Death of a 2-month-old child in June 2019 following admission to hospital with severe breathing difficulties. Child G was found to have died from non-accidental injuries; their father was charged with manslaughter. Learning includes: a need for 'hidden men' training to be reinforced on a regular basis, in order to keep this issue current to practitioners; interventions could be strengthened by a more professionally curious approach around parental history, relationships and dynamics; concerns and subsequent actions need to be clear in the GP record, and information placed on health IT systems; need for better cross border communication to help safeguarding between community midwives and hospitals. Recommendations include: the safeguarding partnership ensures their 'pre-birth protocol' is operating effectively; all assessments and interactions with families to consider the role, presence and the history of fathers to the children and male partners living in or associating closely within a household; the local parent education programme on 'shaking the baby' is delivered by community midwives to both parents if the programme is not delivered in hospital.
      
 Title:  Serious case review concerning Child G. LSCB: Derbyshire Safeguarding Children Board Author: Russell Wate Date of publication: 2022  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.                           Page | 1  Publication          Serious Case Review concerning Child G               Independent Author: Dr Russell Wate QPM   Page | 2  Publication  1.0        Introduction and Background to this Serious Case Review  The subject of this Serious Case Review (SCR) was just two months old when they died following admission to hospital in June 2019 with severe breathing difficulties. The baby is referred to in this SCR as Child G.  At the time of the incident which led to the death of Child G they were living with their mother, who for the purpose of this review is called MG. Also living with MG at the time was her father GFG. The birth father of Child G is referred to as FG. FG lived at a different address with his own father but stayed at MG’s address it is believed on at least two or three occasions a week.   Child G was the first child of MG and FG and was born in April 2019. MG also has children with her former partner. They are referred to as Child G’s siblings in this report.  Child G had been in the care of his father FG, prior to being taken to hospital.  Child G appeared well when MG and GFG left the house. An ambulance was called for Child G when it was reported by FG that Child G was gasping for breath and had gone a funny colour.    The ambulance took Child G to the Sheffield Children's Hospital. A scan showed a head injury with bleeding around the brain and bleeding behind the eyes was also found.  All investigations were completed looking for possible underlying causes of illness. As no underlying causes were identified, it was concluded by the doctors that the injuries were non-accidental.   Child protection investigations commenced as soon as the doctors had given their initial diagnosis of non-accidental injury.  FG was arrested and charged with grievous bodily harm (GBH) with intent; prior to Child G's death. When Child G died this became a murder charge. FG pleaded guilty to manslaughter and received a substantial period of imprisonment in 2020.  As the family were residing in Derbyshire during the timescales of this review, Derby and Derbyshire Safeguarding Children Partnership (DDSCP) have commissioned this Serious Case Review (SCR).    At the time of the incident Derbyshire’s Local Safeguarding Children’s Board (LSCB) was still in operation and therefore this SCR has been completed using the criteria from ‘Working Together’ 2015. The SCR criteria ‘that a child had died and abuse or neglect was known or suspected’ were met for the Local Safeguarding Children Board to undertake a Serious Case Review.  It was agreed at the Derby and Derbyshire Child Safeguarding Review Panel, held on 11th October 2019, that the timeframe for this review would be the period July 2018 to June 2019.  Any significant incident which is relevant to the case but prior to the start of the period in July 2018 was included in the analysis completed by each agency.    Page | 3  Publication                Areas of potential learning in the case, identified by the rapid review process were as follows: • Unknown fathers and the extent to which issues relating to unknown fathers can and should be explored.  • Further understanding of FG’s background and potential risks posed by him.  FG’s mental health records are to be included within the review. • Cross border and cross agency information sharing.  • MG’s parenting capacity and the possible impact of a learning difficulty.  • Professional curiosity – missed opportunities to further explore issues identified during the pregnancy and Child G’s life.            2.0 Summary of the case   This section aims to provide a brief picture of the lived experience of Child G, mother MG and father FG, as seen through their interactions with the services and professionals from the various agencies.    Period prior to July 2018  Prior to the timeframe covered in this review children’s social care services were involved with the children in the family. The nature of the involvement was around parenting issues: such as rough handling, physical chastisement, lack of routines and poor home conditions.  Help and support was provided to the family and none of these referrals led to any child protection procedures or any long-term social worker involvement.  There were suggestions that MG was vulnerable but that she engaged well with the primary school.  The health visitor (HV) on a home visit discovered that MG had a new boyfriend, whom she had met on the internet, and that he had a child/baby who he possibly hadn’t been able to see since their birth.  MG had told the HV that her new partner’s name was FG and where he lived.   It is recorded that in 2017 FG had been referred by his GP in the area he lived and was eventually seen by the mental health local single point of access (SPA). He confirmed that he was struggling to cope and there were indications that he thought of taking his own life. The assessment of him was that he was in a low mood since his mother’s death and he was struggling to sleep, which caused his mood to worsen.  He reported hearing a voice and described it as internal and that it had been present for several years. There were no psychotic tendencies raised. His treatment was to self-refer, if he needed further assistance.  Some months later, an urgent referral was received by the mental health team from FG’s doctor, as he was now hearing third person auditory hallucinations, was self-harming by cutting himself, wasn’t sleeping and was having suicidal thoughts as a Page | 4  Publication  result of the voice. He was seen a week later and a change of medication was prescribed.  Later in May 2018 the sibling’s school raised concerns about neglect. A home visit took place by the early help multi-agency (MAT) worker which confirmed low level neglect. Staff at the school were also concerned that MG was being less forthcoming about entering into a new relationship, when she would normally be open and transparent.  A team around the family (TAF) meeting was held which both parents (MG and the sibling’s father), both schools and the MAT Worker attended.  It was recorded that agencies were worried that MG was in a relatively new relationship with FG, who had regular contact with MG and the siblings.   Antenatal period  MG attended her GP practice at about six week’s gestation with Child G and it was noted that this pregnancy was with a new partner who wasn’t named.   That same month FG was assessed again by SPA. He confirmed that he still heard a voice and that he was now taking his prescribed drugs again. He stated that he was living with his father and he had a partner who was pregnant by him and the baby was due in 2019. There were no concerns raised about him becoming a parent. He was discharged from SPA with a plan agreed and to continue with his medication and self-refer for further bereavement support.    At an antenatal appointment attended by both MG and FG, the community midwife identified risk factors which were later shared with the family’s health visitor and the hospital midwives; they were also discussed with the primary health care team at the GP practice. These factors included that FG had stated that he had experienced previous babies who had died with other partners (there is no further detail known to the review on the truth of this and if so how many babies or how many partners), that he had a history of depression and he was currently being treated by the use of prescribed medication for it. It was also shared that MG had older children living with their birth father and that there had been historical referrals to Starting Point Derbyshire social care first point of contact service. It was recorded that MG had difficulty with literacy.  In January 2019 it is noted by both the school and the community midwife (during an appointment MG attended at the GP surgery) that MG was smoking heavily. There were obvious concerns for the safety of her unborn child. The school suggested to the MAT worker that an unannounced visit would be appropriate, as there were suggestions that she was either smoking or being near people smoking cannabis, since she smelt of “weed”.  There is no record that this unannounced visit took place.  At an initial consultation when MG was first pregnant, the GP noted the new partner of MG, and the non-cohabiting status of the relationship; but there is no other detail recorded.  There were concerns identified about FG by the community midwife in the GP records and this was discussed at the practice safeguarding meeting.    Page | 5  Publication  Whilst FG attended most antenatal clinic and midwife appointments with MG, there were occasions when she attended alone. However, no routine safeguarding enquiry was undertaken regarding domestic abuse.  Postnatal period.  Following the birth of Child G, MG had a planned discharge home. Child G was seen for the routine 8-week check and initial immunisations.  This examination was unremarkable and it was noted that the cough had not completely gone.  A retrospective note was made the following day that both parents were acting appropriately with Child G.   Subsequently MG and Child G were seen at home on a number of occasions in a short space of time; these visits were by the community midwife and then the HV. No further concerning factors were identified during these visits.   As Child G was born outside of Derbyshire, the parents had only received part of the parental educational programme (a multi-agency project to reduce the incidence of shaken baby syndrome) which is delivered to parents of babies in Derbyshire. The educational DVD and signed commitment statement which form part of the Parental Educational Programme were not delivered by the Sheffield Teaching Hospital’s (STHFT) as it was not part of their processes. The community midwife delivered almost all of the programme (an educational leaflet) which she discussed with both MG and FG due to the identified parental reading difficulties. The HV also discussed and showed the information leaflet at the 6-8-week review and offered to show the parents the ‘don’t shake the baby’ clip through ‘you tube’, but it was declined by both parents.  In June the East Midlands Ambulance Service (EMAS) received a 999 call for a child who was reported to have stopped breathing. The attending ambulance crew found Child G child laying on the floor and they commenced medical assistance. The smell of cannabis was noted, but no drug paraphernalia or evidence of alcohol use was seen. It was noted that the room was dirty, unclean and cluttered.   It was established that MG was not at the address when the ambulance arrived, but had been called and was reported to be making her way back to the home address.  FG stated that he had been feeding Child G a bottle when Child G went rigid and started breathing abnormally. FG left the address for a short while as he tried to guide in another ambulance, on his return to the house he was arrested by the police who had arrived at the house a short while earlier.  The ambulance took Child G to the Sheffield Children's Hospital, where a scan showed a head injury with bleeding around the brain and bleeding behind the eyes was also found.  All investigations were completed and these were all normal and it was decided by the doctors that the injuries were believed to be non-accidental, probably caused by something like Child G being shaken. Child G did not make any improvements, and, during the third day of his admission, the decision was made to Page | 6  Publication  withdraw treatment as his injuries were not felt by the doctors to be compatible with life. Child G died the next day.  FG, following his arrest, was firstly charged with grievous bodily harm, then this charge was upgraded, when Child G died and he was charged with murder. He has pleaded guilty to manslaughter and received a substantial period of imprisonment.  3.0 Analysis of significant safeguarding events.  This analysis includes, where possible, the responses to the requests for information made to each agency. It also takes account of the specific requirements of the terms of reference.  The community midwife provided really good care to the family, both within the GP practice and at the family home during the antenatal period. No concerns were raised regarding the family’s engaging with midwifery services. The mother of Child G had been seen both with her partner (FG) and on her own and there were no concerns regarding the relationship between the parents or their commitment to parenting Child G. However, there is an expectation that all women are asked about domestic abuse during their pregnancy and during the antenatal period on at least two occasions and at any other appropriate opportunities, if vulnerabilities are identified.  This did not happen with MG.   There appears to be limited information recorded regarding the father of Child G. At maternity booking it was reported that he stayed with Child G’s mother a few days a week and lived in a different area. He did, however, provide an address for the records, and further follow up could have taken place, during the completion of the assessment period for the siblings. This would have revealed a history of depression, which was managed by medication prescribed by GP, and an unconfirmed report that he had children from previous relationships. Although no disclosure was made, when the community midwife asked the couple about any history of substance misuse, it is documented that the father did not provide a response. MG when seen by the review author stated that she had to answer for him that he used cannabis. The review author understands that at the time of this case the threshold for a pre-birth assessment was significant harm, so fully accepts that this case would not have met that threshold.  But as the threshold has now changed to include child in need cases, the learning from this case highlighted within this report illustrates that a referral would now instigate a pre-birth assessment.    FG is reported but not confirmed to have lost previous children with previous partners. There is no further information presented to the review of how many children or previous partners this may have involved. No further enquiry was made regarding this information, despite the unusual nature of this statement and the potential implications for this pregnancy. Further enquiries made by the SCR panel conclude that these comments about previous children made by FG to be untrue, but nobody, including the police investigation following the death of Child G, is able to confirm this. Page | 7  Publication  No concerns were raised regarding the way that FG presented when he attended school with MG to collect one of Child G’s siblings, with observations in fact made by teachers that the sibling was hugging FG.  The only time that anything was reported that could have warranted any further exploration was the information from MG to health professionals in December 2017, which indicated that FG (with whom MG was now in a relationship) had a child or baby, with whom he had not been able to have contact with. (It must be appreciated that this information came from MG and not FG).  FG was never present during visits and MG was consistent in saying that there was no plan for him to move into the family home.  There is no information on any records to suggest that this was not the case, but FG was never part of any discussions or meetings.   The work undertaken to complete the assessment and following actions were deemed in the local authority internal management review report (IMR) to have been thorough.  The children were all seen and spoken to alone with and no concerns were raised.  MG was seen at home and the concerns discussed with her.  Details of FG were incorporated into the assessment, although he wasn’t present when the visits took place, and no concerns were raised regarding him. However, he wasn’t spoken with. A full chronology of previous involvement was included, together with responses to agency involvement. It was noted in the assessment that there was nothing of concern from the agency checks completed that would indicate that enquiries into FG were required. Neither the community midwife or FG’s GP were contacted, which would have made this a more robust assessment.  There is evidence that MG was asked about her literacy and learning ability, and that some workers took that understanding into consideration when working with her.  However, there was a lack of curiosity about either parent’s histories in this regard and an understanding of this may have informed a greater understanding of their learning and literacy vulnerabilities, which could impact on their parenting ability.  There was no direct police involvement with the family during the time that MG and FG were in a relationship. There were past incidents of note in December 2017 when children’s social care shared anonymous information with the police by submitting a safeguarding referral, which states, “unknown males at address causing anti-social behaviour and possibly using cannabis.” It is difficult to seek clarification or additional information in relation to anonymous reports. At the time of the report there was no additional relevant information available to the police to warrant further development or action.  Derbyshire Police have highlighted in their IMR that the “linking of entities”, which are people, places, vehicles, telephone numbers and incidents on Niche, (Niche is a police IT records management system) is problematic for their organisation. The IMR author states that too many practitioners lack the required knowledge to create a meaningful records management system and this is an ongoing matter which they are trying to resolve. Page | 8  Publication  The attending ambulance crew, at the time of the fatal injury to Child G, raised a safeguarding referral, highlighting the concerns they saw and witnessed. This referral was shared with children’s social care, the Sheffield Children’s Hospital and the registered GP for Child G. The attending crews demonstrated their knowledge and awareness around safeguarding, as they were able to identify the concerning presentation of the patient and behaviours of the adults, allowing them to act appropriately in line with policy and procedure.   Differences in operational recording and practice have been identified between Sheffield Teaching Hospitals (STHFT), who use the family common assessment framework, and that of agencies in Derbyshire, who use the Early Help assessment, which is now much more generally in use nationally. This difference led to ‘safety-netting’ not being shared with community midwives outside of the Sheffield area.  Child G was not known to the Sheffield Children’s Hospital (SCNHSFT) prior to June 2019. Non-accidental injury was quickly considered and subsequently identified by SCNHSFT staff, as the underlying cause of Child G’s illness. Child protection proceedings were initiated according to Trust policies as soon as it became clear that non accidental injury (NAI) was the most likely cause of Child G’s illness.    There was no direct communication between the STHFT and the Derbyshire community midwife regarding the safeguarding concerns. There was reliance that the safeguarding practices in North Derbyshire were the same as Sheffield and that the primary responsibility for communication rested with the community midwife not the hospital. Whilst this is within STHFT guidelines, this may not be the case in North Derbyshire. Better cross border communication would help safeguarding between Derbyshire community midwives and hospitals across the borders of Sheffield and Derbyshire.   There were concerns raised about FG, which were discussed at GP practice meetings and it is recorded that the follow-up was to be completed by the midwife who had, at the time, the most involvement with MG in her pregnancy. It is not known what this follow up was as there is no record of it in the GP records.  An issue was identified relating to the means of sharing Information between GP’s and midwife and/or health visitors because of the use of different computer systems.   There is not good interoperability between the EMIS and SystmOne electronic systems, which needs to be addressed. This is exacerbated when cross-border information-sharing is necessary.    There were in this case three local authorities involved as Child G and mother were from Derbyshire, Child G received some maternity services in Sheffield – meaning that the HV would be unable to see Child G’s health information. FG was involved with various health agencies in South Yorkshire.   Page | 9  Publication  Derbyshire children’s services were not involved with MG’s family when Child G died. The siblings had been closed to the service since April 2019; which was before Child G was born.   Some of the interactions in this case could have been strengthened by a more professionally curious approach being taken by professionals around parental history, relationships and dynamics and the impact this may have had on parenting or MG’s vulnerability within relationships.     4.0 Family perspective              MG’s relationship with her previous partner (the father of Child G’s siblings) had      been ended a while, before she first started connecting with FG, through an online dating site. MG and FG communicated with each other for a period of time, before MG went to visit him.               MG carried on visiting by FG for a short time before FG came to stay a couple of times a week. MG does acknowledge that in truth she knew and knows very little about his background.              There were no occasions that MG felt that FG was a risk to either Child G or to her other children. In fact, they the siblings had a reasonable relationship with him - a comment which they support. The one thing that did concern her was the fact that he used cannabis. MG states she did tell professionals this when asked, and FG didn’t reply to professionals when they asked him. MG had asked him to stop using cannabis.              When Child G was born (not believed to be a planned pregnancy) FG then spent more time staying with MG and Child G.               In MG’s views there is nothing professionals or any agency could have done to prevent what happened to Child G. In her view she had always had and has excellent support by all professionals. MG does though very much want justice for Child G.              Child G’s siblings are all doing remarkably well considering the circumstances of their siblings’ death. The death did affect the older siblings, but they think very positively about Child G.  5.0     Conclusion and Learning  It is quite clear to the review author that, even through the lens of hindsight, there is nothing whatsoever to suggest that the death of Child G could have been predicted.  All of the concerns highlighted in this report, taken separately, still would not have met any threshold for a more intrusive intervention.    Page | 10  Publication  In every review it is important to highlight good practice. The review author and the SCR panel have seen throughout the time period set for the review, and before, the demonstration of good practice by individuals and agencies.   Good Practice • The community midwife provided excellent continuity of care and had developed a good relationship with MG. This is something MG herself wanted to emphasise to the review author.  • The community midwife and the health visitor spent time going over the message in the leaflet “Shaking the baby is just not the deal”, this was face to face with both parents, in recognition of their difficulty with literacy. • The health visitors identified also had a good relationship with MG, and she had also rung the named nurse for safeguarding children to seek advice.  • The communication between health visitor, midwife and also Child GP practice was found to be good. This included the GP’s use of safeguarding meetings. • The schools, in particular the primary school, were very diligent in recording and sharing their concerns.   To develop the learning themes, the SCR panel and the review author have taken into account a previous similar SCR from Derbyshire - related to Child A.  The themes for learning that have arisen from Child G are:                 Learning Themes  Threshold for a pre-birth assessment.   Unknown fathers and the extent to which issues relating to them can and should be explored to identify background history and any potential risks posed by him.    Postnatal parental advice on shaken baby risks.  Identifying parental learning needs and how this could impact on parenting capability.  Professional curiosity – missed opportunities to further explore issues identified during MG’s pregnancy and Child G’s short life.  Cross border and cross agency information sharing.   Threshold for a pre-birth assessment Although the review author understands that the concerns could be viewed as low-level, nevertheless, the case was closed after the pregnancy was known and no pre-birth assessment was undertaken. The review author feels that, had there been a more professionally curious approach in relation to FG, a pre-birth assessment may have been undertaken and the information in relation to FG’s mental health history would have been documented and considered.   Unknown Fathers Page | 11  Publication   It is acknowledged that the ‘hidden men’ training, that has been carried out locally, needs to be reinforced on a regular basis, in order to keep this issue current to workers and professionals.  In addition, managers and workers must take account of all people with whom the children are in regular contact and who may have an impact on a child’s welfare.  There is no evidence to suggest that FG was seen as a risk to the family or unborn Child G, but detailed assessment and curiosity about him and his relationship with MG would have added depth to the analysis of the situation.  Advice to parents on ‘shaking babies’  The “shaking your baby is just not the deal” parent education programme was not completed in full to be compliant with Derby and Derbyshire safeguarding guidelines, although it is acknowledged that really good practice was shown by the community midwife, by holding a discussion with both parents. However, the showing of the DVD and the signing of the commitment form could not be completed, as hospitals over the border in Sheffield do not deliver the programme. A comment at the practitioner learning workshop was that consideration could be made for the commitment form signing being extended to the health visiting service. This would particularly apply in those cases where the baby is born in another area other than Derbyshire but would need to take into account that fathers are not always present at the first HV visit, as by then those in employment would have returned to work. This could also equally apply to those hospitals in other areas which deliver Derbyshire babies.  Identifying learning needs  MG was recorded as requiring assistance with reading and writing for her to understand her pregnancy notes. Despite this, there does not appear to have been any analysis by any professional of how this could impact on her parenting ability.  Professional curiosity  The interventions in this case could have been strengthened by a more curious approach being taken by the respective professionals around parental history, relationships and dynamics and the impact this may have had on parenting or MG’s vulnerability.   The health visiting service provided the universal plus healthy child programme to Child G and core contacts were completed within timescales. However, there have been missed opportunities regarding enquiring about domestic abuse.   There was a lack of professional curiosity during contacts around FG’s caring role of a possible vulnerable adult (his father) and his own mental health needs, with a missed Page | 12  Publication  opportunity to share information with his father’s GP. There was no consideration around the recording of information on FG’s father’s GP record, which could have highlighted safeguarding information.  Information-recording and sharing  There are a number of occasions identified in the review where discussions and interventions were not recorded. Specifically, from a GP perspective it is clear that there were concerns raised during MG’s pregnancy, which were discussed between GPs and the midwife and health visitor and these discussions were mentioned in the GP record, but without any detail of the concerns or actions taken.   Concerns and subsequent actions need to be clear in the GP record, which then leads to the need to ensure information is placed on any or all health IT systems.  Whilst overall the interagency working and sharing of information in this case is really positive, there were some instances where the case file recording suggests key information was not always recorded and shared appropriately with managers, which would also have supported progression of the case.   Where safeguarding concerns are identified in women from outside of the STHFT area, there should be direct communication with the community midwife. First contact should be by telephone, with email confirmation of the content and a written plan for follow up to ensure these are acted on appropriately. This should help to reduce the known problems with cross border communication.   There is a need identified by Derbyshire Police to improve the linking of entries within the record management system, called ‘Niche’. This is recognised by them. In December 2018 the police instigated a process change for the way information was assessed, linked, disseminated, shared and developed. Moving forwards, it is anticipated that patterns of information will be more easily identified, developed and shared with agencies to improve opportunities to mitigate risk suffered by vulnerable individuals and families.   6.0 Recommendations             The individual agency IMRs have identified recommendations and the DDSCP should monitor the implementation and effect of them. This Serious Case Review has identified learning and made some recommendations, as detailed below, and the implementation of these will assist the DDSCP to deal more effectively with similar circumstances in the future, resulting in the improved safety and welfare of children.  Recommendation 1 The Derby and Derbyshire Safeguarding Children Partnership should seek assurance that the May 2020 update to their ‘pre-birth protocol’ has been operating effectively. (An audit after a minimum of six months against this would be an Page | 13  Publication  appropriate method to provide this assurance for this SCR but also the previous SCR ADS18) Recommendation 2  i) The DDSCP should seek to ensure that all safeguarding learning, backed up by proactive guidance and/or policy, highlights to all mothers, fathers, and families about the vulnerability of babies.  ii) All assessments and interactions with families consider the role, presence and the history of fathers to the children and male partners living in or associating closely within a household.  Recommendation 3 There is already in place a research-based parenting education programme ‘shaking the baby it’s just not the deal’, which is led by the midwifery service and delivered in hospital to both parents/carers prior to the discharge of the baby. The DDSCP should gain assurance that, if a baby leaves hospital either within Derby/Derbyshire or from another area (in this case Sheffield) without the parents/carers receiving the full programme, including the DVD /film on YouTube: • community midwives will deliver the full parent education programme to both parents • The health visiting service will ask the parents/carers about their understanding of the programme and record that the programme has been delivered.  If it is identified that there is a need to deliver the programme, the HV will endeavour to do this with both parents/carers.                    