Death of a 2-year-1-month-old girl in 2016 in hospital as the result of multiple injuries. Child died from a serious brain injury sustained whilst in the sole care of mother's new partner. The partner was charged with murder and was sentenced to nine years' imprisonment. The mother was placed on police bail. Family were known to universal services only. Child had a bruise to the face the week before the incident which was recorded by the nursery. Issues identified include: the significant impact of the change in the mother's relationship on her children's safety, a lack of robust recording by the nursery following an injury to Child BS and a lack of robust evidence behind Ofsted's positive rating of the nursery's safeguarding provision leading to a misplaced confidence in their procedures. Also identifies examples of good practice including: supportive and timely postnatal contacts with child health services and contact from the local Children's Centre to offer a range of community services following the birth of both children. Recommendations include: develop common guidance and supporting documentation for local nursery providers; develop public awareness of domestic abuse and the risks to children at the points of parental separation and newly formed relationships; and get assurance from Ofsted that the lessons of the review have been acted on and disseminated throughout the organisation.
      
    Serious Case Review No:  2016/C6112  Published by the NSPCC On behalf of an unnamed local safeguarding children board      This report was written by an independent author and is owned by the commissioning LSCB.  This report is published by the NSPCC with the agreement of the National Panel of Independent Experts.  Publication of this report by the NSPCC does not constitute endorsement of the contents. Copyright of this report remains with the commissioning LSCB.     1        Serious Case Review   Child BS   This report will be published in line with statutory guidance. In order to preserve the anonymity as far as is possible, the author has:  Used letters to reflect each child and adult  made limited reference to the gender of person, other than where not to do so would compromise the reader’s understanding of the report  avoided the use of exact dates  not used any details about local services which could lead to  recognition of individuals       2 1.    Introduction 1.1 Child BS is the first of two children born to their mother, MS, and father, FS. The children were close in age as S1, the sibling child of Child BS, was born when Child BS was 13 months old. MS and FS married prior to the birth of the children however their relationship deteriorated following the birth of S1 and they were separated by the time that Child BS was 20 months old and S1 was 7 months old.  1.2 Other than for routine health and nursery provision, this family was not known to any additional children’s services prior to the incident which precipitated this Serious Case Review. Both MS and FS had access to parental support themselves with the children’s maternal and paternal grandmothers providing both practical assistance and warm loving relationships to the children.  1.3 As the relationship between MS and FS was coming to an end, MS met a new partner, FP.  MS and FP had been in a relationship for approximately five months when the incident which has given rise to this Serious Case Review occurred.  1.4 Child BS was 2 years and 1 month old when an ambulance was called by FP whilst the child was in his sole care. FP stated that Child BS had fallen in the shower and was unconscious. Upon arrival, the ambulance crew identified inconsistencies in what was reported by FP in that the presenting injuries to Child BS did not appear consistent with FP’s version of events. Child BS was taken to the local hospital where the child was determined to be in a very poorly condition. Child BS was subsequently airlifted to a regional children’s hospital where specialist care could be administered.  1.5 Child BS was found to have extensive bruising to the body, a laceration to the liver and a severe brain injury. Medical reports have concluded that the brain injury was consistent with violent shaking, whilst the internal organ injury was consistent with a blunt impact trauma to the abdominal region which would have required considerable force to inflict. It was concluded that the brain injury would have occurred within 48 hours of Child BS’s collapse.  1.6 Child BS underwent emergency surgery but the injuries were so extensive that the child’s young life could not be saved. The cause of death is recorded as multiple injuries, as although the brain injury was the major cause of collapse and subsequent death, the internal injuries to the body were extremely serious and contributed to the fatal outcome.     3 1.7 MS and FP were both arrested on suspicion of having caused the injuries to Child BS and initially both denied having caused any injury to Child BS. MS was placed on police bail and FP was charged with murder and remanded to custody. On the day of the criminal trial, FP pleaded guilty to manslaughter and was sentenced to nine years’ imprisonment.   2. Multi-Agency Decision Making Processes 2.1 The attending ambulance crew notified the police of the suspicious circumstances. The Police notified Children’s Social Care and both agencies attended at the local hospital. Following an immediate Strategy discussion between Police and Children’s Social Care, it was agreed that the three people who had care of Child BS prior to the incident should be permitted no unsupervised contact with Chid BS or S1. S1 was also admitted to the local hospital to facilitate medical examination and a place of safety whilst further facts were established about the family’s circumstances.   2.2 The day following the incident a Strategy Meeting was held. This meeting was attended by a Team Manager and social worker from Children’s Social Care, two police officers, the Named Nurse for Safeguarding Children and Head of Safeguarding for the local hospital and the proprietor and supervisor from a nursery attended by Child BS.  2.3 The meeting established that no agency had any historical involvement with the family that indicated any cause for concern. It was established that MS and FS had separated, and that Child BS attended two half day sessions a week at nursery generally accompanied by either MS, FS or the maternal grandmother. The nursery reported Child BS to be a generally happy child, cheerful and playful with a sunny personality. The nursery reported that they had no reason to be concerned about the overall welfare of Child BS although the previous week Child BS had a bruise to the face which was noted and recorded by the nursery.  2.4 The minutes of the Strategy Meeting record that the proprietor of the nursery referred to the mark as ‘looking like a black eye’ and that when the maternal grandmother was asked how this happened she was unable to give a response. The minutes also indicate that the maternal grandmother advised on a subsequent visit that after speaking with MS there was still no explanation as to how the mark had occurred.    4 2.5 A second Strategy meeting took place 3 days later after the intervening weekend. This meeting was attended by the same agencies as the first meeting with minor personnel changes. The first Strategy Meeting should have identified the need to inform and invite Ofsted to any subsequent meetings but this did not happen. This meeting shared that in the intervening three days, Child BS had died and that FP had been charged with murder and was remanded to custody. MS had been granted police bail pending receipt of expert medical reports in relation to the extensive bruising to Child BS.  2.6 This meeting considered all known information about the key family members and reached a decision that S1 should be placed in foster care with supervised contact arrangements whilst assessments of the family member’s ability to resume care of S1 were undertaken.  The Strategy Meeting identified the need to share information with adult safeguarding services given that a key family member worked with vulnerable adults, and also to inform Ofsted of the death of a child who attended a regulated nursery provision.  2.7 Two further interagency meetings were held, two days and nine days later. The first was referred to as a follow up strategy meeting and was attended by Children’s Social Care, Health and Police. This meeting focussed on exchanging early emerging information and the operational plans for S1. The second meeting was convened under the LADO (Local Authority Designated Officer) process and was attended by Children’s Social Care, Health, Police and Ofsted. This meeting focussed on the ongoing police investigation and Ofsted review of the nursery.  2.8 During the course of this Review it has emerged that some practitioners recall that on the day of the incident two Strategy Meetings were held, one being a less formal case discussion at the point of initial referral to safeguarding agencies and a more formal meeting later in the day.  A great deal of time was invested in trying to reconcile the conflicting memories of practitioners alongside what is recorded about Strategy Meetings and discussions, and ultimately it has not been possible to reach a version of fact on this issue that all practitioners and agencies can agree to. This has exposed a weakness in how Strategy Meetings are chaired and recorded which, although not detrimental in this case, could be if the same situation were to occur in different circumstances. All agencies agreed that it is imperative that Strategy Meetings result in a common understanding of agreements reached and actions to be taken by multi-  5 agency partners in order to achieve efficient and robust child protection investigations and to ensure that records of meetings are accurate and shared in a timely manner.  2.9 A Local Safeguarding Children Board Case Review Subgroup gave consideration as to whether the criteria were met for a Serious Case Review. This meeting unanimously concluded that the criteria for commissioning a Serious Case Review was met under paragraph 5(2) of the Local Safeguarding Children Board regulations 2006  in that a child had died and that abuse of the child was known or suspected. The decision was then made by the Chair of the Local Safeguarding Children Board that a Serious Case Review would be convened.   3.     Methodology 3.1     In order to oversee the Serious Case Review, a Review Panel was established which included representatives of the key agencies from the Local Safeguarding Children Board and the specific agencies that had contact with Child BS or had oversight of regulated services that were used by Child BS. Specifically therefore this included the following representatives:  Local Constabulary, Public Protection Unit Review Officer  Local hospital, Head of Safeguarding and Designated Doctor for Safeguarding  Day Nursery Proprietor, supported by Local Authority Lead Early Years Consultant  Ofsted HMI (Social Care)  Local Authority  - School Improvement Officer  Children’s Social Care Improvement Manager   The Panel was chaired by the Head of Safeguarding/Designated Nurse (Children, Adults and Children Looked After) for the local Clinical Commissioning Group and an Independent Reviewer not connected to any agencies involved was commissioned to facilitate the review and write an Overview Report.  The Panel and Review process was supported by the Local Safeguarding Children Board Business Development Manager and the Board Administrator.   3.2 The Review was conducted in accordance with the guidance contained in Working Together 2013 and set out to achieve the following:   6  a recognition of the complex circumstances in which professionals work together to safeguard children  to establish where possible precisely who did what and the underlying reasons that led individuals and organisations to act as they did  an openness to understanding practice from the viewpoint of the individuals and organisations involved at the time to avoid the over influence of hindsight bias.  3.3 The Review was conducted alongside two legal processes, criminal proceedings in respect of FP and public law proceedings in respect of S1.  The Review carefully considered the most appropriate approach to gathering information about Child BS and the wider family. Two factors influenced the approach to this Review; firstly that there was little information known to statutory agencies and key professional staff from the nursery were witnesses for the criminal proceedings, and secondly that the involvement of key family members was particularly significant and they too were witnesses in the criminal proceedings.  Consultation with the Senior Investigating Officer from the Police confirmed that holding discussions with witnesses for the criminal proceedings risked the integrity of the criminal process and clearly any such risk needed to be avoided. It was agreed therefore that agencies would be asked to complete a brief report and timeline of key interventions, and that following the criminal trial staff with key contributions to make to the Review would be asked to meet with the Independent Reviewer. In addition, MS, FS, FP and maternal grandmother would be invited to meet with the Reviewer and Chair of the Panel.  3.4 The brief report completed by participating agencies and organisations asked that the following questions were addressed:  How was the Child BS or family member known to your agency   What is your analysis of your agency involvement with the Child BS or family member during the period under Review  Were services delivered according to organisation/statutory guidance  Were there any indicators of concerns for Child BS /other family members and how were these responded to  How satisfied is the agency that judgements in respect of safeguarding children were sound and supported by firm evidence  Was information shared across agencies at appropriate points? If not, what may have preventing this from happening   7  Is there any organisation learning that you can identify for your agency from the information available to you  Is there any exceptionally good practice that the agency would want to     highlight  Agencies were asked to provide information from mid-2011 until the date of death for Child BS.  Ofsted was asked to provide information from January 2013 until six weeks after the death of Child BS. Specifically Ofsted was asked to address the questions by substituting the words Child BS/family with regulated setting attended by Child BS.  3.5 On the first scheduled day of the trial for murder of Child BS, FP pleaded guilty to manslaughter and the sentencing proceeded on this basis. As a consequence of this development, no witness information was called.  3.6 The Reviewer and Improvement Manager from Children’s Social Care subsequently met with three professionals who worked with Child BS in the nursery setting. The Reviewer and Chair of the Panel met with MS, FS and Maternal grandmother. The Independent Reviewer and Business Development Manager met with FP in prison following sentencing.   3.7 In the months following FP’s conviction, evidence was scheduled to be taken within the public law proceedings for S1. The panel made the decision to await the outcome before finalising all enquires for the completion of the Serious Case Review. The Court had the  benefit of hearing witness information from the key family members and FP which did provide a greater insight into the events leading up to the critical incident for Child BS.   4.         What was known about Child BS by Agencies 4.1 Child BS was MS’s first pregnancy. MS attended all routine ante-natal care and contacted midwifery and hospital services at any point she had concerns about her health or that of the baby.  The ante-natal care was provided as a seamless service with a high degree of efficiency and personalisation. MS said that as an adolescent she had suffered with a level of anxiety and depression and her mood was assessed throughout the pregnancy. MS reported that that her mood lifted as the pregnancy progressed.  4.2 Child BS was born healthy but with slight jaundice which was monitored by community services post discharge from hospital. MS was given a post natal check at hospital, she   8 was specifically asked about her emotional well- being and no concerns were expressed or detected. As all was well, MS and Child BS were discharged the day after birth.  4.3 Within the first ten days of discharge Child BS and MS were seen on three occasions by the Community Midwife Team. These consultations revealed no concerns about MS or Child BS and both were routinely discharged to the GP and health visiting services.  4.4 The Health Visitor made a primary visit to MS and Child BS within three days of discharge and followed this with a second visit five days later. MS expressed an interest in services available from the Children’s Centre and a referral was made. Child BS was taken to baby clinic for all immunisations, sometimes accompanied by MS alone and sometimes by both MS and FS. Child BS was taken to medical services when the parents had concerns about general health; typically this included occasions when the child was wheezy, had a rash or a stomach upset.  4.5 Having shared with the Health Visitor that she was feeling low in mood due to some work related anxiety, MS attended a consultation with the GP and was prescribed a low level of anti-depressant medication. 4.6 Five weeks after Child BS’s birth, a representative of the Children’s Centre visited the family with the purpose of registering the family with the Children’s Centre. The worker informed MS and FS about the services available and in particular recommended play sessions with opportunities to meet other parents. The family were determined as having no additional needs other than those met through universal services.  4.7 The Children’s Centre records show that the family moved address when Child BS was five months old and that MS would be returning to work. Between the age of seven and ten months, Child BS attended a crèche at the Children’s Centre whilst FS attended an occupational training course.  The Children’s Centre never had any cause to be concerned about the welfare of Child BS.  4.8 Child BS was seven months old when MS booked a further pregnancy with the Community Midwifery team. At ten months old, Child BS was registered at a local nursery for two morning sessions each week.  4.9 Child BS was 13 months old when, four weeks before the expected date of confinement, MS gave birth to S1 by emergency caesarean section. Despite the emergency birth, both MS and S1 were fit and healthy for discharge two days later. Like   9 Child BS, S1 had slight jaundice which was resolved without concern. Within twelve days of the birth, MS took Child BS to clinic for the 13 month immunisations.  MS and S1 were discharged from community midwifery services when S1 was 17 days old. The Health Visitor primary appointment was completed one week later.  4.10 At the primary Health Visitor appointment, MS was observed to be in low mood and reported a physical altercation with a member of FS’s extended family to which the police were called.  MS also shared this information with the GP and confided that she had been feeling low. Police records show that MS had stated that she was the victim of an assault three days prior to the Health Visiting appointment and alleged that she was kicked in the stomach. The alleged offender was traced but not prosecuted due to the burden of proof not being met. 4.11 MS completed a Children’s Centre membership form with the health visitor, listing FS, MS, Child BS and S1 as the family unit. This membership form was shared with a second Children’s Centre which was more local to the changed family address. The second Children’s Centre contacted the first Children’s Centre to request any historical records and after trying unsuccessfully to reach MS by telephone several times, the Children’s Centre wrote to the family to arrange a visit.  The whole family were present during this visit which was conducted by a Family Outreach Worker. The Worker advised the family on what was available to them and as MS and FS expressed an interest in some courses a request for service was generated.  4.12 A further Health Visitor appointment was undertaken when S1 was 4 months old. At this visit, MS advised that she had returned to work one day per week and was feeling well and stable on anti-depressant medication.  4.13 Child BS was 18 months old and S1 5 months old when police officers were called to the family home at 10.35pm after receiving a report of a male and female shouting. MS advised the officers that she and FS were arguing because FS had refused to help with the children and to calm the situation it was agreed that FS would spend the night with a family member. As the children were present in the house, a DASH (domestic abuse, stalking and honour based violence) Risk Assessment was completed by the attending police officer which determined the risk as ‘standard’. In accordance with police procedure, a Protecting Vulnerable Person form was submitted and the information was shared on a Sharing Domestic Abuse report with the Multi-Agency Safeguarding Hub, the Independent Domestic Violence Advisor and Health.  As this was a first known   10 incident, and the risk assessment was completed as standard it is believed that the information was recorded as a contact only in Children’s Social Care records.  4.14 Following receipt of the Sharing Domestic Abuse form, the Health Visitor contacted MS by telephone.  MS reported that all was well and the Health Visitor offered her support if needed. Approximately two months later, MS telephoned the Health Visitor and advised that she had separated from FS. MS stated that she was struggling financially and unable to pay the nursery fees. The Health Visitor contacted the Nursery to discuss the availability of two year old grant provision. The records would indicate that the domestic abuse notification was not shared during this conversation, nor was the information that MS and FS had separated.  4.15 Eight days before Child BS was taken to hospital, Child BS went to nursery with a mark to the face described by the nursery report to this Review as a ‘purple line (like a vein) at the corner of the eye’. A member of staff asked Child BS’s maternal grandmother, who had accompanied Child BS to nursery, to record the mark in a book entitled ‘Injuries In’. This is a book that is used primarily as a record of injuries that could not have occurred within the nursery setting. The grandmother made the following entry ‘[Child BS] has come into nursery with a black eye’.  A staff member wrote below that entry ‘Nana has told me that [Child BS] has got a black eye and that [grandmother] is not sure on (sic) how [child BS] has done it’.  There are no other written records which detail any further information in relation to this injury.  The reports from the nursery for this Review states that staff recall that the grandmother returned the following day and advised that after a consultation with MS, it was understood that Child BS had knocked the eye on the corner of a coffee table.  4.16 Child BS attended nursery the day prior to being taken to hospital. On this day, the Proprietor of the nursery noted the injury to Child BS’s face and recalled it as a green/yellow colour. Staff were asked whether a record had been made of the injury and the proprietor was advised that it had. On this day, Child BS is reported to have presented as happy, laughing, enjoying play as was usual. Child BS had a nappy change and the nursery staff report that they observed nothing untoward about Child BS and noted no bruising to the body other than the injury to the face already stated.  5.         Significant post incident Information     11 This information is taken from a range of sources including agency reports, police witness statements and the contribution of family members. 5.1 On the day on the incident, MS left for work at approximately 7.30 am and Child BS and S1 were in the home with FP.  FP had been staying at MS’s home for approximately two weeks and had agreed to mind the children whilst MS was working following an unexpected change of shift pattern which meant that MS did not have arranged childcare.  5.2 MS stated that Child BS was bathed in a sink the previous evening.  MS stated that she saw Child BS naked and that there was no bruising evident.  5.3 When Child BS was examined at hospital the following day, extensive bruising was present. The injuries are not exhaustively listed, but  included:  A blue/purple bruise of 1x1.5 centimetre to the upper right eyelid  A red/purple bruise 0.5 centimetre diameter to the left side bridge of the nose  A faint bruise of 2.5x1cm behind the left ear  Two very faint green/blue bruises both about 1cm diameter to the left cheek  Red/brown bruising of 9x4 centimetres to the front of the left thigh   5.4 Questions were raised as to whether the injury to either eye was the same injury that had been noted in nursery. The record maintained by the nursery was limited, no record was made of the size or location of the injury and there was no explanation for the injury recorded. MS and Maternal Grandmother explained to the Reviewer that Child BS had a linear bruise to the side on one eye which was caused by a door banging into the child. Maternal grandmother has no recall of stating that the injury was caused by a coffee table, and pointed out that there was no coffee table in the child’s home.  5.5 Following notice of the death of Child BS and the presence of an injury that was without adequate explanation the preceding week, Ofsted suspended the registration of the nursery whilst an investigation was carried out.  This action was taken given that there were alleged failings in safeguarding procedures in the nursery and Ofsted had reason to believe that a child was/or may be at risk of harm in that setting. The investigation was allocated to an Early Childhood Regulatory Inspector, ECRI 1, who contacted Children’s Services to request that they undertake a joint investigation visit to the nursery.    12 5.6 The investigation visit was completed by two Early Childhood Regulatory Inspectors, ECRI 1 and ECRI 2 and the Duty and Assessment Team Manager from Children’s Social Care. The investigative process included interviews of all staff as well as the manager and proprietor that focussed on their understanding, knowledge and practice around safeguarding. The investigation concluded that there was a lack of rigour and robustness in terms of responding to injuries to children that had not been accounted for which potentially left children at risk,  and that the records that were held in respect of such occurrences lacked detail with no clear audit trail to account for steps taken to safeguard children.  5.7 Following the investigation, Ofsted issued a welfare requirement notice that required the provider to:     ensure the setting’s policy and procedures on child protection are implemented effectively to safeguard children     ensure all staff including the provider and manager have an up to date knowledge of safeguarding issues (including those employed at nursery 2)    ensure that any training made available enables all staff to identify signs of possible abuse and neglect at the earliest opportunity      ensure the lead practitioner responsible for liaison with local statutory children’s services agencies and with the LSCB provides support, advice and guidance to any other staff on an ongoing basis and on any specific safeguarding issue as required  Additionally, a Notice to Improve was issued that required the nursery to:    ensure appropriate arrangements are in place for the supervision of all staff including the manager who have contact with children and families. Effective supervision provides support, coaching and training for the practitioner and promotes the interests of children. Supervision should foster a culture of mutual support, teamwork and continuous improvement which encourages the confidential discussion of sensitive issues (W3.1) 5.8 The Early Years’ Service in the Local Authority contacted ECRI 1 to clarify the position with regards to a second nursery which shared common ownership, management and policies and procedures and also to raise a concern that a published Ofsted report had   13 recently judged the nursery and safeguarding as good which was inconsistent with the information that had been gathered in respect of Child BS.  5.9 The inspection report and evidence base of the inspection of the nursery that had recently taken one month prior to the recording made about BS was reviewed by an Early Years HMI and it was concluded that the associated record of evidence did not support the judgement outcomes. The inspection had reported that the ‘staff give good attention to safeguarding children. They have a good knowledge of their roles and responsibilities in this area, which means that they can respond promptly to any concerns and keep children safe’ However, the written evidence from the inspector’s evidence toolkit relating to the visit did not support the good safeguarding judgement as it contained no reference to the Inspector discussing safeguarding with staff members during the inspection. On this basis the inspection was declared null and void and the report withdrawn from circulation.  5.10 An Early Childhood Regulatory Inspector ECRI 3 undertook an investigation visit to the second nursery. ECRI 3 found the provider was not meeting Early Years Foundation Stage (EYFS) requirements in relation to Welfare Requirement 10.1 (availability of staff records) and Welfare Requirement 1.2 in that detailed records were not being kept in relation to concerns about children’s welfare. As a result of these findings the provider was issued with a Notice to improve which specifically included the responsibility to ensure that the safeguarding policy and procedures were implemented by both the provider and staff, in order to safeguard children. The Notice required that the safeguarding policy must include that there be available a detailed record of concerns about children’s welfare, any injuries to children and an explanation of how the injury/ies occurred.  5.11 A decision was made by Ofsted not to suspend the registration of the second nursery on the basis that the threshold for suspension had not been met.  During this Review, this decision has been recognised as inconsistent by Ofsted given that the registration of the nursery attended by Child BS was suspended because Ofsted had reason to believe that the continued provision of childcare by the Registered Person (proprietor) may expose a child to a risk of harm, the same was true of the second nursery working to the same regime.  5.12 Following the suspension of the registration of the nursery, the registered person made arrangements with another day-care provider to offer day-care to 20 children from the   14 nursery with the addition of providing 5 of the staff from the nursery. As the contract to provide day-care remained between the registered provider of the nursery and the parents of the children relocated, this may have constituted a breach of one of the conditions of suspension as it is a criminal offence for a person registered on the Early Years Register or the compulsory part of the Childcare Register to provide a childcare service while suspended. The Registered Provider had informed ECRI 1 of the intention to relocate the staff and children and was not advised that this should not happen.  5.13 Whenever there is a need to consider taking statutory enforcement action, Ofsted hold a Compliance, Investigation and Enforcement (CIE) Case Review. Such a review, in all cases, considers any risks to the safety and welfare of children and any action which may need to be taken or not taken by Ofsted in order to safeguard children The purpose of the CIE Case Review is to review the consistency in the approach to taking statutory enforcement action, explore whether Ofsted has considered all other options before making a decision, review historic information relating to alleged or actual non-compliance, test whether the sufficiency of evidence supports the proposed action and decide whether there is a need to obtain further evidence. Each CIE case review must include a management decision-maker. In this case a Senior Officer, SO 1, was the decision-maker throughout the investigation.  5.14 The Ofsted report for this Review has identified that the CIE Case Review minutes of this case lack analysis and do not provide a detailed record of risk assessment. The standard Ofsted CIE Case Review recording proformas were only partially used for recording the CIE Case Review minutes.  Key sections of each proforma, such as the risk assessment section, had been left blank. This resulted in a poor record of the evidence about how risk has been assessed and how decisions were made.  5.15 Within three weeks of the Investigation visit, ECRI 1 and ECRI 2 undertook a second monitoring visit to the nursery. The intention of the visit was to establish whether staff had a better understanding of safeguarding practices as result of recent safeguarding training and to consider whether the grounds for suspension were still met.  Each staff member was interviewed and the evidence gathered enabled the inspectors to form a view about whether staff at the setting had improved their knowledge of safeguarding practices. A CIE case discussion was held following this visit, SO 1 recommended the suspension should be lifted because the provider took appropriate action to deal with the matter that led to the suspension and Ofsted was now satisfied that there was no   15 risk of harm to children.  The proposed decision was ratified by the Ofsted Regional Director and the suspension was lifted approximately four weeks after it was implemented.   6.        Analysis 6.1 Child BS and the family circumstances were little known to non-universal services prior to the fatal incident that occurred when Child BS was just two years and one month old. This Review provides a good example of how universal services should work with families with young children. The post birth contacts with child health services were supportive and timely and following the birth of both children, the parents were contacted by the local Children’s Centre to offer a range of community services.  6.2 The break-up of the relationship between FS and MS was described as a slow and inevitable process by MS and FS.  The eventual split was not without acrimony, and at the time of Child BS’s death the changing dynamics between the parents had not reached an amicable level. Despite the difference between MS and FS, until the incident occurred both believed that the other was a loving parent to Child BS and S1. The relationship between FS and MS became  strained after the second pregnancy, and this is evidenced by the police being called on two occasions to incidents within the family, once when MS alleged she had been assaulted by a family member of FS and secondly during a loud argument between FS and MS. On each of these occasions, police followed expected standards of procedure and following the second incident information was shared with their partner agencies to support the welfare of BS and S1. 6.3 The Health Visitor followed up the notification of domestic abuse directly by speaking with MS and offering support. Whilst accepting that there is no agreed account of the history of the relationship between MS and FS, it was significant to note a description by MS and some reflections by the Maternal Grandmother that would suggest that Child BS and S1 would have experienced domestic abuse incidents related to alcohol. The incidents were described as non-violent but most certainly abusive. The Chair of the Panel and Independent Reviewer noted that both women would not have termed their spoken experience as domestic abuse and associated this terminology with acts of violence only. MS and Maternal Grandmother both stated that FS could not be faulted as a Dad.    16 6.4 The nursery attended by BS could not recall being specifically told that MS and FS had separated but recalled that this information was shared with them because a difficulty arose with the payment of nursery fees.  The nursery staff experienced three people accompanying Child BS to nursery, this included FS, MS and maternal grandmother and had no cause to doubt Child BS’s relationship with any of these adults. The nursery staff never met FP and did not know of his presence in the life of Child BS.  6.5 The relationship between MS and FP developed very quickly after the ending of the relationship between MS and BS. FP was living with a parent when he met MS and had never co-habited with a partner previously. He had no children and prior to meeting MS he had very little contact with children. The closest extended family member to the children was their maternal grandmother who regularly provided care whilst MS worked. Although she had known FS well, she told the Review that she had only met FP on a few occasions and was unable to provide any observations about his relationships with MS or the children.  6.6 MS considered the relationship with FP was going well, maternal grandmother said that although she barely knew FP she could see that MS was happier and had no reason to doubt the children’s welfare. MS said that Child BS was wary of FP and resistant to his attempts to undertake small tasks such as giving a drink, but she believed that this was because Child BS was exceptionally close to FS, and FP would be accepted over time. In reality, Child BS had no time to adjust to the loss of FS before a new male was introduced to the household.   6.7 Although MS stated that the family dynamics were working well prior to the incident, and they were a ‘normal happy family’, the evidence taken within the public law proceedings in relation to S1 would suggest otherwise.  Four significant incidents were examined which indicate an emerging pattern of cruelty directed at Child BS by FP, the details are as follows:  Seven weeks before the incident, a key to the electricity meter went missing and it was suspected that Child BS had removed and hidden it. The house was damp and cold because the electricity had run out and the key was needed to access the meter. MS spent 20 to 30 minutes in a separate room from FP and the children ringing the electricity company and when she went back into the communal room, FP told her that Child BS had pulled out a clump of her own hair. MS saw that Child BS did have a bald patch of about 1 inch diameter. MS believed FP’s account that   17 Child BS had done this herself. The Court found this to be a 'sadistic' act on the part of FP.    Five days after the above incident, whilst at the parental home of FP, FP found Child BS eating or playing with food in the dog bowl. FP was angry and shouting, he picked up Child BS by one ankle and carried the child, hanging upside-down by a single ankle, from the kitchen into the front room, where he placed the child with MS. It was also reported that he had carried Child BS in that way once before in play, Child BS had not liked it and MS had told him not to do it again. MS was angry with FP and took the children and left the house. After a series of text messages, FP went to the family home and promised that it would not happen again. The Court found this incident to be ‘degrading’ and dangerous, and noted that that MS was shocked and angry by it.   Eight days prior to the incident, FP had care of S1 and texted MS after an accident with S1 stating that every time he looked after the children, they get hurt and he did not want to do it again.  Three days before the incident, Child BS and S1 remained in the care of FP whilst MS attended the funeral of the children’s Paternal Grandfather.  When MS went to collect the children to take them to the family event after the service she noticed a bruise to the inside of Child BS’s knee. MS considered this to be in an unusual place but did not question FP further as to how this happened.  6.8 The totality of these incidents would suggest that the incident which precipitated this Review was not a random act, but the culmination of several acts of cruelty by a man who had some insight that he should not have been taking care of the children.  FP has never given an account of what happened on the day of the fatal attack, but the Court mooted a speculative scenario that FP wakened Child BS and brought the child downstairs. At some point, the child defecated on the living room floor and this, coupled with his mounting frustration with and cruelty towards the child over previous months, triggered an outburst of rage. When Child BS went floppy and lifeless, FP tried but failed to revive the child in a cold shower.  6.9        The Court whilst at pains to point out that FP is solely responsible for the injuries to Child BS,  also found that there was a contributory causal connection between MS’s decision to entrust the children to FP’s care on the day of the incident and the harm that was   18 inflicted. It was concluded that MS did not exercise reasonable caution when entrusting the children to the care of FP following the previous incidents, not because she deliberately took a risk, but because she unreasonably failed to appreciate or understand that there was a risk.  6.10        From the perspective of the Serious Case Review, the question raised is how a mother can be lured into a false sense of security and disregard the warning indicators that all was not well. A psychological assessment may help to understand the underpinning reasons for a person’s distorted thinking patterns however, despite not being in a position to reach such a conclusion about this particular case, this Review does provide a stark reminder of the dangers that  may be associated with transitions in adult relationships for children. FP was introduced to the children whilst they were still making sense of the loss of FS on a day to day basis, both were young children and only through lived experience could they begin to make sense of the changes to their lives and achieve a point of security within the changing relationships. Child BS and S1 were not afforded this opportunity and were thrust into a relationship with a man who had no experience with children and no natural feeling for them. All connected to this case are certain that MS loved both children and would not have deliberately allowed them to come to any harm, but her desire for a relationship and to believe in a ‘normal loving family’ overtook her astuteness to the safety of her children. It is evident from the incidents outlined to the Court that MS did disregard warning signs of FP’s behaviour towards BS, and potentially the incident whereby BS lost a patch of hair from the head could have been visible to others. Neither the child’s grandmother nor nursery staff report having observed this missing patch of hair. This case is a warning to parents who enter into relationships with new partners without placing the children’s needs as their highest priority.  6.11        The one potential indication of injury known to agencies in respect of Child BS was the record contained in the nursery of the injury to the eye. The recording of the injury was woefully inadequate for a number of reasons: - it was not dated, it did not describe the size, location or colour of the injury, the record was entered by the maternal grandmother and there was no conclusion as to how the injury had occurred or what investigations had been made to conclude this. When this recording came to light following the death of Child BS, it became a very significant issue and the nursery was robustly scrutinised through an investigation completed by Ofsted. The action to suspend the nursery was wholly proportionate in the view of the Reviewer, a child had   19 died in abusive circumstances and a regulated provider could not fully account for the safeguarding activity around that child the preceding week.  The ‘Injuries In’ existed to record any injury that a child presented at nursery with, in other words, and injury that could not have occurred whilst at the nursery.  The purpose of this book was described as a protection for the nursery which implied an inherent weakness in recognising the potential for children to be harmed by their caregivers and the need to take a firm and protective approach to the overall welfare of children.  6.12        It should be acknowledged that the nursery had been inspected and given a Good rating for safeguarding one month prior to the substandard recording. Subsequent to the incident, Ofsted reviewed the evidence for the inspection and concluded that the evidence did not support the grading, and this was borne out by the reality of what occurred.  Ofsted have identified that the inspection findings were not supported by robust evidence and although this had in no way contributed to the tragic events leading up to the death of BS, it is a serious matter for the Proprietor who felt that she had been falsely re-assured by a grading of Good which could not withstand scrutiny. The nursery has subsequently introduced a comprehensive system for recording of injuries and explanations, which uses a body map and a series of questions designed to stimulate and challenge professional thinking about the origins of injuries and appropriate consequent actions. 6.13        It is important to state clearly that although the safeguarding practice should have been more robust in respect of the explanation and recording of the injury to Child BS, it is most unlikely,  even if entirely robust, that this would have led to a referral under child protection procedures.  Even if the injury remained unexplained, in the absence of any previous concerns and with no features specifically indicative of child abuse, the actual injury would not have triggered a safeguarding concern per se. The nature of the injury to the eye was a discussion point during the Serious Case Review and clearly this took on a greater significance in the light of what was known subsequently.  It has been described by nursery staff as a relatively faint linear bruise but it was recorded by the maternal grandmother and reported by the Proprietor to the Strategy Meeting as a black eye or like a black eye. Additionally, the nursery staff recalled that the grandmother reported that Child BS had hit the eye on a table, whereas the Grandmother has no recollection of this but did say that she told the nursery that the injury was caused on a door. The confusion over terminology and explanation belied the   20 fact that the recoding system in the nursery at the time of the record was made was not fit for purpose.   6.14        This Review has resulted in significant learning for Ofsted with regard to improving the quality of inspection case recording and the investigation action plans. Ofsted provided the Serious Case Review Panel with an honest appraisal of the organisation’s work in relation to this case and has transparently identified where practice needs to be improved.  In order to ensure a robust understanding of what factors contributed to the elements of compromised inspection practice, Ofsted has conducted an internal management review of this case to explore lines of accountability, quality assurance and management over-sight of the CIE work. It has subsequently instigated changes to improve the robustness of investigations and inspections.  6.15        The Review had identified that both the nursery and Ofsted demonstrated some weak aspects of practice in ensuring the safety of children which could have compromised the safety of children. Although this Review has identified some areas for learning and improvement, the deficits did not contribute to the untimely death of Child BS.   7.        Recommendations  This Review makes few recommendations, accepting that the lessons learnt by individual agencies such as the nursery and Ofsted have either been addressed or are being addressed through internal management systems. The Serious Case Review focus is on what can be learnt by safeguarding agencies, and in this case, the critical pathway of what happened to lead to the death of Child BS was known to FP and MS only.   Recommendation 1  That the Early Years’ Service lead a review and develop common guidance and supporting documentation to be made available to local nursery providers in respect of Safeguarding. The final documentation be presented to the LSCB for a Board badging of approval as a quality standard.    Recommendation 2 That the LSCB seeks assurance from the CSP that the contents of this report are considered in the delivery of the Domestic Abuse action plan with particular reference to the need to develop public awareness of domestic abuse and the risks to children at the points of parental separation and newly formed relationships.    21 Recommendation 3 That the Board require core safeguarding agencies to refresh their approach to Strategy Meetings to ensure that:  LSCB procedures are adhered to  with common records of meetings noted and shared by Children’s Social Care;   That the Chairs of Strategy meetings ensure that any reference to injuries are specific, descriptive and contextual;  Ofsted, as a matter of course, are invited to all Strategy Meetings that give consideration to events that have potentially occurred within a regulated setting.   Recommendation 4 That the Board seeks assurance from Ofsted that the lessons of this review have been acted on and disseminated throughout the organisation.   