Death of a 1-month-old infant in Winter 2014. Ambulance service found Child BV unresponsive in 2-year-old sibling's bedroom, lying between the bed and wall. Both parents had consumed large quantities of alcohol the previous day and could not remember how or why BV was in sibling's room. Family were known to universal services only, including GP, health visiting and nursery service. There was no current or historic involvement with children's services or the police. Father attended Accident and Emergency one month prior to BV's birth, after a collapse linked to alcohol withdrawal. He disclosed that he was a regular heavy drinker and saw GP afterwards but did not seek further treatment as suggested. Sibling's nursery noted that Father smelt of alcohol on two occasions following BV's birth. Issues explored include: alcohol use and the safe care of children; the importance of engaging with fathers; the importance of professionals sharing information about excessive alcohol use by families; safeguarding requirements for nursery providers; and safe sleep support. Uses the Welsh Model for case reviews. Recommendations include the Safeguarding Children Board (LSCB) to: campaign to raise awareness for parents, carers and professionals about the risks of alcohol use and the care of young children; explore opportunities to better engage with expectant and new fathers; and look at introducing safe sleep assessments to be undertaken by health professionals.
      
 Title:  Serious case review: Child BV: overview report. LSCB: Blackpool Safeguarding Children Board Author: Amanda Clarke Date of publication: 2015  This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC.  This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above.                              Serious Case Review Child BV Concise Child Practice Review  Review Process This serious case review was commissioned by the Independent Chair of Blackpool Safeguarding Children Board (BSCB) on 6th March 2015, in agreement with the recommendation of the BSCB Case Review Sub Group that the circumstances surrounding the death of a child met the criteria for a serious case review.  Circumstances resulting in the review   Subject of the review:   Child BV:  Aged 1 month (deceased)  In the winter of 2014 in the early afternoon, the ambulance service was called to the address of Child BV who was said to have been found at home in a bedroom, in a position between a bed and the wall, unresponsive. Life support was initiated at the scene and continued in the ambulance but sadly attempts at resuscitation were unsuccessful and Child BV was pronounced dead at hospital.  The full circumstances resulting in the death of Child BV in this case are yet to be established by the coroner. However, it is known that at the time of the ambulance attending the home, both parents and a sibling were present. Accounts have been obtained that the couple were celebrating a special occasion at home and in a local public house, with friends and the two children, with alcohol being consumed by the adults throughout the afternoon and evening, and overnight into the next day. Child BV’s Mother went to bed around 1am, leaving Father and Child BV, who was in a baby rocker, downstairs, with guests still present. Father finally went to bed at 6am, when the guests left. It is unclear what happened next but Mother recalls attending to the young sibling at 4am, and feeding Child BV at around 5am. It is not known where Child BV was placed to sleep after this final feed or by which parent. Child BV was said to normally sleep in the parents’ bedroom where there was a moses basket. It is known that the family slept through the whole morning until being woken by Child BV’s sibling for a nappy change at 12 midday. At this time the Father could not initially locate Child BV, who was not in the parents’ room, but eventually found the baby on the floor between a bed and wall in the sibling’s bedroom. Both parents cannot account for how Child BV came to be found there.     Child BV was 1 month old at the time of the death. The Child lived with birth parents and one sibling who was aged two at the time. Both parents worked but at different times of the day and the care of Child BV and the sibling was shared between them. The couple had lived in the same area for a number of years, although the Mother was originally from elsewhere in the United Kingdom. Both children were born in the local area, accessing the same local services. Child BV’s sibling attended a private nursery close to the home for three funded afternoon sessions per week.   Child BV before the incident was described as a generally well child. The family accessed only universal services and engaged with professionals as necessary. There was no current or historic involvement with children’s services or with the police.  BSCB_SCR BV_FINAL_9November2015 1 Legal Context:  A serious case review was commissioned by Blackpool Safeguarding Children Board, following agreement at Blackpool Case Review Sub Group in accordance with Working Together to Safeguard Children (Department for Education 2013).  Regulation 5 of the Local Safeguarding Children Boards (LSCB) Regulation  2006 sets out the functions for LSCBs. This includes the requirement for LSCBs to undertake reviews of serious cases in specified circumstances. Regulation 5(1) (e) and (2) set out an LSCB's function in relation to serious case reviews, namely:  5. (1) (e) undertaking reviews of serious cases and advising the authority and their Board partners on lessons to be learned.  (2)  For the purposes of paragraph (1)(e) a serious case is one where:   (a) abuse or neglect of a child is known or suspected; and   (b) either (i) the child has died; or (ii) the child has been seriously harmed and there is cause for concern as to the way in which the authority, their Board partners or other relevant persons have worked together to safeguard the child.  The methodology used was the Child Practice Review process (Protecting Children in Wales, Guidance for Arrangements for Multi-Agency Child Practice Reviews, Welsh Government, 2012).  This is a formal process that allows practitioners to reflect on cases in an informed and supportive way. Documenting the 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 detail of the analysis undertaken of the case is not the focus of the reports which are succinct and centre on learning and improving practice. However, because a review has been held, it does not mean that practice has been wrong and it may be concluded that there is no need for change in either operational policy or practice. The role of Safeguarding Boards is to engage and 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 so doing the Board may identify additional learning issues or actions of strategic importance. These may be included in the final child practice report or in the action plan as appropriate.  Methodology:  Following notification of the tragic death of Child BV in this case, and agreement by the chair of the Blackpool Safeguarding Children Board to undertake a Child Practice Review, a Review Panel was established in accordance with guidance. This was Chaired initially by Linda Evans, Principal Social Worker for Blackpool and subsequently by Paul Threlfall, Business Development Manager for BSCB, and included representation from relevant organisations within Health, Education, the Police, the Ambulance Service and Social Care.  Amanda Clarke, an independent reviewer from Derbyshire was commissioned to work with the panel and to undertake the review. The time period for this review is between 30th April 2014 and 26th December 2014 to reflect the point at which Mother booked as pregnant with Child BV to the time of death. Full terms of reference for the review are included in Annex 1.  All relevant agencies reviewed their records and provided timelines of significant events and a brief analysis of their involvement. These were considered by the panel and provided opportunity for panel members to raise questions and clarify understanding of the circumstances of the case and of the separate services provided. The agency timelines were merged and used to produce an interagency timeline. This was carefully analysed by the Reviewer with the Panel and informed of the areas of interest that required further exploration and consideration. The process also allowed BSCB_SCR BV_FINAL_9November2015 2 for the identification of the key practitioners required to attend a learning event in order to understand the detail of the single and interagency practice in this case.   The Reviewer and a member of the panel met with the Mother of Child BV in July 2015 to gain an understanding of her experiences of the services offered. An offer was made to meet with the Father of the Child and he was eventually able to contribute to the review in a telephone call with the Reviewer in September 2015. This valuable insight into their experiences was shared with the Panel and the Mother’s views were shared with practitioners attending the learning event. Account was taken of the views of the parents when writing the report and recommendations, and the Reviewer is grateful for their contribution.   The learning event was held in July 2015 and was attended by 5 professionals who had had direct involvement with Child BV and/or significant family members, in addition to the Reviewer who facilitated the session, the Chair of the Panel and a minute taker. The learning event was organised in line with Welsh Government guidance (Child Practice Reviews: Organising and Facilitating Learning Events, December 2012) and minutes were recorded of the event. With the support of panel members and the Blackpool Safeguarding Children Board team, further enquiries were made with health professionals who were unable to attend the learning event, and this information is included in the report.    Following the learning event, the 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 review. This 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 to the panel in advance of the panel meeting on 24th September 2015.  The Reviewer will offer to meet again with the family to provide them with the opportunity to see a copy of the report when completed and agreed by the Blackpool Safeguarding Children Board. Learning from the full report will be made publically available after consideration by the Blackpool Safeguarding Children Board Case Review Sub Group and the Board.  ANALYSIS: Practice & Organisational Issues Identified  Child BV and the family, were engaged with a number of universal services during the period of this review, including the GP, the Ambulance Service, a Nursery, Midwifery and Health Visiting Services. Scrutiny of the timeline, information shared and reflections at the panel meetings and the learning event have highlighted areas of good practice and also provided an opportunity for wider learning to emerge about the ways in which services work together. The following is an analysis of the issues identified:  1. Safe care of children and use of alcohol   Father of Child BV admits to being a daily heavy drinker and had collapsed a month prior to Child BV’s birth with a fit suspected as linked to alcohol withdrawal. The nursery of Child BV’s sibling had also twice noticed Father smelling of alcohol during drop off/ pick up times for the sibling, in the early weeks after Child BV was born. Incidents of significance outside of the review time period included Father attending the Emergency Department in 2009 with possible alcohol induced gastritis, and a Health Visitor record in the first month of Child BV’s siblings’ life (in 2012) which noted Father admitting to using alcohol daily but declining an offer of support. However neither historical episode considered individually was cause for concern.  In the 24 hours leading to Child BV’s death both parents said that they had consumed a large BSCB_SCR BV_FINAL_9November2015 3 quantity of alcohol. This was whilst caring for their two young children. After socialising the previous afternoon, in a local public house with the children present, and continuing into the evening at home, Mother went to bed in the early hours. This left Child BV downstairs with Father, with the sibling already in bed. It is unknown what happened in terms of Child BV being put to bed or where after being fed at 5am, as both parents were unable to account clearly for their actions regarding Child BV overnight and into the following morning.   Alcohol was evidently a feature in the lives of Child BV’s family, due to Father’s regular drinking, including over the 24 hours leading to the death. However, prior to the incident in the winter of 2014, the parents appeared to be providing a relatively safe environment for their children. There was no evidence at the address, or noted by visiting professionals, before this incident to suggest alcohol was a problem impacting on the children.   In post natal appointments parents, and mothers-to-be in particular are asked questions about their alcohol consumption, substance misuse and smoking. Both parents of Child BV were present at the health visitor’s ante natal visit in August 2014 when drinking and smoking was discussed. The couple described themselves at the time as “social drinkers” but this was not explored further. The phrase “social drinkers” is a well known expression but its use by professionals as a description of parents’ alcohol consumption requires additional clarification, particularly in patient/ family records.     Mother was able to repeat safe sleep advice that she had been provided by professionals through both pregnancies, and Father also remembered receiving safe sleep information. It was apparent that no guidance was shared in this case either before or after Child BV was born relating to safe care of children whilst parents are drinking alcohol. Alcohol use is included in safe sleep guidance both nationally and locally, but this relates to risks of bed sharing with babies when under the influence of alcohol. There is limited specific information for parents and carers about the risks to children in terms of safe care when adults have consumed large quantities of alcohol.    Blackpool Safeguarding Children Board issued guidance in October 2012 titled Assessing the Impact of Alcohol Use on Children and Families-  described as signposting guidance for practitioners who work with Parents and Carers. However, health professionals informed the review that this guidance is rarely used even though research shows that an estimated 2.6 million children in the UK live with a parent whose drinking puts them at risk of neglect and 705,000 live with a dependent drinker including 26,000 babies under 1 in England (Source: Journal of Public Health, Victoria Manning et al 2009). The 2012 guidance (above) is for professionals, albeit infrequently used, and there is no consistent message or advice provided to parents and carers regarding alcohol use and the risks to children when in their care.  Clear information for parents and carers containing key messages about alcohol use and safe care of children, would highlight the risks, and not just with regard to safe sleeping of infants, which is evidenced as being provided satisfactorily in the locality where this incident took place. Additionally, information provided to the licensing trade regarding the consequences of caring for children whilst adults are under the influence of alcohol in licensed premises may provide a further opportunity for some children to be safeguarded.             2. The benefits of multi agency coordination through Early Help processes to support children and families.   Working Together 2015 is very clear that local agencies should work together to provide early help assessment and effective services for children who may benefit from them. In Blackpool, the Common Assessment Framework was replaced by the Getting It Right Framework introduced in 2013. This provides a Continuous Assessment Tool (CAT) which should be used to assess and plan early help interventions, whilst also serving as a referral form into higher tier interventions if this is deemed necessary. This is underpinned by Thresholds for Intervention guidance.   BSCB_SCR BV_FINAL_9November2015 4 What was known about Child BV and the family placed them into Level 1 of the Blackpool Children in Need model for thresholds, as a child (and family) who was routinely in receipt of community services  and assuming a backdrop of universal Education and Health service. However, there were episodes which, if identified or explored further, may have created an opportunity for the assessed level of need to have increased to level 2 which supports disadvantaged children who could benefit from extra early help –to make the best life chances, with services operating at a preventative level.  The episodes of note were Father’s collapse and attendance at the hospital one month prior to Child BV’s birth. This was due to suspected alcohol withdrawal, resulting in Father disclosing to a professional that “he drinks 7 plus pints per day, he has a new family on the way, he is stressed and tired and has another child to look after”. This information was shared with the GP (by routine letter) and the Father attended a GP appointment the next day, as instructed by the hospital. The second episode within the same period/early weeks of Child BV’s life was the sibling’s nursery noting that on two occasions during a month Father came into the nursery to collect the sibling whilst smelling of alcohol.   It is essential that all professionals working with children and families recognise the important role they have to play in offering early support based on identified need, concerns, sharing information and taking prompt action to ensure risk and need is managed effectively and to prevent an escalation of problems.  In view of the episodes outlined above Child BV (and the sibling) may have benefited from the coordinated approach that underpins Getting It Right (GIR) Early Help processes. There was satisfactory involvement and support by universal services  but the apparent lack of consideration for a GIR assessment did not bring all those involved to a collective view of the needs of Child BV and the family. Therefore, professionals continued working in professional isolation.  Consideration of engaging all the professionals involved through a GIR (Early Help) Assessment may have enabled better information sharing regarding Child BV and the sibling, and engaged the parents in a more holistic assessment of need and planning of services. It may have enabled the earlier support of Horizon, the local drug and alcohol treatment service, if a referral had been agreed by Father. Consequently this may have provided an opportunity for health professionals to explore issues of alcohol and the safe care of the children with both parents.  In Blackpool there has been considerable scrutiny both internally and externally whether Early Help proceses are embedded and fully understood by all professionals including how to invoke such a process. Some, but not all, professionals in Child BV’s case appeared confident in their knowledge of Early Help and support, and their role requirements.      3. Engaging Fathers  A number of local and national reviews have highlighted the importance of professional communication with both parents. In Blackpool the serious case review regarding Child BT considered this issue, and the NSPCC have produced a summary (March 2015) of the learning from national reviews with regard to “Hidden Men”. There was a sense in this case that Child BV’s Father athough not hidden, was sometimes distanced from services and professionals especially those involved specifically for Child BV. There was limited professional communication with Child BV’s Father about the pregnancy, parenting and Child BV in general apart from at one ante natal home visit. The Mother in this case described Father as particularly involved with the care of the sibling and this is verified by the Nursery’s experience of the family. It is clear that there was more routine contact between Father and professionals regarding the older child. Father, himself agreed with this observation but stated this was for family and work reasons only.  Engaging fathers, and fathers-to-be, can be a challenge even, as in this case, when parents are BSCB_SCR BV_FINAL_9November2015 5 living together in a relationship. The focus of professionals often remains on the mother as she is the person carrying the unborn child, with health needs of her own, and still in many families she will be the parent, at least initially, providing the majority of care to the new born baby.  In Child BV’s case the family dynamics meant that Father was usually caring for the sibling of Child BV when health appointments took place, and Mother said that it was agreed by the couple that she attended appointments at the clinic or hospital by herself, as this was easier, and more beneficial for the sibling, a toddler, not to have to attend lengthy appointments. It is positive that records show Father was seen and took part in one ante natal visit at the home, when safe sleeping, smoking, drugs and alcohol use were discussed with both parents but Father was not involved with health professionals during the pregnancy after that.  How fathers can be better engaged and encouraged to be involved and to accept ante natal support, can be an issue for health professionals. Those involved need to remain professionally inquisitive with fathers, and/or with mothers regarding fathers’ involvement in caring for the new baby or other children, and to identify any additional support and guidance which may be required.   Recording requirements for midwifery and health visiting professionals, could include some similar routine lifestyle enquiries with fathers as well as mothers which would assist in information gathering and may lead to identification of additional needs within families. Furthermore, information with a focus on Fathers who, due to other circumstances, cannot meet with health professionals, would be useful to reinforce significant safety messages. However this information would need to get the attention of fathers for the messages to be embedded and make a difference. The NSPCC have undertaken research with Fathers on this issue which includes some useful and creative methods of sharing important information with men (NSPCC, All Babies Count-The Dad’s Project 2014).    4. Referral processes for alcohol support  At the hospital where Father attended after a collapse suspected as linked to alcohol withdrawal, it is positive that an Alcohol Liaison Nurse (ALN) Service is available over 7 days during daytime hours of 07.00 to 17.30. They will see any patient in the hospital whether an in-patient or having attended Accident and Emergency. Their criteria is anyone who is alcohol dependant or identified as at high risk (as per amount of units they are drinking). If a patient presents out of ALN service hours and is seeking support, then whoever sees them may make a referral to the ALN and contact is then made offering an out-patient appointment.   When Father attended hospital and was seen by the Doctor it was evening time and the ALN service was not available. The Doctor examining Child BV’s Father has been spoken to outside of the learning event, as he was unable to attend. He recalls the Father and the consultation. The advice given was for Father to attend his own GP where the expectation was that the GP would discuss a referral for additional alcohol community support. The advice was followed by Father as an appointment with the GP took place the next day. The Safeguarding Lead for the Father’s GP Practice confirmed the records show that contact details were given to the Father for Horizon, the drug and alcohol treatment service, with the advice that Father self referred. The GP did not make a referral for the Father, as stated in the initial agency timeline for the review. Unfortunately the Father did not contact Horizon himself, hence Horizon did not commence a service with Father until after the death of Child BV, when Father requested their support.   The referral pathway in the community for Horizon may require examination and promotion. Whilst a willingness of users to seek support is required for the service to succeed, not all people with a dependancy on alcohol will be proactive in asking for help immediately, as appeared to be the case for the father of Child BV. Clearer referral processes may encourage and enable those requiring alcohol support to request it and therefore provide them with the opportunity to receive help. An audit of self referrals, compared to referrals made by professionals, may provide useful information BSCB_SCR BV_FINAL_9November2015 6 regarding the expectations and thoughts of users when requesting support, and give an insight into what advice was given by professionals when self referral was being suggested.       5. The importance of systems that enable communication between professionals when more than one professional is involved in an organisation.  Although involved with only universal health services there were a number of professionals occupied with the care of Child BV’s family. In the GP practice, health visitors and midwives were in touch with Mother in particular, and the GP saw Father regularly, as did a smoking cessation support service at the GP Practice (during the two months prior to the incident).   Whilst it is accepted in this case there was minimal additional information to share, the attendance at the Emergency Department after Father’s collapse linked to alcohol withdrawal (see above) and his subsequent disclosures to the hospital Doctor would have been worth sharing between those professionals involved with the family. The Reviewer was told there is now a Safeguarding Adults Nurse (SAN) in the Safeguarding Team based at the local hospital. Part of her role is to liaise with accident and emergency staff regarding adults admitted with domestic abuse, substance/ alcohol misuse, and mental health. The SAN has facilitated training within the department raising awareness of recognising and responding to adults who may be vulnerable and those whose reason for admission may have a significant impact on their children. Where there are  safeguarding concerns regarding an adult who is caring for children, the SAN will share this information with the Health Visitor Liaison Nurse (also based at the hospital) and the universal health visitor is informed of the admission and the concerns.  Father did attend the surgery and saw the GP the day after the collapse, and similar disclosures were made by him there as at hospital. This information was not communicated with the midwifery and health visiting professionals who were involved with Child BV’s family, and at this time the Mother was 8 months pregnant. Unfortunately this cannot be explored further as the GP is no longer at the Practice and information has been provided from GP records by the GP Safeguarding Lead.   Any information regarding excessive alcohol use within a family and additional stresses on parents at a similar stage in pregnancy must be of note. At the learning event professionals spoke of a Health Visitors’ Team Inbox where information can now be shared throughout the practice via email. This was confirmed by the GP Safeguarding Lead who also spoke of a flagging system applied to records in the practice to highlight any safeguarding issues. The Team Inbox as a new communication system, and the flagging of records, if used consistently could offer an opportunity for information, and any risks, to be shared.    6. Safeguarding requirements for Nursery Providers  Child BV’s sibling had commenced funded nursery sessions at a local private nursery for one half term prior to Child BV’s death. The nursery staff were able to share that they perceived a satisfactory parent/ nursery relationship was being developed, particularly with Father who had most contact with them due to his regular care of the sibling. A number of positive interactions were reported but on two occasions in the first 4 weeks of Child BV’s life it was recounted that Father attended to collect the sibling smelling of alcohol, although thought not to be under the influence. This was passed on verbally through the management line of the nursery but not recorded, so dates and other details are unavailable. No action was taken and there were no other connected concerns or incidents which would have warranted referral to children’s services. Father did tell the Reviewer he remembered attending the nursery possibly smelling of alcohol which he said was due to his late night working hours as a disc jockey.     At the learning event assurance was provided that a more effective recording system is now in BSCB_SCR BV_FINAL_9November2015 7 place and that staff attendance at safeguarding training is under review. This should improve awareness of general safeguarding requirements including the need for accurate record keeping, and also knowledge of the important role which nursery providers can play in early help processes. Blackpool Council provides support to all registered early years providers through the Early Years and Child Care Team.           7. Safe sleep support  Due to the circumstances of the death of Child BV safe sleep processes have been scrutinised in detail by the panel and at the learning event. Safe sleep materials are shared by the three Pan-Lancashire Local Safeguarding Children Boards and have recently been reviewed, and were        re-launched in late August 2015. The Pan-Lancashire Child Death Overview Panel have commissioned The Lullaby Trust to facilitate training to raise awareness of the need to promote safe sleeping arrangement for infants and toddlers. Training sessions will take place throughout 2015 and 2016.  Professionals involved with the parents of Child BV were clear that appropriate safer sleep advice had been provided to the Mother in particular, during her pregnancy for Child BV and also to both parents together at the ante natal health visitor appointment. Mother told the Reviewer she was aware of current safe sleep guidance, and could remember this also from her first pregnancy. Father also had some awareness. Yet sadly Child BV was found unresponsive in an unusual sleeping arrangement for such a young baby.   To promote more robust safe sleep processes some local safeguarding board areas now ask that health professionals undertake a self sleep assessment. The process is designed to gather as much information about a baby’s sleeping situation in order that appropriate advice is given. The assessment format requires midwifery and health visiting team members to indicate yes / no answers and also add free text. This must be completed in full for every baby. The main difference is that it is imperative that anyone who completes a safe sleeping assessment sees where the baby is sleeping in order to promote safe sleeping of babies and infants and give appropriate advice which is relevant to the circumstances of each family. Currently in Blackpool this type of baby safe sleep enquiry is not undertaken.  It is evident that safe sleep information for parents is provided consistently in the area however the introduction of a safe sleep assessment process could assist in embedding safe sleep messages in families.   The contributing risk factor in this case appears to be the use of alcohol, (see above) and the absence of information regarding safe care of young children whilst using alcohol.    Practice issues  Two practice issues were highlighted for individual organisations as a result of the learning review. These issues are not subject to separate recommendations as practice improvement is already in place but the organisation’s own governance arrangements will need to monitor that issues continue to be resolved;  1. Ensure the communication systems between the local hospital, the Safeguarding Adults Nurse, GPs, health visiting and midwifery staff as described in this review are used effectively by all professionals. 2. Confirm that accurate record keeping relating to all safeguarding concerns in the nursery involved in this review is standard practice.  BSCB_SCR BV_FINAL_9November2015 8  Good Practice Identified  Good practice was identified during the review, by the panel, by professionals at the learning event and also by the mother of Child BV, where professional commitment, persistence and professional curiosity resulted in an enhanced service;  1. The Hospital Doctor was professionally curious about the care and whereabouts of the sibling of Child BV whilst treating the Father in the Accident and Emergency Department for his collapse. The rapport between Doctor and patient also enabled information to be disclosed as to how Father was feeling and some of his family circumstances, and this was recorded and shared.  2. The Health Visitor was proactive in encouraging an early appointment with the GP and ensuring the parents were supported regarding a concern relating to the shape of Child BV’s head. This action was recognised by Child BV’s Mother who thought this was good practice. Unfortunately the Child died prior to the paediatric appointment taking place.    Conclusion  The findings of this serious case review do not indicate that inter-agency practice or the practice of any individual or organisation could have altered the outcome of this case or that the death of Child BV could have been predicted or prevented.  Areas of good practice were noted. Scrutiny of practice, however, always provides an opportunity to consider ways in which services may be improved and therefore the following recommendations, based on the learning from this case, have been made:  Recommendations In order to promote the learning from this case the review identified the following actions for Blackpool Safeguarding Children Board and its member agencies:  1. Blackpool Safeguarding Children Board should ensure the development and implementation of an awareness raising and educational campaign for parents and carers, and  professionals, including those involved in licensing and the licensed trade, about the risks associated with the use of alcohol and the safe care of young children when adults are under the influence.  Intended outcome: Parents and carers will be better informed about the risks of using alcohol when caring for young children and feel more informed in making choices about alcohol use and providing appropriate care. Information for professionals will highlight the risks and ensure opportunities for professional curiosity relating to parental alcohol use and care of children are not missed.   2. Blackpool Safeguarding Children Board should continue to actively promote to all agencies the use of Early Help Assessment through the Getting It Right Framework and should scrutinise numbers initiated by partners, and take action as appropriate to further promote its use. Intended outcome: To increase use with the aim of better holistic assessments for children and identification of additional needs within families, to improve outcomes for children and families and BSCB_SCR BV_FINAL_9November2015 9 enable a shared understanding of risk.  3. Blackpool Safeguarding Children Board should explore new opportunities of better engaging all expectant and new fathers to promote communication, and provide advice and support for both parents relating to pregnancy and safe care of infants. Intended outcome: To ensure that fathers are provided the same opportunities as mothers regarding safe parenting information and support, contact which may inform professionals of other issues impacting on families. 4. The referral pathway for Horizon should be reviewed, potentially by an audit of self referrals compared to agency referrals, to ensure that professionals promote the service as effectively as possible and that there are no unnecessary barriers for service users. Intended outcome: To ensure self referrers are encouraged and supported by professionals to be able to make informed choices, and are easily able to access alcohol and substance misuse services themselves. 5. Blackpool Safeguarding Children Board should explore, in consultation with the the Pan- Lancashire Child Death Overview Panel, the introduction of a safe sleep assessment process to be undertaken by health professionals for all new babies in the Pan Lancashire area.  Intended outcome: To increase the effectiveness of safe sleep support provided to parents and carers, with additional opportunities to reinforce appropriate advice.    References  • Working Together to Safeguard Children H M Government March 2013 and 2015 • Hidden men: learning from case reviews. Summary of risk factors and learning for improved practice around ‘hidden’ men - NSPCC March 2015 • Blackpool Safeguarding Children Board Serious Case Review Child BT • All Babies Count: The Dad’s Project- NSPCC 2014 • Derby and Derbyshire Safeguarding Children Boards Guidance to Support Safe Sleeping Practices in Babies and Infants -July 2014 • Manning V, Best D, Faulkner N & Titherington E (2009).’ New estimates of the number of children living with substance misusing parents: results from UK national household surveys’. BMC Public Health 9: 377.           BSCB_SCR BV_FINAL_9November2015 10 Statement by Reviewer REVIEWER  Amanda Clarke (Derbyshire County Council)  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  (Signature) A.Clarke   Name  Amanda Clarke    Date   9 November 2015   Chair of Review Panel   (Signature) Name                            Paul Threlfall  Date                                                      BSCB_SCR BV_FINAL_9November2015 11 Annex 1       Terms of Reference for a Concise Child Practice Review    Introduction  This Review is being commissioned by the Chair of Blackpool LSCB in accordance with the learning and improvement framework for LSCBs described in Working Together to Safeguard Children guidance (HM Government 2013, now 2015). The concise Child Practice Review is being undertaken in accordance with Protecting Children in Wales: Guidance for Arrangements for Multi-agency Child Practice Reviews (Welsh Government 2012).  A multi-agency panel established by Blackpool LSCB will conduct the concise Review and report progress to the Board through its Chair. Membership will include an independent Lead Reviewing Officer, and representatives from key agencies with involvement.  Child Practice Review members Independent Reviewer:  Amanda Clarke, Derbyshire County Council Chair of panel:    Linda Evans, Principal Social Worker, Blackpool Council                                                           Paul Threlfall, Board manager, BSCB  Panel Members:  Designated Nurse, Blackpool CCG     Named Nurse, Blackpool Teaching Hospitals     Project Improvement Manager, Blackpool Council     Head of Access and Inclusion, Blackpool Council     Designated Doctor, Blackpool Teaching Hospitals     Review Officer, Lancashire Constabulary     Safeguarding Manager, North West Ambulance Service    Timeframe for the review  The CPR will cover the time period of 30 April 2014 to 26 December 2014. Any significant incident relevant to the case but prior to the start of the period 30 April 2014 may be included in the analysis completed by each agency.   Subject(s) of the review Subject:   Child BV Other Family:   Sibling     Mother     Father   The purpose of the review is to:  • Determine whether decisions and actions in the case comply with the policy and procedures of named services and the LSCB;  • Examine inter-agency working and service provision;   BSCB_SCR BV_FINAL_9November2015 12 • Determine the extent to which decisions and actions were child focussed;   • Examine the effectiveness of information sharing/ working relationships between agencies and within agencies;   • Explore whether appropriate Baby Safe Sleep advice and guidance had been provided to both parents;  • Explore what advice and guidance had been shared with parents relating to drug and alcohol use and its potential impact on children;  • Examine if opportunities to explore alcohol issues within the family were taken;  • Explore the involvement and engagement by services with fathers, particularly of new babies in order to consider risk;    • Consider the management of safeguarding concerns by nursery providers   The panel will also: • Seek contributions to the review from appropriate family members and keep them informed of key aspects and progress;   • Hold a learning event for practitioners and identify required resources;   • Establish any learning from the case about the way in which local professionals and agencies work together to safeguard children;   • Identify any actions required by the LSCB to promote learning to support and improve systems and practice.   Tasks specific to the review panel:   1. To set the time frame for the review, see above;   2. Agencies that have been involved with the child and family will provide information of significant contacts by preparing an agency timeline with a focus on the purpose and scope of the review, see above:  BSCB_SCR BV_FINAL_9November2015 13 3. Other agencies/services may be asked to provide a timeline following review of the information provided;   4. Agency timelines will include a brief analysis of relevant context, issues or events, and an indication of any conclusions reached. Information about action already undertaken or recommendations for future improvements in systems or practice may be included if appropriate. The case summary may include any relevant additional background information from significant events outside the timescale for the review;   5. Agency timelines will be merged to create a composite timeline and used by the Panel to undertake an initial analysis of the case and form hypotheses;   6. A full and accurate genogram of the subject family will be prepared for the panel and to assist the learning event;   7. The Panel, through the Chair and Lead Reviewer will seek contributions to the review from appropriate family members and provide feedback to the relevant family members at the conclusion of the review process;  8. The Panel will plan with the Lead Reviewer a learning event for practitioners’ to include identifying attendees and the arrangements for preparing and supporting them prior to the learning event and feedback following the event;   9. The learning event will explore hypotheses and draw out the key learning from the case including any recommendations for the development or improvement to systems or practice;  10. The Panel will receive and consider the draft child practice review report prepared by the lead reviewer, to ensure that the terms of reference for the review have been met, the initial hypotheses addressed and any additional learning is identified and included in the final report;   11. The Panel will agree conclusions from the review and an outline action plan and  make arrangements with the Lead reviewer for presentation to the LSCB for consideration and agreement;   12. The Panel will plan arrangements for feedback to the family and the practitioners in  attendance at the learning event and share the contents of the report following the  conclusion of the review, and before publication;   13. The Panel will take account of any criminal investigations or proceedings related to the  Case;   14. The Chair of Blackpool LSCB will be responsible for making all public comment and  responses to media interest concerning the review until the process is completed.  It is anticipated that there will be no public disclosure of information other than the  CPR report for publication.     BSCB_SCR BV_FINAL_9November2015 14 