite information or disclosure of Sarah’s pregnancy the school would not have been in a position to provide supportive interventions.   Family: Sarah’s mother raised her concerns in a timely and appropriate manner. She also took her daughter to the GP to address her presenting needs as she saw them. Sarah consciously or unconsciously did not Serious Case Review: Baby W Overview Report  30   disclose her pregnancy and clearly states she would not have done so in any circumstance.   3. Was the communication with baby W's mother age appropriate and effective, and was her voice heard?  Yes, on both counts. Evidence from agency records and the ANRs paint a picture of age appropriate service delivery throughout, with a particular focus on Sarah’s choice and views. For example, several systems are in place in the school to ensure that the voice, choices and views of young people and their parents are considered and valued. However, from a health perspective, as previously outlined as a ‘missed opportunity’, an opportunity was missed to provide Sarah with age appropriate contraceptive advice prior to her pregnancy with Baby W. Also, it would have been age appropriate to refer Sarah directly to the IAPT service rather than expect her to self-refer. Also, the IAPT screening tool needs to be focused and amended to consider the needs of young people at the transitional period of their life.  Evidence suggest that service delivery was age appropriate and considered her level of sufficient understanding and maturity, in particular when considering that Sarah is an intelligent and articulate young woman. The crux of the matter here is that agencies could not have possibly known the full extent of Sarah’s ‘reality’ or the potential consequences of her future actions. Essentially Sarah had denied her own reality.   4. Were presenting issues, concerns and risks appropriately considered and analysed and acted upon in an appropriate way?  Yes, on the whole presenting issues were dealt with appropriately and in a timely manner.   a) Primary Healthcare, GP Surgery: An opportunity was missed to address Sarah’s sexual activity by advising her on sexual health matters. Her presenting mental health issues were appropriately managed via regular mental health reviews.  However, further consideration of the NICE Serious Case Review: Baby W Overview Report  31   guidelines prior to prescribing medication to address Sarah’s presenting mental health needs may have beneficial, not only in alerting the potential seriousness of prescribing medication at this stage, but also in asking if she was pregnant. As previously highlighted, different professional responses here would not have reasonably changed the course of events.  b) IAPT: Yes, all potential concerns and risk were potentially considered. The service has also amended their referral form to include a direct question on the likelihood of pregnancy.  c) Health Overview Report: The lack of advice provided by the GP Registrar around Sarah’s acknowledgment of her sexual activity resulted in a ‘missed opportunity’ to gather a wider analysis of the facts and potentially make a more formal referral to sexual health services. d) Education: As previously mentioned, there was one occasion when her school attendance fell below the required threshold at which a EWO referral should have been triggered. Despite this omission, the school appear to have considered and analysed the information and behaviours presented in a reasonable manner.   5. Was service delivery timely, effective and in line with the agency's practice, safeguarding best practice and LSCB policy and guidance?  a). Primary Healthcare, GP Surgery: GPs are not employed by the Clinical Commissioning Groups; they are independent contractors who deliver services against a National Contract.  The National Contract for General Medical Services (GMS) has little room for contract variation and is performance managed through NHS England.  Therein clinical governance and holding GPs to account is managed through robust practice performance across all fields of medicine including safeguarding and allegations.  Breach of the contract can and often does lead to notification to the General Medical Council whereby as a professional body, can ultimately remove practitioners from the register and correspondingly remove their authority to practice medicine  The National GMS contract does not stipulate the level of safeguarding that GPs need to be trained to in safeguarding children or adults.  In the recent Serious Case Review: Baby W Overview Report  32   reconfiguration of the NHS and NHS contracts GPs were all required to demonstrate competence and skill to be revalidated as contractors to deliver primary care services.  Safeguarding training to level 2 was stipulated in April 2014 that GPs required whilst acknowledging continuing development was required.  At the same time the Care Quality Commission (CQC) became the regulatory review body for primary care and accordingly GPs are now subject to statutory review.  Within Lincolnshire, there has been a consistent drive to encourage GPs to undertake safeguarding children to level 3, and since the authorisation of CCGs brought commissioning for quality improvements closer to providers a safeguarding training database for GPs has been developed and has identified that more than 58% of GPs have undertaken training to that level.  CCGs, whilst not holding the GPs to account against the national contract, do commission local services over and above the contract to address local health needs and ensure that the contractual route includes safeguarding to the requisite level along with compliance against CA 2004 S11 and LSCB multi-agency policy and procedure. b). IAPT: From the date of receipt of the self-referral form through to clinical assessment, a total of 19 days passed. Within this time, several attempts to contact Sarah were made and an appointment was secured following contact in response to written communication within 3 days. All communication was recorded and both written and verbal communication was noted and analysed in line with policies and guidelines during the scope of the review and no risk or safeguarding issues were created c). Health Overview Report: The services delivered by the GP practice were timely in the sense that at each point she attended she was seen, the fact that all attendances for her reported mental health issues were managed by a single GP allowed for a continuation of assessment and provided a good level of service.   Serious Case Review: Baby W Overview Report  33   Adherence to safeguarding policy, in terms of service delivery is not assessable, as no safeguarding concerns were identified, and therefore the application of safeguarding procedures did not apply.  e). Education: As previously mentioned, there was one occasion when her school attendance fell below the required threshold at which a EWO referral should have been triggered. Despite this omission, the school appear to have considered and analysed the information and behaviours presented in a reasonable manner.   6. Did the service offered to Baby W's mother meet her needs? Yes, on the whole the service delivery offered to Sarah met her presenting needs. Sarah made either a conscious or unconscious decision to conceal crucial information regarding her pregnancy from professional services. On inspection of the available information, it would have been unreasonable to expect services to be aware of Sarah’s pregnancy. a) Primary Healthcare, GP Surgery: The services offered met Sarah’s presenting needs. However, a more proactive approach may have elicited further information regarding her needs. Again, it must be noted that Sarah made either consciously or unconsciously did not share the full extent of her needs with the GP, which ultimately shaped the decisions made around service delivery.  b) IAPT: Yes, based on the information self-reported by Sarah.  c) Health Overview Report: The responses from the GPs to Sarah’s stated needs were in the most part met.  It can be debated as to whether or not further questioning may have elicited responses that could have then directed access to additional services, such as contraceptive advice. Additionally there is some evidence to suggest that the prescribing of medications for the level of anxiety/ depression was not the most appropriate treatment for her mental health needs. There is a level of analysis evident in the GPs actions, given that it is indicated that he made a clinical judgement based upon her failure to follow the self-referral advice - however a less intrusive action could have been for the GP to initiate a direct referral either to the single point of access or to a CAMHS specialist.  Serious Case Review: Baby W Overview Report  34   d) Education: Yes, as illustrated in the good practice section, the school offered a wide range of accessible support.   7. Are there alternative services that could have been commissioned that could have better meet Baby W's mother's needs? No, all relevant services are commissioned within the County, but were not accessed by Sarah.   8. Did individual agency resources have any implications for service delivery? No.  3.5 In conclusion, based on the evidence presented for this SCR, it is the Independent Author’s view that the death of Baby W could not have been predicted or prevented. This is also a view voiced by Sarah as she did not feel that there was anything that could have been done differently by services.  3.6 Sarah presented with no physical signs or symptoms of pregnancy with alternative plausible explanations offered for her low mood and attendance at the GP surgery. The services and support offered by each agency was proportionate and reasonable in light of Sarah’s presenting needs.  3.7 It is the view of the Independent Author that the missed opportunity identified would not have reasonably led to a different outcome for Baby W. The presenting information and the challenges of identifying concealed/denied pregnancies made the task of preventing this tragedy an impossible one for all agencies involved.  4. LEARNING  4.1 Good Practice example: The School  The school demonstrated evidence of a proven track record of exemplary pastoral care support for all their students. As previously stated, the school are also to be commended for their willingness to learn and reflexively develop their practise.   4.2 Lessons to be learnt 4.2.1 Concealed/denied pregnancies are very rare and pose a significant challenge for agencies as there is not a prescribed typology of women prone/most at risk of concealing/denying their pregnancy. Also, it appears that in some cases there is no Serious Case Review: Baby W Overview Report  35   rationale for this action and the limited normative signs and symptoms of pregnancy makes this a very challenging and risky task for agencies. However, building awareness and formulating procedures and guidance will only help to assist services in this task.   4.2.2 NICE provides guidance on the prescribing of anti-depressants to young people.  Following the guidance alerts GPs and health professionals to the risks involved and the various options available for safely treating young people with depression.  4.2.3 Best practice would be that GP Registrars are trained in safeguarding before they see children and young people without supervision.  The discussion of cases involving young people with their Practice supervisor should be more rigorously conducted with a focus on promoting sexual health amongst this age group. Case discussions involving young people should focus on the GMC’s 0 – 18: guidance for all doctors, which emphasises the need for a confidential sexual health service to be available to young people.  Elements of the General Medical Council in its Safeguarding Children & Young People Toolkit, 2011 should be incorporated in these case discussions.  4.2.4 It is important that all young people receive sexual health advice and contraceptive advice and that GPs ensure that patients who are young people receive this advice either via their Practice’s sexual health services or through alternative services e.g., the school health service.   4.2.5 Knowledge of the confidential and supportive help that school nursing services and school services can provide to young people is essential if all options available to young people are to be considered by GPs.  4.2.6 Continued assurance is required that all clinicians working in services designed for adults will be aware of and act accordingly regarding referrals received for 16 & 17 year olds.   5.  IMPLEMENTATION OF LEARNING Recommendations from the ANRs  Serious Case Review: Baby W Overview Report  36   The ANRs have provided evidence of actions already undertaken in response to individual agency recommendation. These recommendations have been identified by each ANR author in their own reports and have been signed off at a senior level within the respective agency. The Board accepts responsibility for overseeing and ensuring their implementation. 5.1 AGENCY NARRATIVE – GP PRIMARY HEALTH CARE SERVICES   5.1.1 The Lincolnshire LSCB should consider developing a multi-agency guidance on concealed pregnancy and birth. 5.1.2 NHS England together with the Lincolnshire CCGs liaise with GP Practices and Training Practices to encourage access for all GPs and GP trainees to the GMC’s 0 – 18: guidance for all doctors, which emphasises the need for a confidential sexual health service to be available to young people alongside the General Medical Council Safeguarding Children & Young People Toolkit, 2011. And within case discussions / supervision that practice is benchmarked against both documents. 5.1.3 NHS England and the Lincolnshire Clinical Commissioning Groups liaise with Community Health Services and GPs to promote the contemporary school nursing service available to young people.    5.2  IMPROVED ACCESS TO PSYCHOLOGICAL THERAPIES (IAPT)  5.2.1 LPFT includes a standard question about pregnancy on all referral forms in order to improve opportunities for effective assessment of the needs and associated risk management of unborn children and their families.  5.2.2 LPFT will develop Safeguarding Screening Tools (16 & 17 year olds) designed specifically for clinicians working with Young People who access services commissioned mainly for adults.  5.2.3 The Safeguarding Screening Tools (16 & 17 year olds) will also identify risks and recommended actions associated with drug and alcohol use by children/young people.  5.2.4 LPFT will ensure that all referrals for 16 & 17 year olds accessing services designed for Adults are identified via alerts on the clinical systems and paperwork at point of referral. 5.2.5 LPFT will add a prompt regarding effective liaison with GP in all cases relating to 16 & 17 year olds accessing Adult services in the Safeguarding Screening Tool. Serious Case Review: Baby W Overview Report  37     5.3 HEALTH OVERVIEW REPORT  5.3.1 The GP and GP Registrar should ensure that this case is used for reflection within their appraisal and revalidation systems. 5.3.2 The GP and GP Registrar should ensure that they complete level 3 safeguarding training within the next three months. 5.3.3 The GP practice should reconsider this case within their Significant Event Meetings - with a particular focus upon the available guidance around concealed pregnancy. 5.3.4 The hosted safeguarding team should ensure that the learning from this review is shared across all GP practices- with particular focus upon:  the revised requirements for GPs (including Registrars) to be trained to Level 3, and identification of appropriate learning opportunities that will support them to achieve this;  Appropriate supervision provision for GP registrars.  The NICE Guidance for treatment of children and adolescents with mental health issues.  The availability of additional support services that young people can access - e.g. school nursing service.  The requirement to consider additional assessment for young people who report sexual activity at an early age. 5.4 POLICE No agency recommendations.  5.5. THE SCHOOL:  5.5.1 All students with attendance below the required threshold to be referred to the Educational Welfare Officer (EWO). Serious Case Review: Baby W Overview Report  38   5.5.2 Safeguarding training to explicitly refer to pregnancy scenarios.  5.5.3 The introduction of an out of hours phone line for staff to contact the school child protection, vulnerable and looked after children officer.  5.6 Recommendations by the Independent Overview Report Author  5.6.1 Due to the lack of global and national research on concealed and denied pregnancies, the LSCB to write to the DOH to invite the Department of Health to establish a repository of cases of all incidents of concealed and denied pregnancy. The aim is to contribute to informing a larger database to assist in implementing appropriate care for this group of women and inform future practice guidance. This can also inform any future need for specific research in this area.   5.6.2 The LSCB should develop multi-agency good practice guidance, procedure, assessment framework and risk assessment matrix on concealed/denied pregnancy.   5.7 Progressing Recommendations and dissemination of learning  5.7.1 As the commissioner of this SCR, the LSCB will monitor the progress of the resulting recommendations and action plan.   5.7.2 Any future related inter-agency training and learning events will incorporate the key learning and good practice examples from this SCR.   5.7.3 The key messages will be presented and shared with statutory partner during a LSCB meeting.   5.7.4 Each agency safeguarding lead will disseminate key lessons to be learnt within their own agencies.   5.7.5 Key messages will also be disseminated at the LSCB sub-group meetings.   5.8 The Integrated Action Plan   Serious Case Review: Baby W Overview Report  39   5.8.1 The integrated action plan has been agreed by the agencies involved in the SCR, agreeing to adhere to the procedure of monitoring progress.   5.8.2 Agency leads are expected to report and evidence the progress of each action.   Ceryl Teleri Davies  Independent Overview Author  April 2015   6 REFERENCES   Ali. E.A. & Paddick. S.M. (2009). An exploration of the undetected or concealed pregnancy. British Journal of Midwifery, 17 (10), pp.647-651.  Del Giudice. (2007). The evolutionary biology of cryptic pregnancy: A re-appraisal of the ‘‘denied pregnancy’’ phenomenon. Medical Hypotheses. 68, pp. 250–258  Earl, G. (2000). Report for the Area Child Protection Committee. (LSCB internal document).  Earl, G. Baldwin, C., & Pack, A., (2000). The behaviour of women who conceal pregnancy may harm their children. Childright 171, pp. 19-20.  Friedman, S. (2007). Characteristics of Women Who Deny or Conceal Pregnancy. Psychosomatics, 117-122. Friedman, S. (2005). Child murder by mothers: A critical analysis of the current state of knowledge and a research agenda. The American Journal of Psychiatry, 1578-1587 Jackson, M. (2000). Infanticide: historical perspectives on child murder and concealment, 1550–2000. Aldeshot: Ashgate Jenkins, A., Millar, S., & Robins, J.  (2011). Denial of pregnancy – a literature review and discussion of ethical and legal issues. Journal of the Royal Society of Medicine. 104 (7), pp.286–291.  NICE, 2005.  Depression in children and young people: Identification and management in primary, community and secondary care. [Online] Available from: http://www.nice.org.uk/guidance/CG28 (accessed on the 7th February 2015).  Nirmal, D.T, I. Bethel, J. Bhal, P. (2006) The incidence and outcome of concealed pregnancies among hospital deliveries: an 11 year population-based study in South Glamorgan. Journal of Obstetrics and Gynaecology. 26 (2) pp. 118-121.  Thynne, C., Gaffney, G. Neill, M, Tonge, M & Sherlock, C. (2012). Concealed Pregnancy: Prevalence, Perinatal Measures and Socio-Demographics.  Irish Medical Journal.  105 (8), pp.263-265.  Serious Case Review: Baby W Overview Report  40    Vallone, D. H. (2003). Preventing the Tragedy of Neonaticide. Holistic Nursing Practice, 223-228. Wessel, J. B. & Buscher, U. (2002). Denial of Pregnancy: Population based study. British Medical Journal (International Edition), 324 (7335) pp.458.     