Death of a 9-week-old boy in November 2014 due to non-accidental head injury. Mother called 999 following a call from Child Ks father, indicating that Child K required medical assistance. Child K was staying with his father at the time. Child K died in hospital three days later and father was arrested.. Mother was a single parent and had worked well with health services during pregnancy and birth. Father previously known to Children's Social Care, associated with families where incidents of harm had occurred to two infants. Both children involved became subject to Child Protection Plans and it was acknowledged that Child Ks father had intermittently been involved in their sole care. Father was not charged with any offence relating to these injuries as shortly after the second incident he was sent to prison on unrelated offences. Child K was White/Black British. Uses the Child Practice Review process. Learning includes: health professionals working with families should remain professionally curious and be respectful when engaging in an effective relationship with parents; where information about fathers is not obtained by the time a child is 6-weeks-old, this should be treated as unusual and result in a review of the family. Recommendations include: ensure partner agencies have robust recording systems which include both parents' names, alias names, date of birth, address, GP, details of previous children; review Revised Practice Guidance on Bruising Babies (April 2015) to include guidance following a report of an injury in a pre-mobile baby when no bruise mark can be found on the day of disclosure.
      
 Title:  Serious case review: Child K. LSCB: Nottingham City Safeguarding Children Board Author: Kathy Webster Date of publication: 2017  This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC.  This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above.                                             Serious Case Review Child K                     Publication Date:  May 2017 Author:   Kathy Webster1    1. Introduction   1.1 This Review was commissioned by the Independent Chair of Nottingham City Safeguarding Children Board (NCSCB) on 15th January 2015, in agreement with the recommendation of the Serious Case Review Standing Panel; who considered the case and found that the circumstances surrounding the death of Child K met the criteria for a Serious Case Review.   Circumstances of the Serious Case Review  Subjects of the Review  Child – Child K age at death - 9 weeks – White/Black British Mother – age 29 - White British Father – age 39 - Black Caribbean    1.2 This review was undertaken as a result of the death of a 9 week old baby in the winter of 2014. A 999 call had been made by Child K’s mother indicating that Child K was in distress and required medical assistance. This call was made whilst Child K was in the care of his father. The local Ambulance Service attended the father’s home where the child had been staying and on arrival found that the child was in a serious condition. Mother was not present but had been contacted by Child K’s father.  1.3 Child K was taken to hospital, where after resuscitation Child K was transferred to the hospital’s Paediatric Intensive Care Unit (PICU). Child K was cared for a further three days on PICU and despite the best efforts of the medical team and nursing staff, care for Child K was withdrawn with the permission of his parents. Child K died the same day that treatment was withdrawn from a suspected non-accidental head injury. There were a number of other injuries noted on Child K’s body and the case was referred to the Coroner.  1.4 Child K’s mother was a single parent with no previous children. Health professionals who had contact with her reflected that there was nothing unusual about Child K’s mother and therefore, nothing that would make her stand out from any other pregnant woman or new mothers living in the local area. The area where mother lived was set in an environment where there was significant deprivation (deprivation index 35)1 including poor housing alongside more affluent properties and living conditions. The people living in the area are described as being an ethnically mixed population.  Mother appeared to work well with the health services that were provided to her during her pregnancy, birth and the early weeks of Child K’s life. It was reported that mother had good support from her family and friends.  1.5 Father was previously known to Children’s Social Care under a different name and had been associated with families where incidents of harm had occurred to infants. The first incident had occurred approximately 19 years prior to Child K’s birth and involved a 14 month old child who sustained a number of bruises to the face and body. Three years later another baby aged 8 weeks sustained a number of injuries which were deemed non-accidental. At the time of both incidents the children involved became subject to Child Protection Plans and it was acknowledged that Child K’s father had intermittently been involved in the sole care of both of the children concerned prior to them being injured.                                                    1 The English Indices of Deprivation 2015 Statistical Release 2  1.6 Father was not charged with any offence relating to these injuries as shortly after the second incident Child K’s father was sent to prison on unrelated offences. This matter is further explored at point 6.1 in this report.  1.7 The relationship between Child K’s mother and father was described as being “on and off” by professionals. At the beginning of the pregnancy the mother told health professionals that she and father were not together as a couple and that she did not have a relationship with him. Later in the pregnancy and following the birth, mother indicated that father would have some involvement in Child K’s care and she was happy for this, indicating that both mother and father were having contact with each other.   1.8 Mother lived with Child K in a one bedroom flat and father was living alone at his own address in another part of the city. Mother told the reviewer that she was keen for Child K to know his father and his father’s family.   1.9 Mother described Child K as an “easy, perfect baby”. Child K was growing and developing well and mother was happy caring for Child K. Health professionals had no concerns about the care given by Child K’s mother but knew very little about father, other than his name and that he had Child K staying overnight with him on a regular basis. In fact, father was caring for Child K from the age of three weeks for two nights per week.       2. Legal Context:  2.1 This Serious Case Review was commissioned prior to the publication of Working Together to Safeguard Children (2015). This Serious Case Review was undertaken in line with the principles of learning and improvement set out in Section 9 of Working Together to Safeguard Children (Department of Education March 2013).   3. Methodology:  3.1 The methodology used for this Serious Case Review was the Child Practice Review process (Protecting Children in Wales, Guidance for Arrangements for Multi-Agency Child Practice Reviews, Welsh Government, 2012). The decision to conduct the Serious Case Review in this way was considered and agreed by the NCSCB following the change in statutory guidance following The Munro Review of Child Protection: Final Report: A Child Centred System (May 2011). Munro suggests that Local Safeguarding Children Boards should use any learning model which is consistent with the principles in the Working Together to Safeguarded Children Guidance: chapter 4 on learning and improving (HM Government 2013).     3.2 The Child Practice Review process was introduced in Wales in January 2013 to replace their Serious Case Review process. This is an innovative formal process that allows practitioners to reflect on cases in an informed and supportive way. Documenting the full history of the child and family is not the primary purpose of the review. Instead it is an effective learning tool for Local Safeguarding Children Boards to use where it is more important to consider how agencies worked together. The full details of the case are not the main focus of the report which is succinct and centres on analysis, learning and improving practice. Although a review has been held, it does not mean that any practitioner or any professional practice has been wrong and it may be concluded that there is no need for change in either operational policy or practice.   3.3 The role of the NCSCB has been to engage with the partner agencies involved, to contribute to the analysis of case issues, to provide appropriate challenge and to ensure that the learning from the review can be used to inform systems and practice development. In  doing so, the Board may identify additional learning issues or actions of strategic importance. These may be included in the final Serious Case Review report or in the action plan as appropriate. 3   3.4 A Review Panel was established in accordance with the guidance. This was independently chaired by Amanda Clarke, Manager of Derbyshire Safeguarding Children Board and included representation from relevant organisations within Health, Police, Local Authority Children Services, and Probation. Whilst Probation had no role in the events leading up to the death of Child K, they had been involved historically with the father.  3.5 Kathy Webster, Consultant/Designated Nurse, Safeguarding Children and Children in Care, from Derbyshire Clinical Commissioning Group, was commissioned to act as the Independent Reviewer and to write the Serious Case Review Report.   3.6 The scope for the time period of this review is from 18th February 2014 to 11th November 2014 and covers the point from which it was known that mother was pregnant up until the date of Child K’s death. Significant historical events and incidents relating to Child K and family outside the scope of the review were also considered.   3.7 All agencies reviewed their records, provided timelines of significant events and a brief analysis of their involvement. This information was considered by the Review Panel and provided an opportunity for panel members to raise questions and clarify their understanding of the circumstances of the case and of the separate services provided. Agencies’ timelines were merged and used to produce an integrated timeline. This document was carefully analysed by the Independent Reviewer and the Panel who jointly identified the areas of interest requiring further exploration and consideration. The process also allowed for the identification of the key practitioners who were required to attend a Learning Event. The purpose of a Learning Event is to understand the detail of the single and inter-agency practice in this case. A summary of the integrated timeline is attached as Appendix 1.  3.8 The Chair of the Panel and Independent Reviewer met with Child K’s mother at her home address to gain an understanding of her experiences of the services offered. An invitation to meet with the father was offered. No response to this offer was received.    3.9 The feedback from mother was shared with the 16 practitioners attending the Learning Event held on 17th August 2015 and with the Panel on 05th October 2015.   3.10 The Learning Event was facilitated by the Independent Reviewer and was attended by the Chair of the Panel, Children’s Officer of the NCSCB and practitioners involved with Child K. The Learning Event was organised in line with Welsh Government guidance (Child Practice Reviews Organising and Facilitating Learning Events, December 2012). A record of the event was made and has been retained by NCSCB.  3.11 Following the Learning Event, the Independent Reviewer collated and synthesised the learning to date for discussion with the panel. Practice issues originally identified by the Panel were re-examined in the light of the findings of the Learning Event. This also provided opportunity to identify issues requiring further clarification with practitioners or managers. In reviewing the findings, the Panel gave consideration to what could be done differently to further improve future practice. A draft report was provided for Panel meeting held on 05th October 2015.      3.12 Both parents were contacted prior to publication and offered the opportunity to discuss and comment on the findings and conclusion of the review. Child K’s mother took up this offer. Father did not engage.     4  Analysis of  Practice and  Organisational Issues Identified  The following information has been extrapolated from the detailed scrutiny of multi-agency involvement and reflection by practitioners and panel members.  There were areas of good practice noted by the reviewing panel and also identified by Child K’s mother. A number of areas have been identified where multi-agency practice could be improved in order to provide better safeguarding arrangements across agencies in Nottingham City. These are as follows:   4. Identification and support of fathers and recognition of their involvement in the life of a child.  “Men play an important role in children’s lives and have great influence over the care they receive. Despite this, they can be ignored by professionals who tend to concentrate their focus on the quality of care provided by mothers and female carers” (Hidden men: learning from serious case reviews – NSPCC 2015)  4.1 One of the main features of this case is a lack of knowledge and information known to professionals working with mother and Child K (including during her pregnancy) about the father of Child K. Generally, the belief of practitioners who attended the Learning Event was that father and mother were not together as a couple and that their relationship was described as being “on and off”. Mother originally told health professionals that father would not be supportive in the care of Child K. This position subsequently changed with mother stating that father would be supportive and was going to be involved in the care of Child K. Health professionals did not have any information about father except for a name that was recorded in the Health Visitor record at the antenatal visit on SystmOne. SystmOne is the electronic patient record which is used to input child and family information and to record any patient contact and relevant health intervention.     4.2 There were a number of opportunities identified at the Learning Event for professionals to obtain further relevant details about father. The Independent Reviewer shared with the Learning Event that mother was asked why she had not provided information about the father at the booking appointment which is the standard time for midwives to obtain information about fathers. Mother had stated that she was “just not ready” to tell professionals at the beginning of the pregnancy.  Asked if she would have provided full details of father at a later stage she replied that she “would have been happy to do so”. In fact, mother thought that professionals would ask a lot more questions than they did about father.   4.3 Health professionals working with families should remain professionally curious and be respectful when engaging in an effective relationship with parents. Honest and open dialogue between all participants should be an expectation of any effective health care relationship with patients/parents. More information about who is going to be involved in the baby’s/child’s life should be a routine part of gathering information to inform a holistic health assessment.  4.4 The midwifery and health visiting professionals at the Learning Event stated that a new field to capture father’s details more effectively had now been added to the electronic patient record (SystmOne). The Learning Event concluded that in cases where information about fathers was not obtained by the time a child is six weeks of age; this should be viewed as being very unusual and result in a review of the family situation with the Named Midwife/Nurse/Doctor within the health provider organisation offering services for the child. The Learning Event recommended that the father’s details section of SystmOne should become a “mandatory field” and include relevant details (name, dob, address, GP, previous children and their dob and any contact arrangements). It was felt that a “mandatory field” reminder on the SystmOne record would be a supportive tool to help practitioners fully comply with record keeping requirements and to act as a prompt to request information at a later stage.   4.5 When Child K was five weeks old mother informed health practitioners that father had been caring for Child K on an overnight basis. Although the Independent Reviewer felt this was a little unusual given 5  that the baby was still very young, practitioners did not feel this was unusual for the community in which they worked. The Independent Reviewer felt that this may have been a good opportunity for the health visiting team to make telephone contact with father to ensure that he had made the relevant safe sleeping arrangements and any other advice which is routinely given to new mothers. An invitation to attend the local children centre could also have been considered. Health providers and commissioners should consider how services engage and work with new fathers; particularly those providing primary care in the absence of the birth mother over significant periods, to ensure that they are adequately supported.   4.6 It is evident from the timeline that not only is little known about father but that he was rarely seen by the health professionals until after the child was injured. There was an incident when Child K was 5 days old when it was recorded that “parents” pointed out that Child K had a Conjunctival Haemorrhage suggesting that father is present at this point. There is nothing to suggest that the conjunctival haemorrhage was anything other than a condition relating to the birth. A Body Map had been included in the Parent Held Record which suggested that there were no marks on the child at the new birth examination in the hospital. There is Health Guidance on Conjunctival Haemorrhage which was appropriately followed with no further action being required other than observing the child’s eye over a number of days until the haemorrhage had resolved.   5. Importance of joined up assessment and record keeping.   5.1 Nottingham City has good multi-agency team working arrangements based around the Children Centre model. Midwives, Health Visitors and Local Authority Family Support Services see families in the same building and have good working relationships.  5.2 There is an issue for midwives in that the maternity service has separate IT recording systems, in the hospital (Medway) and the community (SystmOne.) These were not compatible with each other although it is understood that there is ongoing work to have a unified record for midwives.  5.3 Maternity services has a system in place that enables community midwives to record information about social circumstances onto Medway, ensuring appropriate relevant information is shared with hospital colleagues to ensure continuity of care. The Learning Event heard that there was an arrangement in place at the time for community midwives to help each other out by way of inputting each other’s information onto the Medway system. This may have led to a discrepancy between the hospital and community midwifery record in relation to the enquiry on domestic abuse which took place at the community midwives first appointment and resulted in the hospital and community midwifery records reporting different responses to the domestic abuse question.  5.4 The Independent Reviewer was told by the mother that she attended Antenatal classes but this was not recorded in any of the Midwifery records. It is important for Maternity Services to review their recording systems to ensure that the hospital and community IT record systems are unified to avoid duplication of work and to avoid inputting mistakes and omissions.    5.5 Midwives have a further patient record “Patient Hand Held Record” which the pregnant mother keeps until after the discharge by the midwife. The antenatal record is retained by the hospital after delivery and the postnatal hand held record is returned to the hospital for filing in the mother’s record, when discharged from midwifery services. This means that midwives working in the community have 3 records to complete. Although the mother’s held record is a nationally recognised process it gives added weight to the rationale that the Midwifery records should be rationalised as identified above.  5.6 Health Visitors also use the SystmOne IT system which can be seen by midwives and other members of the Health Team (excluding hospital midwives who currently do not have access) and in most cases it does link with GP systems. However, in this case the GP system in use is EMIS. There are plans for EMIS to be linked with SystmOne in the near future.  6  5.7 When Child K’s mother was approximately 16 weeks pregnant she attended the Children’s Centre for an unplanned contact with the midwife following a mix up with the dates for her appointment. At this contact, mother stated that she was “struggling to manage” with finances and the midwife advises mother to see a Family Support Worker in the Children Centre for advice.  The extent of the problem is not fully understood by the midwife and although the mother stated that she was to meet with a Family Support Worker, she did not in fact do this; consequently the issue around mother’s ability to manage later in the pregnancy was not followed up.  5.8 This may have been an opportunity for the midwife to consider the additional needs of the mother and to make a more formal “request for services” from the Family Support Service. This may have promoted multi-agency professional discussion and information sharing. Effective joint working and assessment provides opportunities to build up a picture of the family dynamics to enable a better understanding of the strengths and weaknesses within families to better safeguard children.  5.9 It was recognised at the Learning Event that had health professionals been aware of fathers past history, this would have led to a Child Protection referral being made on behalf of the unborn child.   6. Flagging records and tracking adults who pose a risk to children.   6.1 Information from the Police indicates that the Crown Prosecution Service (CPS) decision not to charge father for the previous assault on another child was taken because, although there was sufficient evidence to support a criminal prosecution for this assault, the fact that father was already serving a substantial prison sentence for unrelated matters meant that the advising lawyer felt it was not in the public interest to charge with the assault on the child. Had father been prosecuted for this offence he would have been identified as an individual posing a continuing risk to a child and his movements through the criminal justice system would have been the subject of the national notification system. It should be stressed that this decision had no implications in this case given the wider circumstances described above. That said this is an issue which in other cases may have implications for how potentially risky individuals are identified and so merits comment in the context of this review.   6.2 Following Child K’s emergency admission to hospital Children’s Social Care, when contacted, were able to quickly identify father despite his change of name.   7. Multi-agency Protocol to support and clarify what to do when a pre mobile baby has a bruise or mark reported which can no longer be seen.  7.1 There was an incident reported when Child K was 5 weeks of age. Mother reported to the visiting Nursery Nurse (from the Health visiting team) that Child K had a mark near his right eye. The explanation given was that whilst Child K was staying overnight at his father’s house, Child K’s cousin (also a baby and six weeks older than Child K) who was also present at the house, was lying next to Child K and accidentally hit Child K in the face leaving a mark as described.   7.2 At this stage the practitioner could not see a mark as indicated. Child K was undressed and examined with no marks noted on the record. It was also recorded that Child K was clean, warm and appropriate care was observed by mother.    7.3 Mother recalled the incident to the Independent Reviewer and mother stated that she was very worried about what was going to happen when professionals saw the mark. She expressed that she felt the mark was there when the Nursery Nurse inspected Child K’s face and mother was surprised that no further action was taken. The Nursery Nurse appropriately discussed the incident with the case holding Health Visitor and it was decided that no further action was needed.    7.4 The Health Visiting Team at the Learning Event reflected that if they had made a referral to Children’s Social Care at this point (because there was no injury to be seen) Social Care would not have 7  taken any action. The Independent Reviewer asked the Children’s Social Care manager what they felt the response would have been. The Children’s Social Care manager stated that this incident may not have triggered a Child Protection investigation at this point, but may have triggered relevant information checks on Social Care data systems for both of the parents. This may have led to Social Care identifying that the father was a risk to children and a Child Protection investigation would have been initiated at this point.  7.5 On examining the NCSCB Revised Practice Guidance on Bruising in Babies (April 2015) the Independent Reviewer found that the guidance does not cover what to do in situations where there is a reported injury/bruise/mark in a small baby which cannot be seen on the day of examination. This should be addressed and should be done so urgently through the NCSCB policy and procedure group.   8. Parental Education Programme to aid in the prevention of non-accidental head injury.  8.1 This case centered on a 9 week old baby who died following a non-accidental head injury.  Non-accidental head injury remains the most common cause of fatal child maltreatment. An analysis by the NSPCC released in November 2013, puts the number of babies under one suffering from a serious non-accidental head injury in England and Wales each year at approximately 24 per 100,000 live births. At least half of the survivors have significant neurological impairments.  8.2 This form of child abuse differs in a number of ways from other more common and more visible forms of abuse;  1) A single event may cause a catastrophic outcome 2) Often there are no visible signs of injury 3) There is frequently no intent to harm the child 4) The immediate and follow on outcome is worse than with other causes of head injury in childhood (Bruce & Zimmerman 1989) 8.3 Shaking events do not appear to be related to race, class or family circumstance (Sinal et al., 2000)  although risk does increase in families where there are more stressors and fewer resources (Sanders et al.,2003). 8.4 In the majority of cases the perpetrator is thought to be the father or father figure for the infant (Dias et al 2005) with the primary trigger being linked to inconsolable crying. 8.5 Whilst it is recognised that shaken baby events are a crime, it is also a Public Health issue. There are a number of research studies which highlight the effectiveness of Public Health programmes which focus on the prevention of shaken baby syndrome (Centre for Disease Control and Prevention – U.S. 2010). 8.6 A number of effective strategies have been suggested in research that helps to raise awareness and to educate parents and caregivers about the serious impact of baby shaking injuries; to inform them about crying behaviour, and safe ways to reduce and prevent baby shaking events. Strategies have included hospital based primary prevention programmes which target parents of new-borns (Dias et al 2005) and NSPCC “Helping parents cope with babies crying” pilot programme, (April 2014) which centres on parental education. Wider community focus initiatives involving schools, father groups and multi-agency professional education and training have also been suggested.    8.7 The overarching advice suggests that a framework for the prevention of shaken baby events should be built on what is already available, feasible and has the greatest level of evidence of effectiveness. 8   8.8 Programmes to reduce the incidence of shaken babies have already been successfully implemented internationally and across areas of England and Wales. NCSCB should work with commissioning partners across Public Health, Clinical Commissioning Groups, NHS England and the Local Authority, to review the available research and consider the options for the implementation of a suitable Public Health programme; which addresses the need to raise awareness of the dangers of shaking a baby and how to cope with inconsolable baby crying.  9. Good Practice   9.1 A number of areas of good practice have been identified as follows:   Continuity of care by the midwife during the pregnancy   Additional visits by the Health Visitor to mother to provide support for mother   Continued support by the GP and the GP practice particularly following the child’s death.  Local Stop Smoking Service who managed to reduce mother’s smoking down to 1 cigarette per day, during her pregnancy. Mother felt that this was a good service and she would use them again in the future if she wanted to stop smoking  Local Ambulance Service who diverted their journey immediately to assist Child K following the alert, thus enabling them to get to the child within 3 minutes  Emergency Department and Paediatric Intensive Care Unit effective working arrangements to ensure seamless care of Child K between the two departments.  Rapid, effective joined up response by Nottingham City Emergency Duty Team, Police, and NUH following the incident. 10. Conclusion  10.1 There is nothing to suggest that any professional in this case could have predicted or prevented the death of Child K, neither has there been any reason to believe that the child’s ethnicity had any bearing on the case.  10.2 Professionals who came into contact with Child K and the family acted in good faith and in accordance with the policy and procedures available to them at the time. Scrutiny of practice always provides an opportunity to consider ways in which services may be improved and therefore the following practice issues, based on the learning from this case, have been made as follows:   11. Practice Issues – a practice issue is a practice activity which should already be in place and requires action to strengthen practice effectiveness.   1. Health Professionals working with children and families should be reassured that parents expect to be asked “contentious” questions and for professionals to be curious about absent fathers and family dynamics.  2. Maternity Services should review their patient recording systems to ensure that the hospital and community IT record systems are unified as far as possible.  9  Improving Systems & Practice  - RECOMMENDATIONS   12. In order to promote the learning from this case, the review identified the following actions for Nottingham City Safeguarding Children Board and its member agencies:  1. NCSCB should ensure that this report is made available to partner agencies (including CPS) to share with local practitioners and cross border LSCBs to inform practice and widen learning.  2. NCSCB should ensure any practice issues identified in this review are considered by the partner agencies identified. 3. NCSCB should ensure that partner agencies providing services for children and families have robust recording systems which include details about both parents and identify: parents’ names, alias names, DOB, address, GP, names of previous children and their DOB and any contact arrangements in place for those children.  4. NCSCB should request evidence from the Commissioners and Providers of Maternity Services and Health Visiting Services that they have reviewed their services and can demonstrate arrangements which promote, engage and support fathers of new babies. 5. NCSCB should review the following Guidance:  Revised Practice Guidance on Bruising in Babies (April 2015) to include what to do following a report of an injury in a pre-mobile baby when there is no bruise or mark to be found on the day of disclosure. 6. NCSCB should request Public Health review all the relevant research and evidence, alongside consideration of the local context; in order to advise the safeguarding board on the most effective method to communicate to parents and families of the dangers of shaking a baby, and how to cope with an inconsolable crying baby. REFERENCE  * Protecting Children in Wales – Guidance for arrangements for multiagency - Child Practice Reviews (Welsh Government 2012) * Working Together to Safeguard Children. DFE 2013   * The Munro Review of Child Protection: Final Report: A Child Centred System. (May 2011)   * The Dad Project (NSPCC 2015) * Family Support Pathway – Nottingham Children Partnership 2014-2015 * Revised Practice Guidance on Bruising in Babies (April 2015) * Subconjunctival Haemorrhage  Guidance – Nottingham Children’s Hospital (2014)  * Dias, Mark, Smith, Kim, deGuehery, Kathy, Mazur, Paula. Li, Veetai and Shaffer, Michele – Preventing   Abusive Head Trauma Amongst Infants and Young Children.   *Paediatrics’ official journal of the American Academy of Paediatrics’ Volume 115 No 4 pp 470-477. *Preventing Shaken Baby Syndrome – A guide for health departments and community-based organizations (U.S. Department of Health and Human Services - Centres for Disease Control and Prevention (2010). *NSPCC - Helping Parents Cope With Babies Crying – Evidence from a pilot programme to support parents and keep babies safe (Sally Hogg and Denise Coster – April 2014)  10  Statement by Reviewer  Kathy Webster. Consultant/Designated Nurse for safeguarding children and children in care            Statement of independence from the case - Quality Assurance statement of qualification  I make the following statement that prior to my involvement with this learning review:-    I have not been directly concerned with the child or family, or have given professional advice on the case.  I have had no immediate line management of the practitioner(s) involved.   I have the appropriate recognised qualifications, knowledge and experience and training to undertake the review.  The review was conducted appropriately and was rigorous in its analysis and evaluation of the issues as set out in the Terms of Reference. Reviewer 1      Name       Kathy Webster     Date 8th April 2016     Chair of Review Panel      Name Amanda Clarke   Date    06.04.2016             NCSCB 04.01.2016 11 Appendix 1 Composite Timeline Date Source of information Agency  Significant Event 05.02.2014 GP records - mother GP Patient Pregnant  -   18.02.2014 Hospital Record NUH Booking appointment: Full information (inc. mental health screening) gathered on pro-forma.  18/03/2014 SYS1 (GP record) NUH (Community Midwives) Unplanned contact with Community Midwife at Children’s Centre, attended a week earlier as had mixed appointment dates: stated „struggling to manage‟. Advised to see Family Support Worker 18/3/2014 Hospital Record NUH Antenatal appointments: Attended Ante-natal clinic alone. Birth plan details recorded – wanted Mum present if assisted delivery 01.04.2014 GP records – CM GP Letter  of contact with New Leaf - support to stop smoking and therapy in progress  27/05/2014 SYS1 (GP record) NUH (Community Midwives) Booked Ante-natal appointment: needs support re. Housing and benefits. Due to see Family Support Worker that day 03.06.2014 SystmOne Record:   Nottingham CityCare Health Visiting and School Health Health Visitor – Routine Home visit: disclosed fathers identity, and mother stated that she was happy for him to be at the birth. 30/06/2014 SYS1 (GP record) NUH (Community Midwives) Booked ante-natal Appointment:  „”resumed relationship with father of unborn – wishes to be involved” Domestic violence questions asked – CM response „Never‟.  29/8/2014 SYS1 (GP record) NUH (Midwifery support worker MSW) Home visit by the Maternity Support Worker (MSW) to look at where Child K is going to sleep, talk about safe sleeping, feeding, induction of labour and postnatal exercise. 06/09/2014 Hospital Record NUH Hospital Admission: Admitted to Nottingham City Campus in early labour accompanied by mother and friend (not partner) 07/09/2014 Hospital Record NUH Failure to progress in labour: Caesarean Section performed.  07.09.2014 SystmOne Record:   Nottingham CityCare Health Baby born 39/40, 3.97kg by emergency caesarean section. (75th Centile) NCSCB 04.01.2016 12 Date Source of information Agency  Significant Event Visiting and School Nursing Service 08/09/2014 Hospital Record NUH Child K - Neonatal examination undertaken: heart murmur heard but probably not significant. Murmur not heard when examined the next morning. Body Map completed correctly denoting no marks were seen. 09/09/2014 Hospital Record NUH Mother and Child K Discharged:  12/09/2014 SYS1 (GP record ) Baby record NUH (Community Midwives) Midwife home visit to perform Newborn blood spot screening. Parents pointed out small sub conjunctival haemorrhage on the right eye. Not previously documented. Parents said they saw it 3 days before. 17/09/2014 SYS1 (GP record) Nottingham CityCare Health Visiting and School Nursing Service Health Visitor Birth visit at Home : stated not in relationship, good support from father of Child K 29/09/2014 SYS1 (GP record) NUH (Community Midwives) Post-natal appointment with Community Midwife: Discharged. Records returned to NUH for filing. Doing well and good support. Discussion re. SIDS, contraception and registration of birth recorded in record. 13.10.2014 SystmOne Record:   Nottingham CityCare Health Visiting and School Nursing Service Rearranged appointment for routine weight review by Community Nursery Nurse Baby 5 weeks old weighed; is 4.87 kg – noted as “in between 75th and 50th centile.    During visit - Mother reported that child K had a mark near right eye due to cousin (who apparently is 6 weeks older) hit him by accident.  The worker present recorded that no mark could be seen near the right eye today”.  28.10.2014 SystmOne Notes Nottingham CityCare Health Visiting and School Nursing Service Routine 6-8 week review carried by Health Visitor at 7 weeks old   04.11.2014 GP records  GP mother  Routine postnatal examination of mother 04.11.2014 GP records  GP Child K 6-8 week medical by GP. No concerns noted and for immunisations 1st immunisations administered by Practice Nurse and all vaccinations given documented NCSCB 04.01.2016 13 Date Source of information Agency  Significant Event to system 08.11.2014 Emergency Operations Centre (EOC)Call Logs  East Midlands Ambulance Service 08.57hrs 999 call received from Mother Mother, who was not with baby, stated that Father had telephoned her saying that Child K was choking and not breathing and that father was unable to get through to raise help on the 999 telephone system, he said Child K was not awake and comatose.  08.11.2014 EOC Call Logs EOC Sequence of Events Log East Midlands Ambulance Service 08.58hrs Ambulance despatched to Child K fathers address An Ambulance was diverted from a lower graded call to this location. 08.11.2014 EOC Call Logs EOC Sequence of Events Log Recording of outgoing call  Patient Report Form (PRF) East Midlands Ambulance Service 09.03hrs Ambulance crew at patients side EOC call ended Child K unresponsive  08.11.2014 EOC Call Logs EOC Sequence of Events Log Patient Report Form (PRF)  East Midlands Ambulance Service 09.13hrs:  Ambulance departed scene for Emergency department. Life support and a pre-alert call was made to the Hospital, unfortunately Child K‟s condition did not improve on route to the hospital.  09.19hrs:  Ambulance arrived at ED 10.21hrs:  Police informed of details 10.54hrs:  Ambulance safeguarding referral raised 08/11/2014: 9.57 Hospital Record NUH Child K admitted to QMC Emergency Department  08/11/2014   Time 10:16  EMAS notified Police  POLICE Call received from Ambulance regarding a 2 month old child.  Call made by the At 1715 hours on 08/11/2014, Police Officers attended the PICU NCSCB 04.01.2016 14 Date Source of information Agency  Significant Event 08/11/2014: 10.20 Hospital Record NUH Admitted to ICU after resuscitation in ED. Examination showed potential NAI injury. Referral to Children Social Care Services Emergency Duty Team and Police by Senior Registrar. 08/11/2014: 18.45 Hospital Record NUH Meeting of Critical Care Consultant with parents: Poor prognosis explained. EDT and Police already involved: decision made that parents access to Child K should be supervised by either of maternal grandparents 08/11/2014 T/C Doctor at Queens Medical Centre Social Care Contact made with EDT. Concerns raised in respect of nature of the injuries  08/11/2014 Social workers electronic records Social Care Strategy Discussion undertaken and Section 47 enquiries initiated  Visit to PICU at 5.40 by Social Workers from EDT. Police are present during the visit.  09/11/2014 Hospital Record NUH Consultation with other specialties finds no brain activity for Child K.  10.11.2014 GP records – CM GP Contact from Health Visitor by telephone to indicate Child K was admitted to hospital in cardiac arrest, when in care of father. Suspected NAI.  11/11/2014: 11.00 Hospital Record (Nursing record) NUH Strategy meeting convened by Social Care and held at NUH. 11/11/2014: 16.29 Hospital Record NUH Care was withdrawn at 16:29.  The case had been referred to the Coroner.  Full bereavement protocol initiated including a keepsake box. 11/11/2014 Social workers electronic records Social Care Child K was withdrawn from life support care and passed away approximately 16:41pm Father arrested at the hospital.     