Executive summary of a serious case review into the death of a nine week old baby girl from non-accidental injuries sustained whilst in the care of her father. The review was unable to identify any warning signs, even with the benefit of hindsight, which should have led professionals working with the family to believe the child was at risk of such injuries. Recommendations include GPs and health visitors should improve record keeping and information sharing and be able to demonstrate an effective working relationship.
      
 Title:  Serious case review concerning Abigail: executive summary LSCB: Wakefield and District Safeguarding Children Board Author: Peter Ward Date of publication: 2012  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.                             Wakefield and District Safeguarding Children Board   Serious Case Review Concerning Abigail   Executive Summary   Author of Executive Summary – Peter Ward, Independent Social Work Consultant  9th October 2012    Table of Contents   1  Introduction   3 1.1 The Serious Case Review Process 3  1.2 Circumstances leading to decision to carry out a Serious Case Review  3 1.3 Key People and Agencies Involved in the Review  4 1.4 Involvement of Abigail’s family in this Serious Case Review  5 2 Summary of Events  5 3 Key issues and priorities for learning and change    8 4 Recommendations  10      3 1. Introduction  1.1 The Serious Case Review Process  1.1.1 Serious Case Reviews are undertaken by Local Safeguarding Children Boards following a child death in which abuse or neglect is suspected to be a factor and in certain cases when a child sustains life threatening injuries or experiences serious sexual abuse.  1.1.2 Statutory guidance concerning the Serious Case Review process is provided by HM Government in Chapter 8 of ‘Working Together to Safeguard Children 2010’.  This requires the Local Safeguarding Children Board and individual agencies to review their involvement with the child and their family, in cases that meet the criteria for a Serious Case Review.  1.1.3 The purpose of a Serious Case Review is to establish what happened, whether information was fully shared by those professionals involved and procedures appropriately followed, so that any loop holes can be closed and lessons learned to minimise a possible repeat for another child.    1.1.4 Chapter 8 of ‘Working Together to Safeguard Children 2010’ makes it clear that Serious Case Reviews are not inquiries into how a child died or was seriously harmed, or into who is culpable.  1.2 Circumstances leading to the decision to carry out a Serious Case Review  1.2.1 Abigail was admitted to Hospital via ambulance with head injuries and extensive facial bruising when she was nine weeks old.  She was having difficulty breathing and the clinicians who attended her considered her to be close to death.  Abigail’s parents reported that the head injuries had been sustained accidentally whilst she was in the care of her father.   Abigail was stabilised and then received a CT scan that showed extensive intra and extracranial injury and multiple skull fractures. There were no other signs of injury.   1.2.2 The Consultant Paediatrician at the hospital referred Abigail to Wakefield Metropolitan District Council Family Services on the evening of her admission due to concern that the injuries were not consistent with the explanation offered by her father.   1.2.3 Due to the severity of the injuries, Abigail was then transferred to the Paediatric Intensive Care Unit (PICU) in another hospital.  She was felt to be close to death and it was confirmed that she had extensive brain injury and multiple skull fractures.   1.2.4 The day after Abigail’s admission to hospital her father was arrested, interviewed and subsequently charged with Section 18 Assault.  He was detained in custody for two days until he appeared in court and was granted bail.     4 1.2.5 Four days after Abigail’s admission to hospital a decision was made to withdraw treatment on the basis that there was no prospect of recovery from these injuries.  Abigail died the following day at just nine weeks of age.   1.2.6 The Homicide and Major Enquiry Team (HMET) commenced a criminal investigation into the circumstances surrounding the death of Abigail.  Her father was arrested again, on the day of her death, and has since been convicted of her murder.    1.2.7 A post-mortem was subsequently carried out. This did not identify any additional injuries.   1.2.8 The Independent Chair of the Wakefield and District Safeguarding Children Board made the decision to hold a Serious Case Review Panel on 6 December 2011.  The Serious Case Review Panel was held two weeks later and later that day the Panel recommended that a Serious Case Review be undertaken and the Independent Chair of the Wakefield and District Safeguarding Children Board made the decision to do so.   1.3 Key People and Agencies involved in the Review  1.3.1 Peter Ward, the Independent Overview Report Author, has a background in social care and has worked in management and front line social work.  He is qualified to degree level in social work and has a post-graduate diploma in management studies.  He is now the Director of Arrow Social Care Consultancy Limited and as such undertakes investigations and other consultancy work on an independent basis.  Since 2005 he has been involved in Serious Case Reviews as an Independent Overview Report Author, Individual Management Review Author and Panel Chair.  His appointment is in accordance with the guidance at 8.33 in Chapter 8 of ‘Working Together to Safeguard Children 2010’ which states that: “The overview report should be commissioned from a person who is independent of all the local agencies and professionals involved and of the LSCB(s).  The overview report author should not be the chair of the LSCB, the SCR sub-committee or the SCR Panel.”  1.3.2 The independent chair of the Wakefield and District Safeguarding Children Board is Edwina Harrison.  Ms Harrison also chaired the Serious Case Review Panel for this Serious Case Review.  In addition to the chair the following people were members of the Serious Case Review Panel: � Assistant Director, Yorkshire, Barnardo’s � Consultant Paediatrician, Mid Yorkshire Hospitals NHS Trust (MYHT) � Head of Safeguarding, NHS Wakefield � Named Nurse Safeguarding, South West Yorkshire Partnership Foundation Trust � Business Manager, WDSCB (Advisor to the Panel) � Service Manager, Inclusions, Wakefield Metropolitan District Council (WMDC) Family Services � Crime Manager, West Yorkshire Police     5 1.3.3 Peter Ward, the Independent Overview Report Author was not a member of the Serious Case Review Panel but attended panel meetings in order to undertake his role.    1.3.4 The Serious Case Review Panel received and considered Individual Management Reviews (IMRs) from the following agencies: � MYHT � NHS Wakefield District – Primary Care � NHS Wakefield District – Commissioning (The Health Overview report)  1.4 Involvement of Abigail’s family in this Serious Case Review  1.4.1 In accordance with usual practice, the Serious Case Review Panel took the view that key family members should be given an opportunity to contribute to the review.  The Panel wished to invite Abigail’s mother and father to contribute to the review and an approach was made to West Yorkshire Police regarding the appropriateness of this whilst Abigail’s father was charged with his daughter’s murder and awaiting trial.  It was agreed that an invitation would be extended to Abigail’s mother to meet with the IORA and the Head of Safeguarding NHS Wakefield (hereafter referred to as the Head of Safeguarding) but that any possible contact with Abigail’s father would wait until after the completion of his trial.  The meeting with Abigail’s mother duly took place at her home.  Abigail’s maternal grandmother was also present at Abigail’s mother’s request.  Now that Abigail’s father has been convicted of her murder he will be invited to meet with the Independent Overview Report Author and Head of Safeguarding.     2. Summary of Events  2.1 This Serious Case Review covers a period of nearly 10 months from Abigail’s mother’s antenatal booking appointment to the date of Abigail’s admission to hospital.  Abigail was the only child of her mother and father and lived with both of them for the whole of her short life. The parents were not married but it is believed that they were in a stable relationship. The family are white, British with English as their first language, which is typical of the area in which they live.  Both of her parents were in employment.  Abigail’s maternal and paternal grandparents lived within a few miles of Abigail’s parents and in both cases were involved in caring for Abigail.  Other members of the extended families also lived locally.    2.2 The only organisations that were involved with the family, in connection with Abigail, during the period covered by this review were their GP Practices and Mid Yorkshire Hospitals NHS Trust.  Abigail’s father was registered with one GP Practice throughout the period covered by this review whilst Abigail and her mother were registered with a different GP Practice.   Mid Yorkshire Hospitals NHS Trust provided maternity care and a health visiting service.  There was also one paediatric outpatient appointment.    2.3 Prior to becoming pregnant, Abigail’s mother had been registered with one GP Practice since she was a young child.  The Practice had allowed her to remain as a patient when she moved to an address outside the    6 geographical area normally covered by the Practice but when she became pregnant she was asked to move to a different Practice.  She did so and saw a health care assistant at the new Practice.  A routine alcohol screen was undertaken and her past history and family history was taken with nothing of significance identified.  Abigail’s father was registered with the GP Practice that he had been with since he was a child.  2.4 At the antenatal booking appointment the midwife carried out a pre Common Assessment Framework (CAF) assessment which indicated that there were no issues of concern and no additional needs, and initial perinatal mental health screening, which identified no potential risk factors.  Mid Yorkshire Hospitals NHS Trust procedures require the carrying out of a pre-CAF assessment at all antenatal booking appointments with the aim of identifying additional needs at the earliest possible opportunity.  Subsequently, Abigail’s mother attended seven antenatal appointments at the GP Practice where she was seen by the same midwife on every occasion.  In addition she attended the antenatal drop in clinic twice.  Abigail’s mother attended all planned antenatal appointments.  The midwife did not routinely document whether or not Abigail’s father was present at antenatal appointments.    2.5 The only incident of note during the pregnancy occurred at approximately 31 weeks when Abigail’s mother reported diminished foetal movements at an antenatal appointment.  She was referred to the Antenatal Day Unit for further assessment where monitoring criteria were met after 20 minutes; this indicated normal foetal activity and she was discharged home.    2.6 When Abigail’s mother was 36 weeks pregnant a health visitor carried out an antenatal visit at the home address.  The health visitor recorded that Abigail’s mother and father were both present at this visit and Abigail’s mother said that her partner was supportive.  The health visitor undertook an appropriate assessment and provided safety information including prevention of sudden infant death, ‘never shake a baby’; management of pets and smoking cessation.    2.7 Abigail’s mother self referred to the labour ward on two occasions, 15 hours apart and was discharged on both occasions because labour was not yet established.   A midwife attended the family home later that day and Abigail’s mother was readmitted to the labour ward in the early hours of the following morning.  A decision was made to progress to Emergency Caesarean Section because labour had not progressed and Abigail was born by Caesarean Section about 41 hours after her mother had first self referred to the labour ward.  2.8 The following day, whilst Abigail and her mother remained in hospital, Abigail was diagnosed with bilateral Cephalhaematoma, a collection of blood overlying a baby’s skull which causes a visible swelling on the head.  It is a condition commonly associated with birth trauma and a potential complication is jaundice which can occur as the result of the breakdown of the blood cells under the scalp.  The following day it was found that the swelling had improved and a decision was made to discharge Abigail and her mother home and to follow up four weeks later.      7  2.9 Following Abigail’s discharge home three home visits were carried out by community midwives, one by a health visitor and one by a staff nurse from the Health Visiting Team.  These were all routine visits and no concerns were identified.  The midwives noted that the swelling of Abigail’s head was going down.  There is a record of Abigail’s father being present at the first postnatal visit from the midwife, of him engaging fully in this visit and also of him being present when the staff nurse visited.  There is no record of whether he was present at the visit by the health visitor.  2.10 In addition to the above visits to the family home, Abigail was seen by a midwife at a drop in clinic when she was 14 days old and attended a Paediatric outpatient review at hospital when she was 34 days old.  This was a planned appointment to review her Cephalhaematoma which was found to be fully resolved.  No further hospital follow up was planned and a discharge letter was sent to the GP and health visitor.  At this appointment Abigail’s parents reported that Abigail was feeding well but was sometimes unsettled. The parents associated this with colic and had tried two different medications which are both available to buy ‘over the counter’ without a prescription.    2.11 The home visit from the staff nurse took place two days after the outpatient appointment and was a routine visit to carry out Abigail’s 4 – 6 week review.  The only issue of any concern raised by the parents was that Abigail was slightly constipated and the parents were given advice in relation to the management of this and informed that if there was no improvement they should contact the health visiting team or GP for further advice.  The staff nurse has documented that there was no indication that Abigail was exhibiting symptoms associated with infantile colic.    2.12 12 days after the home visit by the staff nurse, the family saw a GP for Abigail’s mother’s routine postnatal examination and Abigail’s routine six week check.  No problems, including colic, were reported, and no issues with father’s level of support were identified.  Abigail was fully examined but nothing abnormal was detected although she had ‘snuffles’.  2.13 Approximately six hours later the family returned to the GP surgery reporting a history of Abigail crying all day due to colic.  The family were seen by a different GP who examined Abigail but did not detect anything unusual.  The GP had a long chat, gave colic advice, advised Abigail’s parents how to seek help overnight if required and issued a prescription for Tilactase to treat the colic symptoms.  Six days later a repeat prescription for Tilactase was issued.  During the course of this review the GP has said that a referral to the health visitors had been considered, but discounted as being “pointless”.  This was because the perception of the GP, and other GPs in the Practice was that referrals to the Health Visitor Team often elicited little or no response.  GPs from the Practice who were interviewed as part of this review also stated that patients report to them that they do not contact the Health Visitor Team because they do not find it helpful.  No evidence has been provided to the review to support these statements made by the GPs.     8 2.14 During the course of this review, Abigail’s mother told the Independent Overview Report Author and Head of Safeguarding that she did not have any problems with Abigail and that usually Abigail did not cry.  However on this day Abigail cried constantly for seven hours which is why they took her to see the GP.  Abigail’s mother also told the Independent Overview Report Author and Head of Safeguarding that Abigail did not suffer from colic again after she had started on the colic drops.  2.15 Eight days after the GP appointment, Abigail’s mother and paternal grandmother took Abigail to the baby clinic where a health visitor gave Abigail’s first immunisation.  This was a planned appointment and no concerns were reported.  Two days later Abigail saw a GP due to bilateral conjunctivitis for which eye drops were provided.  There is no record of who took Abigail to this appointment and no record of any discussion about anything else.  This was Abigail’s second visit to the GP with conjunctivitis, having previously been seen at 19 days of age with left eye conjunctivitis and ‘snuffles’.    2.16 On the evening of the following day, Abigail was admitted to the Emergency Department at Hospital with significant head injuries.  Sadly she died four days later as a result of the injuries.    3. Key issues and priorities for learning and change    3.1 Abigail’s death at nine weeks of age was a tragic event which is believed to be the result of non-accidental injuries she sustained whilst in the care of her father.  This review has not identified any factors that should, even with the benefit of hindsight, have led practitioners working with the family to predict that she was likely to sustain such injuries.  Abigail’s family were never identified as requiring specialist child in need or child protection services and, given the information that was known about the family, this was appropriate.  Abigail’s mother and father were both in their mid-twenties and in employment; they lived together and had support from their parents and other members of the extended family.  There was no known history of domestic violence, substance misuse or mental ill health.    3.2 Only universal services were involved with this family during the period under investigation.  The findings suggest that there were no indications that should have led to the involvement of specialist, protective services.  There was one occasion when Abigail’s parents reported excessive crying from Abigail; they believed that this was the result of colic and they sought help from the GP who provided a listening ear, practical advice and a prescription for colic drops.  This consultation took place 11 days before Abigail sustained the injuries that led to her death and during that 11 day period Abigail had two unrelated contacts with health professionals when her parents did not raise any further concerns about excessive crying and/or colic.    3.3 Although this review has not identified any factors that should have led practitioners working with the family to predict that Abigail was at risk, it is important that the review is used to identify areas where improvements can be made for the future and also to identify examples of good practice.     9 Agencies have carried out comprehensive reviews of their involvement with Abigail and her family in order to do this.  3.4 A significant finding was the difficulties in the relationship between GPs at the Practice where Abigail and her mother were registered and the Health Visiting team covering the local geographical area.  This demonstrates that the link health visitor arrangement instigated after a previous Serious Case Review has not been effective with that GP Practice.  Furthermore, GPs’ concerns about the Health Visiting Service had not been appropriately addressed with the result that Abigail was not referred to the health visitor in connection with colic because the GP did not think the health visitor would respond appropriately.  3.5 A key finding in a Serious Case Review undertaken in Wakefield in 2010 was that agencies had paid insufficient consideration to the child’s father and had not involved him enough.  Recommendations were made to address this.  This review has shown that, progress has been made and there is a commitment to continued progress within MYHT to ensure that staff consider the father / father figure when working with babies and young children.  3.6 The Serious Case Review undertaken in 2010 also identified difficulties with the management of information received by Child Health and the 0-19 service.  This review has found that there are still problems processing the information and these are exacerbated by an increase in the amount of information being received by the service.  The result of this is that, where there is not a priority need for a health visitor or school nurse to be given information about the outcome of a hospital appointment, it typically takes between five and ten weeks for information received by Child Health to be sent on to health visitors and school nurses.  A recommendation is made to address this problem.  3.7 Although practitioners asked Abigail’s parents questions in relation to issues such as domestic abuse, substance or alcohol misuse, mental health and any current or previous involvement with children’s social care services or the police they did not consistently record that they had done so and did not always record whether or not Abigail’s father was present at contacts.  It is anticipated that the introduction of Euroking should alleviate this record keeping problem within the midwifery service.  As a result of comments made by Practitioners about finding it difficult to ask such questions, supervision will be used to underpin a training needs analysis.  3.8 SystmOne, a computer based information system, is not being used to its full potential and this is having an adverse impact on the quality of information sharing.  One issue is that GPs cannot see the full health visitor record and in addition professionals are not using SystmOne to request tasks from colleagues.    3.9 Abigail’s mother was required to change GP Practice when she became pregnant because she lived outside the geographical area ordinarily covered by the practice and the Practice Nurse incorrectly told her that the Health Visiting Team would not provide a service to her at her address.     10 Although the GP Practice was entitled to ask Abigail’s mother to change Practice when she informed them that she changed her address it is regarded as inappropriate for a Practice to agree to a patient remaining in the Practice when they report a change of address which is outside the practice boundary, thus implying that the practice is happy for the patient to remain on their list,  and then to ask them to move to a different Practice when they require different or more intensive services whether those services are from the GPs or from other health professionals. It is not considered necessary for this SCR to make a recommendation regarding this issue as Primary Care Contracting will discuss it with the relevant GP Practice.  3.10 Although outside the scope of this review, Abigail’s mother and maternal grandmother have expressed their concern at not receiving any bereavement support, albeit that the GP tried to visit Abigail’s mother.  This review has found that the Health Visiting Team did not offer bereavement support but it was offered and provided by the West Yorkshire Police homicide service.  The Chair of Wakefield & District Safeguarding Children Board is going to ask the Child Death Overview Panel to review the existing bereavement support pathway.  3.11 An example of good practice within this review was that both the Midwifery and Health Visiting Services had an appropriate number of contacts with the family.  In addition the Midwifery Service provided good continuity of care to Abigail’s mother and the GP demonstrated a high level of commitment by seeing the family late in the afternoon on the day that Abigail had been crying for several hours.  The GP carried out an extensive consultation despite being due to finish work for the day.  4. Recommendations  4.1 The following five recommendations are made within the Individual Management Reviews and the Health Overview Report and these have all been accepted and signed off by the individual agencies.    Recommendation 1 – from MYHT IMR  The Associate Divisional Director of Operations (Integrated Care Division - MYHT) will ensure that robust systems are in place to enable information to be processed and shared with front-line practitioners in an effective and timely manner.   Recommendation 2 – to MYHT from Health Overview Report  By the 30th November 2012, the Rotational Service Lead for Children’s Services (MYHT) will undertake an evaluation into how the role of the link worker for GPs, as outlined in one of the recommendations from a previous Serious Case Review (Child D), has been established within every practice in the district.   Where deficits are identified an action plan will be prepared to address the gaps. This will be undertaken by 31st December 2012. The    11 recommendation will not be considered complete until the resulting action plan is fully implemented.  Recommendation 3 – to MYHT from Health Overview Report  The Chair of the MYHT Trust Safeguarding Group will ensure that, at the January 2013 meeting completed MYHT recommendations from Serious Case Reviews identified in the current Individual Management Reviews as not having been completed/ adhered to will be revisited.  Where it is identified that the recommendations have not been fully implemented, these recommendations will be reopened and actions monitored as part of this Serious Case Review Action Plan.  Recommendation 4 – to General Practice 2 from NHS Wakefield District, Primary Care IMR  Practice 2 must take urgent action to improve communication and demonstrate an effective working relationship with their Health Visitor team. This will be achieved by the end of March 2013.  Recommendation 5 – to all General Practices from NHS Wakefield District, Primary Care IMR  Given the importance of effective working relationships between GPs and Health Visitors, all GP practices will be required to demonstrate to the PCT that they have robust and effective mechanisms in place to ensure information is shared with Health Visitors and when received from Health Visitors is acted on in a timely way.  4.2 There has been a thorough process by which the Independent Overview Report Author and Serious Case Review Panel have been involved in discussing and refining the individual agency recommendations.  The Panel and Independent Overview Report Author are in agreement with all the recommendations.     4.3 The Independent Overview Report Author makes the following additional recommendations:  Recommendation 6 - to NHS Wakefield District  1. The named GP for Safeguarding Children for NHS Wakefield District will ensure that GP Practices are aware of the action they should take to escalate concerns if they are believe that other health professionals are not fulfilling their responsibilities.  Recommendation 7 - to General Practice 2  2. The Practice Manager at Practice 2 will make the manager of the Health Visiting Service aware of any recent examples of health visitors failing to respond to requests for advice or a service from the Practice.     12 4.4 Action plans have been written for the implementation of all the recommendations.  These action plans will be monitored by the Quality and Review Sub Committee of Wakefield & District Safeguarding Children Board to ensure that they are fully implemented.  