Death of an 18-day-old baby in March 2012. Child A died while in bed with mother and her partner who had both consumed alcohol the previous evening; Child A's death was considered accidental. Identifies lessons learned, including: need for commissioners to be aware of what they can expect from services in terms of the methodologies used, what outcomes can be expected and how progress will be reported; need for health professionals to be aware of the wider safeguarding of children; and need for the flexible interpretation of 'did not attend' policies in order for the needs of individual children and families to be taken into account. Makes recommendations, covering children's social care, health services and Coventry Safeguarding Children Board.
      
 Title:  A summary of findings concerning the death of Child A: date of serious incident: March 2012. LSCB: Coventry Safeguarding Children Board Author: Mike Harrison Date of publication: 2014  This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC.  This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above.                             COVENTRY SAFEGUARDING CHILDREN BOARD SERIOUS CASE REVIEW A summary of findings concerning the death of Child A  DATE OF SERIOUS INCIDENT: March 2012   References relating to the subject child, family members, organisations professionals and places have been coded and anonymised.   Independent Lead Reviewer    Mike Harrison  Independent Chair CSCB      Amy Weir   Date of report: May 2014     1  Summary of case  Child A died in March 2012 at 18 days old while in bed with mother and her partner. Both the mother and her partner had consumed alcohol the previous evening. The cause of death was deemed accidental, but a feature of the death was consistent with overlay in bed.  In the last three years there have been 2 child deaths where overlay has been a feature in the death. In both cases the children were less than 2 months old. Similar features in these cases include parents having been bed sharing with the child at the time of death and that they had been intoxicated with alcohol.  Following an earlier local focused approach to reducing bed sharing related deaths, both mothers had received clear information about the risks and how to prevent this including the safest way to put babies to sleep. This is known because in both cases mothers stated they had been given these messages but thought this could not happen to them. In both cases these were not their first born children. In these cases mothers had experienced personal difficulties which had made them vulnerable and this in addition to the alcohol over-consumption placed their children in a vulnerable position.  Lessons Learned from the Review  The review highlighted the importance of all assessments being carried out on a multi-agency basis. The value of all of the agencies involved in a case contributing to one holistic assessment with a jointly agreed outcome cannot be overstated.  In order to assist professionals to minimise risk to children, and to gain insight into the functioning of families, it is essential that those professionals using commissioned services are aware of what they can expect from those services. Issues such as what methodologies are used, what outcomes can be expected and how progress is reported are all important issues revealed by this review.   The complex task of compiling assessments of children in need or in need of protection can be greatly enhanced by using appropriate scales and tools to provide an objective assessment, based on evidence and informed by research evidence. This is of particular importance where there are problems in a family such as alcohol misuse, substance misuse or domestic violence.   When assessments are informed by outcomes of interventions or programmes carried out with a family by partner agencies, the social worker compiling the assessment needs to check back with the agency concerned about the outcome. This process will allow for the triangulation of information and guards against a reliance on ‘self-reporting’ by family members as occurred in this case.  This review has highlighted the need for records to be kept up to date and minutes of meetings circulated in a timely way both to parents and other professionals. This 2  includes the need to ensure that those present during home visits to service users and at meetings are clearly recorded.  When other children of the family have been previously subject to a child protection plan which has been discontinued, it would be helpful for a strategy or at least a child in need meeting to be convened to consider the risks to the new child being in the care of the parent responsible for the previous abuse; this should even be considered in situations where children have been made subject to orders in private law proceedings as part of the child protection plan.   Comprehensive background checks are an essential component to ensuring the safeguarding of children. This review has identified that when an adult is known to be visiting a house where children live who are subject to a child in need plan or a child protection plan it is necessary for comprehensive checks to be carried out.   In cases such as the one under review, health care professionals may not be primarily involved in child protection. However they should be aware of and maintain a focus on the wider safeguarding of children and promoting their welfare while carrying out their role.  Where agency policies such as a ‘did not attend’ policy exist such policies need to be flexibly interpreted to take account of the needs of individual children as in this case.  In accordance with existing procedures children  who are the subject of child in need or child in need of protection plans need to  be seen alone as part of on-going work  in order to safeguard them and promote their welfare.  Recommendations and progress made   Below are the recommendations made and a summary of the work undertaken to address these recommendations. The work to address the issues raised in all eight recommendations has been completed or are now included within other improvement plans to be pursued. Where further planned activity to assess that learning has been effectively embedded is highlighted below and will be progressed through the relevant Safeguarding Children Board Subgroup work plan.     Children's Social Care   1. The Directorate should ensure that its current quality assurance framework is being implemented effectively in order to ensure that sufficient rigour is being applied in relation to the monitoring of social workers' practice and recording.  Completed  The framework has been continually reviewed internally and also evaluated independently including via a safeguarding children peer review to ensure it is robust and effective in monitoring practice and recording. The findings of audits are reported to senior managers within children services. Findings are shared at workshops with 3  team managers and senior practitioners. Key issues are disseminated to practitioners these include the variability in practice.   In addition standards for recording have been agreed and disseminated, this is compiled into a dashboard which social care managers access. More recently audit results are compiled into a monthly audit summary report.  Also the quality of practice and recording is being monitored through multiagency audits undertaken by the Safeguarding Children Board.    There was an Ofsted inspection in 2014 which highlighted some continuing concerns about the QA Framework. There is now an Improvement Plan in place which is pursuing the improvements required and the LSCB will continue to monitor progress and to test out through audit that changes have been made and are having impact. 2. The Directorate should reinforce the requirements to: a) engage partner agencies in the undertaking of assessments in order to ensure that these are completed on a multi-agency basis and that other professionals not only provide information but contribute their views and analysis and are involved in determining outcomes. Completed Workshops to reinforce the importance of agency consultation / involvement in assessments have been delivered across social care. The workforce development plan incorporates learning from Serious Case Reviews; assessments are an explicit part of this. These have been and continue to be delivered. Multi agency learning events for practitioners and managers have been delivered which explicitly cover the need for multi-agency participation in assessments. In addition posters specifically aimed at social care staff have been produced which include a reminder of undertaking holistic assessments.    In addition this is being monitored through multiagency audits undertaken by the Safeguarding Children Board include whether assessments have had multiagency input.   There was an Ofsted inspection in 2014 which highlighted some continuing concerns about the quality of assessments. There is now an Improvement Plan in place which is pursuing the improvements required and the LSCB will continue to monitor progress and to test out through audit that changes have been made and are having impact.   b) Seek background information and undertake lateral checks in relation to members of the household when assessments are being undertaken.             Completed   4  The single children and family assessment has been implemented and all social care staff have attended a briefing which explain the changes, this has explicitly included the need to obtain background information and undertake lateral checks. The Children and Families Assessment record has been amended in light of this SCR finding to better evidence lateral agency checks are carried out.   In addition practice standards for undertaking assessments have been reinforced with all frontline practitioners across neighbourhood services and senior practitioners’ caseloads are being reduced to facilitate support to front line staff with practice improvements.   See comment above regarding Improvement Plan.  3. The Directorate's Manual for Recording Service User Information (last updated May 2002) should be reviewed and updated, in particular to ensure that it is consistent with the Protocol system.   Completed  The recording policy has been updated; these updates are also reflected in the online manual of procedures. Staff have been briefed on the requirements; posters are displayed in all social care offices as a reminder of the requirement. The audit tool kit referred to earlier includes the requirement to consider timeliness of recording. The social care electronic recording system protocol produces reports monitors the timeliness of recording and consistency of recording.   However capacity related to caseloads does impact on recording, currently social care have increased the number of staff to provide more capacity and reduce caseloads to enable staff to undertake these processes effectively.    4. The Directorate should examine the feasibility of providing all social work staff with a secure email address to facilitate the sharing of information between agencies.  Completed  The Local Authority has explored the feasibility of this, while it is not possible for all staff to have secure email addresses, all staff are able to access and use a secure functional email address. Follow up work has been done to check this is taking place and provided to the CSCB.    The Health Community    NHS Coventry and Rugby Clinical Commissioning Group   5. The author of the GP Individual Management Review recommended that Coventry and Rugby CCG should develop a commissioning plan with Coventry and Warwickshire Partnership Trust and the maternity services to implement shared care planning for pregnant women deemed to be at unusually high risk due to previous psychiatric disorders in line with National recommendations. This should include planned intervention and 5  monitoring by primary care in the postnatal period. The overview health author recognises that this may not have altered outcome in this case but would strengthen provision for this vulnerable group of mothers.  Completed The review of services took place in September 2013, this included considering relevant guidance documents and the current perinatal and psychiatric services. This identified that the correct services are being commissioned. However the review did highlight that an increase in resourcing to meet the demand for services is required. Health providers have agreed to be commissioned across the health economy.      While the review itself has been completed further activity continues, posts required have been identified and appointments due to be made in Summer 2014.            University Hospital Coventry and Warwickshire NHS Trust  6. UHCW needs to review its processes for information sharing with GPs when adults attend the emergency department. Child A’s mother’s partner’s attendance, while only of relevance to his own physical and mental health at the time, may have been an important piece of information if his GP was asked to provide details of his physical and emotional wellbeing as part of the core assessment when he was in a relationship with Child A’s mother. Completed The process has been reviewed –GP’s in Coventry can check if a patient has attended via the Trust electronic record system. Any patient who is admitted has an electronic discharge summary written and disseminated on the same day electronically to the Coventry GP.  GPs from outside the Coventry area receive a paper copy of the discharge letter.           Coventry and Warwickshire Partnership Trust  7. The recommendations of the Coventry and Warwickshire Partnership Trust (CWPT) are about already existing policies and procedures. Completed  The CWPT have put in place a bespoke safeguarding child protection supervision policy in addition to the Trust wide Supervision policy which has incorporated safeguarding children and child protection. The use of this policy in practice is being audited in September 2014.    Supervision in relation to staff who work with children for whom there are safeguarding or child protection concerns has been imbedded in policy and practice.  The above processes were in response to a safeguarding audit that was undertaken to identify if the relevant documents have been completed where there are safeguarding concerns about adults and children. This established that while there is a high level of sharing of concerns with the appropriate services not all cases had risk assessments and care plans/ strategies documented. CWPT have emphasised the 6  need for this with all staff and a subsequent audit is being undertake in September 2014.      Additionally an audit into adult mental health supervision was conducted to establish the knowledge and use of specialist safeguarding supervision. This identified a need for greater awareness and timely access to specialist supervision.  Supervision formed part of the audit programme of the Safeguarding Children Board Practice and Quality assurance Subgroup for 2014- 2015.     Coventry Safeguarding Children Board   8. a. The author makes two specific recommendations. Firstly, that the Coventry LSCB either commissions, or undertakes, a programme of work to enable frontline practitioners from general practice and social care to come together to jointly explore the difficulties experienced by GPs and social workers in working effectively together. Specifically to identify local initiatives that could be put in place to address some of these difficulties. Central to this would be a direct dialogue involving frontline practitioners from both general practice and social care.   Completed Initially activity included a survey being carried out with GP’s and social workers, response helped inform focus group discussions in exploring how to improve communication and joint working between social workers and GP’s across the city.   The focus group considered the role of social workers, information sharing and barriers to communication. Solutions included spending GP protected learning time on understanding the role of social workers, having easier access to social workers, piloting social workers to request telephone consultation with the GP to schedule in set time to speak with each other.   This work has now commenced, in February a GP protected learning event took place where social workers were also in attendance, the event included awareness on information sharing and improving multiagency working, themes including learning from SCR’s, early help and domestic violence. Over 200 GP’s attended this event.   The communication between these professionals will feature in future audit programme for LSCB, after activity to improve communication has had adequate time to bed in and can be evidence in audit.  b. Secondly, the author is aware that this case represents the second such case involving overlay death in the city in recent months. In the previous case, Child W, it was concluded that clear written and verbal information had also been given to parents yet ignored. The author believes that it would be useful for further research to be undertaken in respect of how parents can be most effectively assisted to understand safe sleeping information and the dangers co-sleeping presents particularly where the parents are known to misuse alcohol. This proposal may be something that the Department for Education (DfE) and the Department of Health (DH) may wish to consider commissioning.    Completed  7    The Chair of Coventry Safeguarding Children Board has written to the Parliamentary Under Secretary of State for Health and the Parliamentary Under Secretary of State for Children and Families outlining the concerns in these cases and asking for research to be undertaken to enable professionals to effectively support parents where alcohol is a factor when co-sleeping. A response has been received and the Under Secretary of State for Children and Families is currently monitoring this issue through Child Death Overview processes.  8  